REVIEW

AHMAD B. TARABISHY, MD BENNIE H. JENG, MD

Cole Eye Institute, Cleveland Clinic Cole Eye Institute, Cleveland Clinic; Assistant
Professor of Ophthalmology, Cleveland Clinic
Lerner College of Medicine of Case Western
Reserve University

Bacterial conjunctivitis:
A review for internists
■ A B S T R AC T is common in
B children and adults presenting
ACTERIAL CONJUNCTIVITIS
with a
Bacterial conjunctivitis is common and occurs in patients red eye. Although most cases are self-limited,
of all ages. Typical signs are a red eye and purulent appropriate antimicrobial treatment acceler-
drainage that persists throughout the day. Gonococcal ates resolution and reduces complications. It is
and chlamydial conjunctivitis must be treated with critical to differentiate bacterial conjunctivitis
systemic antibiotics. Bacterial conjunctivitis due to most from other types of conjunctivitis and more
other organisms can be treated empirically with topical serious vision-threatening conditions so that
antibiotics. Red flags suggesting a complicated case patients can be appropriately treated and, if
requiring referral to an ophthalmologist include reduced necessary, referred to an ophthalmologist.
This paper is an overview of how to diag-
vision, severe eye pain, a hazy-appearing cornea, contact nose and manage bacterial conjunctivitis for
lens use, and poor response to empirical treatment. the office-based internist.
■ KEY POINTS ■ CAUSES VARY BY AGE
Viral conjunctivitis typically presents as an itchy red eye
Conjunctivitis is a generic term for inflamma-
with mild watery discharge. Many patients have signs tion of the conjunctiva due to various infec-
and symptoms of a viral upper respiratory tract infection tious agents (bacteria, viruses, or fungi) and
(eg, cough, runny nose, congestion) and have been in noninfectious causes (eg, allergic, chemical,
contact with a sick person. and mechanical). The organisms that cause
bacterial conjunctivitis tend to differ by
Having both eyes glued shut in the morning had an odds patient age (TABLE 1).
ratio of 15:1 in predicting a positive bacterial culture, In neonates, conjunctivitis is predomi-
whereas either itching or previous conjunctivitis made a nantly bacterial, and the most common organ-
bacterial cause less likely. ism is Chlamydia trachomatis. Chlamydial con-
juctivitis typically presents with purulent uni-
In adults, Neisseria gonorrhoeae causes hyperacute lateral or bilateral discharge about a week after
conjunctivitis and is associated with concurrent, often birth in children born to mothers who have
cervical chlamydial infection. Many infants
asymptomatic genital infection. Gonococcal conjunctivitis with chlamydial conjunctivitis develop
should be treated with a single dose of ceftriaxone chlamydial pneumonitis: approximately 50%
(Rocephin) 1 g intramuscularly plus saline eye-washing. of infants with chlamydial pneumonitis have
concurrent conjunctivitis or a recent history
Corticosteroid drops should not be prescribed for a red of conjunctivitis.1
eye before consultation with an ophthalmologist because Source of funding: Dr. Jeng is supported in part by a Research to Prevent
these drops may worsen some conditions. Blindness Challenge Grant to the Department of Ophthalmology of the
Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University, and National Institutes of Health 1KL2 RR024990
Multidisciplinary Clinical Research Career Development Programs Grant.

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 BACTERIAL CONJUNCTIVITIS TARABISHY AND JENG

TA B L E 1 affected 92 recruits at a military training facili-

ty and 100 students at Dartmouth University.5
Common causes S pneumoniae is also associated with conjunc-
of bacterial conjunctivitis tivitis-otitis syndrome, accounting for approxi-
in the United States mately 23% of culture-proven cases.4
Neonates Moraxella species, S aureus, and coagulase-
Chlamydia trachomatis negative staphylococci are less common caus-
Staphylococcus aureus es of bacterial conjunctivitis in children.6–8
Haemophilus influenzae In adults, the most common causes of bac-
Streptococcus pneumoniae terial conjunctivitis are S aureus and H influen-
zae. Conjunctivitis caused by S aureus is often
Children
H influenzae recurrent and associated with chronic ble-
S pneumoniae pharoconjunctivitis (inflammation of the eye-
S aureus lid and conjunctiva). The conjunctivae are
colonized by S aureus in 3.8% to 6.3% of
Adults healthy adults.9–11 In addition, about 20% of
S aureus
people normally harbor S aureus continually in
Coagulase-negative Staphylococcus organisms
H influenzae the nasal passages, and another 60% harbor it
S pneumoniae intermittently; in both cases, the bacteria may
be a reservoir for recurrent ocular infection.12
Other organisms that commonly cause
conjunctivitis in adults are S pneumoniae,
Neisseria gonorrhoeae is a rare cause of coagulase-negative staphylococci, and
neonatal conjunctivitis. The onset is some- Moraxella and Acinetobacter species.13
what earlier than in chlamydial conjunctivitis,
ie, in the first week of life, and this organism ■ HOSPITAL-ACQUIRED CONJUNCTIVITIS
classically causes severe “hyperacute” conjunc-
H influenzae tivitis with profuse discharge and may result in Little has been published about hospital-
conjunctivitis corneal involvement and perforation. Routine acquired conjunctivitis. In a neonatal inten-
antibiotic prophylaxis at birth has markedly sive care unit, the most common organisms
spreads easily reduced its incidence and complications. isolated in patients with conjunctivitis were
in schools and Other bacteria that can cause neonatal coagulase-negative staphylococci, S aureus,
conjunctivitis include Staphylococcus aureus, and Klebsiella species.14 We found that about
households Haemophilus influenzae, and Streptococcus 30% of children who developed bacterial con-
pneumoniae.2 junctivitis after 2 days of hospitalization at
In children, bacterial conjunctivitis is Cleveland Clinic harbored gram-negative
most often caused by H influenzae or S pneu- organisms. In addition, in patients who were
moniae, which accounted for 29% and 20% of found to have conjunctivitis caused by
cases, respectively, in a prospective study in Staphylococcus species, the rate of methicillin
Israel.3 Whether patients had been vaccinated resistance was higher in those hospitalized for
against H influenzae in this study is unclear. more than 2 days than those with
H influenzae conjunctivitis spreads easily in Staphylococcus species who were hospitalized
schools and households. It is associated with for less than 2 days. This suggests that the bac-
concurrent upper respiratory tract infections terial pathogens encountered in hospitalized
and otitis media (conjunctivitis-otitis syn- children with conjunctivitis differ from those
drome): 45% to 73% of patients with purulent found in the outpatient setting.15
conjunctivitis also have ipsilateral otitis media.4
S pneumoniae, the second most common ■ EYE DISORDERS
cause of bacterial conjunctivitis in children, is PREDISPOSE TO INFECTION
a common cause in epidemic outbreaks among
young adults. Newly described unencapsulated The conjunctiva is a transparent membrane
pneumococcal strains caused outbreaks that that covers the sclera and lines the inside of

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the eyelid. It is a protective barrier against
invading pathogens and lubricates the ocular
surface by secreting components of the tear
film (although the lacrimal glands contribute
more to the tear film).
Several unique anatomic and functional
features of the ocular surface help prevent
bacterial infection in the healthy eye. The
tear film contains secreted immunoglobulins,
lysozyme, complement, and multiple antibac-
terial enzymes, and it is continuously being
flushed and renewed, creating a physically and FIGURE 1. Bacterial conjunctivitis. Note the
immunologically adverse environment for purulent discharge, the red eye, and
bacterial growth. chemosis.
Disorders involving the eyelids or tear
film such as chronic dry eye and lagophthal- The cornea is frequently involved, and
mos (in which the eye cannot close complete- untreated cases can progress within days to
ly) may predispose the eye to frequent infec- corneal perforation. Unlike most other
tions. Also, an adjacent focus of infection, types of conjunctivitis, gonococcal con-
such as inflammation of the lacrimal gland junctivitis should be treated as a systemic
(dacryocystitis), can cause recurrent or chron- disease, with both systemic and topical
ic conjunctivitis.16 antibacterial therapy.2
Acute bacterial conjunctivitis typically
■ CLINICAL FEATURES presents abruptly with red eye and purulent
OF BACTERIAL CONJUNCTIVITIS drainage without significant eye pain, discom-
fort, or photophobia. Visual acuity does not
Inflammation of the conjunctiva causes injec- typically decrease unless large amounts of dis-
tion (dilation of conjunctival vessels) and in charge intermittently obscure vision. In bacterial
some cases chemosis (conjunctival edema). Chronic bacterial conjunctivitis, ie, redconjunctivitis,
Discharge may be seen in bacterial, viral, or eye with purulent discharge persisting for
allergic conjunctivitis. In bacterial conjunc- mild to severe
longer than a few weeks, is generally caused by
tivitis, discharge varies from mild to severe Chlamydia trachomatis or is associated with a purulent
but usually appears purulent (FIGURE 1) and per- nidus for infection such as in dacryocystitis.
sists throughout the day. Meibomian gland discharge
secretions in the medial canthus that accumu- ■ BACTERIAL CONJUNCTIVITIS persists
late during sleep and are not present during VS OTHER CAUSES OF A RED EYE throughout
the day should not be confused with true dis-
charge. Clinical signs and symptoms of infection with the day
Bacterial conjunctivitis is commonly clas- certain organisms have been extensively
sified according to its clinical presentation: described, but a meta-analysis17 found no evi-
hyperacute, acute, or chronic. dence that these textbook features help to dis-
Hyperacute bacterial conjunctivitis pre- tinguish between bacterial and viral causes of
sents with the rapid onset of conjunctival conjunctivitis. Instead, whether a bacterial
injection, eyelid edema, severe, continuous, cause was likely was best determined from just
and copious purulent discharge, chemosis, and three features: having both eyes glued shut in
discomfort or pain. the morning had an odds ratio of 15:1 in pre-
N gonorrhoeae is a frequent cause of dicting a positive bacterial culture, and either
hyperacute conjunctivitis in sexually active itching or previous conjunctivitis made a bac-
patients; the patient usually also has N gon- terial cause less likely.18
orrhoeae genital infection, which is often In general, however, viral conjunctivitis
asymptomatic. N gonorrhoeae conjunctivitis typically presents as an itchy red eye with mild
also occurs in neonates, as noted above. watery discharge. Many patients have signs

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 BACTERIAL CONJUNCTIVITIS TARABISHY AND JENG

TA B L E 2 the clinician to a more serious condition and

prompt a referral to an ophthalmologist for an
Differential diagnosis urgent evaluation (TABLE 2). A complete review
of a red eye for internists on how to manage a red eye was
Acute glaucoma* recently published in this journal.21
Allergic conjunctivitis
Anterior uveitis* ■ TREATMENT
Blepharitis
Chemical conjunctivitis Systemic treatment needed
Dry eye for gonococcal or chlamydial infections
Episcleritis The US Centers for Disease Control and
Foreign body* Prevention recommend treating gonococcal
Infectious conjunctivitis conjunctivitis with ceftriaxone (Rocephin) 1
Keratitis* g in a single intramuscular dose plus topical
Scleritis* saline lavage of the eye.22,23 Sexual partners of
Subconjunctival hemorrhage the patient should be referred for evaluation
*Associated
and treatment, as should mothers of affected
with severe pain, decreased vision, or a hazy
cornea and requires urgent referral to an ophthalmologist neonates and the mother’s sexual partners.
Chlamydial conjunctivitis is also treated
with systemic antibiotics. In neonates, the
treatment is the same as for pneumonia caused
and symptoms of a viral upper respiratory tract by C trachomatis: erythromycin taken orally for
infection (eg, cough, runny nose, congestion) 14 days. In adults, it can be treated with a sin-
and have been in contact with a sick person. gle oral dose of azithromycin (Zithromax) 1 g.
Ipsilateral preauricular lymphadenopathy is Some authors recommend that H influen-
common in viral conjunctivitis and strongly zae conjunctivitis also be treated with sys-
suggests this diagnosis.19 temic antibiotics, as it is frequently associated
There is no Viral conjunctivitis is often epidemic and with concurrent otitis media.24
firm rule on is easily contagious. Several epidemics have
been traced to eyecare facilities. Adenovirus Topical antibiotics hasten cure
which topical conjunctivitis is extremely contagious and can Other types of bacterial conjunctivitis usually
antibiotic to be transmitted both between people and via resolve spontaneously: early placebo-controlled
inanimate objects; it has been reported to be studies found that more than 70% of cases of
use spread by workers in health care facilities.20 bacterial conjunctivitis resolve within 8 days.25
Allergic conjunctivitis is also common. However, treatment with antibacterial agents
Patients typically report itching and redness of leads to a faster clinical and microbiological
both eyes in response to an allergen exposure. cure26 and reduces the chance of rare compli-
Other allergic symptoms may be present, such cations27 and of transmitting the infection.
as allergic rhinosinusitis, asthma, or atopic A number of topical antibiotics are effec-
dermatitis in response to seasonal or perennial tive for treating bacterial conjunctivitis (TABLE
environmental allergens. 3),28,29 but there is no firm rule about which
Other causes of a red eye. Many patients one to use because no significant differences
with a red eye have conjunctivitis, but other have been found in clinical outcomes with dif-
conditions can also present in a similar man- ferent agents.28 Factors such as cost, local
ner. Whether a patient has a serious vision- resistance data, and risk of adverse effects
threatening condition (eg, acute-angle closure should be considered; however, we know of no
glaucoma, microbial keratitis, or anterior studies of the cost-effectiveness of treating
uveitis) can usually be determined with a bacterial conjunctivitis.
focused ophthalmologic history and physical
examination. Any alarming clinical features Is culture necessary?
such as severe pain, decreased vision, or a hazy A predictable set of organisms accounts for
cornea in a patient with a red eye should alert most cases of bacterial conjunctivitis in out-

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patients, so many physicians start therapy TA B L E 3
empirically without culturing the conjuncti-
va. But in the hospital the organisms and Topical antibiotics used to
their antibiotic resistance patterns are more treat bacterial conjunctivitis
varied, so culturing the conjunctiva before Bacitracin (Ak-Tracin, Bacticin)
starting broad-spectrum therapy may be war-
ranted.15 For an outpatient with possible Chloramphenicol (AK-Chlor, Chloroptic,
Chloromycetin)
hyperacute conjunctivitis, it is reasonable to
perform a Gram stain in the office if the Ciprofloxacin (Ciloxan)
facilities exist, but it is not essential because Gatifloxacin (Zymar)
urgent referral to an ophthalmologist is war-
ranted regardless of the results to rule out Gentamicin (Gentak, Gentasol)
corneal involvement. Levofloxacin (Quixin)
Unfortunately, antibiotic resistance is
increasing even among outpatients. Moxifloxacin (Vigamox)
Susceptibility of the most common ocular Neomycin (Neosporin)
pathogens to ophthalmic antimicrobial
Ofloxacin (Ocuflox)
agents has dropped dramatically: S pneumo-
niae and S aureus have developed high rates Polymyxin B and trimethoprim (Polytrim)
of resistance.30 Recent data also suggest that Sulfacetamide (Cetamide, Ocusulf-10, Sodium
treatment with topical ophthalmic antibi- Sulamyd, Sulf-10)
otics can induce resistance among coloniz-
ing bacteria in nonocular locations.31 Tobramycin (AK-Tob, Tobrex)
Widespread systemic treatment with
azithromycin or tetracycline for control of
endemic trachoma in two villages in Nepal lenses should be thrown away. Nondisposable
resulted in increased rates of antibiotic resis- lenses should be cleaned thoroughly as recom-
tance among nasopharyngeal isolates of S mended by the manufacturer, and a new lens Antibiotic
pneumoniae. S aureus is developing resistance case should be used. resistance
to methicillin and to fluoroquinolones, such Patients who use prescription eye drops
as levofloxacin (Levaquin).32,33 But fluoro- for glaucoma should continue to use them, but is increasing,
quinolones are still effective against most the bottles should be replaced in case they even in
bacteria that cause conjunctivitis or kerati- have been contaminated by inadvertent con-
tis, and because they penetrate the cornea tact with the eye. outpatients
well, they should be used if clinical features Over-the-counter lubricating eye drops
suggest corneal involvement. Remember may be continued if desired, but a fresh bottle
also that most patients recover without or vial should be used.
treatment even if the organism has apprecia-
ble antibiotic resistance.28 ■ WHEN TO REFER

Corticosteroids should be avoided Red flags indicating that a patient may have a
Although corticosteroid drops (either alone or serious vision-threatening condition that
combined with antibiotic drops) may quickly requires urgent referral to an ophthalmologist
relieve symptoms, some conditions that pre- include severe eye pain or headache, photopho-
sent as a red eye with watery discharge, such as bia, decreased vision, or contact lens use.
herpetic keratitis, worsen with corticosteroid Patients with hyperacute cases should also be
use. We recommend that internists avoid pre- referred at once to rule out corneal involvement,
scribing corticosteroid drops. although the internist should start treatment for
gonorrhea. In addition, patients with apparent
Remove contact lenses, replace eye drops bacterial conjunctivitis that does not improve
Contact lenses should be taken out until an after 24 hours of antibiotic treatment should also
infection is completely resolved. Disposable be referred to an ophthalmologist. ■

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 BACTERIAL CONJUNCTIVITIS TARABISHY AND JENG

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18. Rietveld RP, ter Riet G, Bindels PJ, Sloos JH, van Weert HC. Predicting ADDRESS: Bennie H. Jeng, MD, Cole Eye Institute, i32, Cleveland Clinic,
bacterial cause in infectious conjunctivitis: cohort study on informa- 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected].

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