This is the current release of the guideline.

Acute bacterial conjunctivitis (non-hyperacute) in children and adults

Note: Conjunctivitis may be defined as any inflammation of the conjunctiva. The inflammation can be characterized by itching, tearing, discharge, irritation, or a foreign body sensation. Acute bacterial conjunctivitis is usually characterized by a mucopurulent discharge, conjunctival injection, hyperemia, and morning matting of the eyelashes.

Children and adults with diagnosed or symptoms suggestive of acute bacterial conjunctivitis

Diagnosis/Evaluation

1. Patient history
   • History of present illness
   • Past medical history
   • Medication history
   • Family medical history
   • Psychosocial history
   • Dietary history
2. Physical examination
3. Diagnostic tests (resistant or recurrent infections)
   • Cultures
   • Smears
   • Scrapings
   • Conjunctival biopsy

Management/Treatment/Prevention

Prevention of Acute Bacterial Conjunctivitis

1. Patient education on disease transmission
2. Informing patient of the need for frequent hand washing and good hygiene

Pharmacological Therapy to Treat Acute Bacterial Conjunctivitis

1. Topical antibiotic therapy
   • Norfloxacin 0.3%
   • Ciprofloxacin 0.3%
   • Ofloxacin 0.3%
   • Levofloxacin 0.5%
   • Lomefloxacin 0.3%
   • Moxifloxacin 0.5%
   • Gatifloxacin 0.3%
   • Chloramphenicol 0.5%
   • Sulfacetamide Sodium 10%
   • Erythromycin 0.5%
   • Gentamicin Sulfate 0.3%
   • Trimethoprim Sulfate-Polymyxin B 10,000 U/1 mg/mL
   • Fusidic acid 0.1%
   • Tobramycin 0.3%
   • Povidone-iodine 1.25%
   • Bacitracin ointment
2. Ocular steroids and steroid-antibiotic
   • Prednisolone (Pred Forte)
   • Fluorometholone 0.1%, sulfacetamide sodium 10% (FML-S)
   • Fluorometholone 0.1% (FML)
   • Neomycin, polymyxin B, dexamethasone 0.1% (Maxitrol)
   • Gentamicin 0.3%, prednisolone acetate 0.1% (Pred-G)
   • Tobramycin 0.3%, dexamethasone 0.1% (Tobradex)

General Management Principles

1. Patient education and counseling
2. Follow-up laboratory evaluation of cultures and smears
3. Referral to ophthalmologist as indicated for persistent or recurrent infections

To select evidence for critical appraisal by the group, the citations in the Clinical Guidelines in Family Practice for acute bacterial conjunctivitis were reviewed.

Additionally, the Medline, Embase, and the Cochrane databases were searched for dates January 1998 through January 2005. Medical Subject headings (MeSH) were employed using ScienceDirect, UpToDate, and OVID Medline interface searching bacterial conjunctivitis in the title, abstract, and indexing forms. Additional resources were found using bibliographies of relevant articles.

Not stated

Quality of Evidence

I: Evidence obtained from at least one properly randomized-controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

III: Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees

IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Not stated

Review of the literature with group consensus. Consideration was given to patient preferences and length of treatment. Guidelines were drafted by graduate students following review of the literature.

Strength of Recommendations

1. There is good evidence to support the recommendation that the treatment be specifically considered in the management of acute bacterial conjunctivitis.
2. There is fair evidence to support the recommendation that the treatment be specifically considered in the management of acute bacterial conjunctivitis.
3. There is insufficient evidence to recommend for or against the inclusion of the treatment in the management of acute bacterial conjunctivitis, but recommendations may be made on other grounds
4. There is fair evidence to support the recommendation that the treatment be excluded from consideration in the management of acute bacterial conjunctivitis.
5. There is good evidence to support the recommendation that the treatment be excluded from consideration in the management of acute bacterial conjunctivitis.

A formal cost analysis was not performed and published cost analyses were not reviewed.

A group of Family Nurse Practitioner students developed a draft which was submitted to the University of Texas at Austin School of Nursing faculty for review. The draft was later revised to incorporate faculty recommendations.

Quality of evidence (I, II-1, II-2, III, and IV) and recommendation grades (A-C) are defined at the end of the "Major Recommendations" field.

1. A comprehensive history of presenting symptoms should include onset of symptoms, duration, recent exposure to individuals with "pink eye," unilateral or bilateral presentation, development and type of discharge, matting of eyelashes particularly in the morning, and the presence or absence of ocular pain, blurred vision, or photophobia (Brook, 2002; British United Provident Association [BUPA], 2004; Burns et al., 2004; Editorial Board, 2004; Gross, 2002; Morrow & Abbott, 1998; Uphold & Graham, 2003).
2. The past medical history and family medical history should elicit any treated or untreated cases of acute bacterial conjunctivitis in the individual or family members. Additionally, current medications, the presence of systemic disease, contact lens use, tobacco exposure, social support, medication compliance, trauma, travel, occupation, hobbies, and drug allergies should be noted. (Brook, 2002; Burns et al., 2004; Editorial Board, 2004; Gross, 2002; Mather et al., 2002; Morrow & Abbott, 1998; Uphold & Graham, 2003).
3. Diagnostic tests are not generally indicated for uncomplicated cases. Cultures, smears, scrapings, and conjunctival biopsy are warranted with resistant or recurrent infections (Burns et al., 2004; Mather et al., 2002; Uphold & Graham, 2003).
4. Acute bacterial conjunctivitis may be prevented with meticulous hand washing and good hygiene. Patients should be advised to avoid sharing eye drops, towels, washcloths, makeup, and pillows (strength of recommendation A; quality of evidence III). (Brook, 2002; BUPA, 2004; Burns et al., 2004; Editorial Board, 2004; Gross, 2002; Mather et al., 2002; Morrow & Abbott, 1998; Strauss, 2003; Uphold & Graham, 2003).
5. Multiple randomized, controlled studies comparing different topical antibiotics versus each other (Norfloxacin 0.3%; Ciprofloxacin 0.3%; Ofloxacin 0.3%; Lomefloxacin 0.3%; Levofloxacin 0.5 %; Chloramphenicol 0.5 %; Sulfacetamide Sodium 10%; Erythromycin 5mg/g; Gentamicin Sulfate 0.3%; Trimethoprim Sulfate-Polymyxin B 10,000 U/1mg/1ml; Fusidic acid 0.1%; and Tobramycin 0.3%) found no significant difference in the rates of clinical or microbial cure (strength of recommendation A; quality of evidence I) . (Carr, 1998; Hwang et al., 2003; Isenberg et al., 2002; Jackson et al., 2002; Jauch, Fsadni, & Gamba, 1999; Kettenmeyer et al., 1998; Lichtenstein & Rinehart, 2004; Mather et al., 2002; Montero et al., 1998; Schwab et al., 2003).
6. Fourth generation fluoroquinolones (Moxifloxacin and Gatifloxacin) have demonstrated through an in vitro study to overcome resistance to staphylococcal organisms that have displayed resistance to second- and third-generation fluoroquinolones, namely ciprofloxacin, ofloxacin, and levofloxacin (strength of recommendation A; quality of evidence II-2). (Marlin, 2003).
7. One randomized controlled study reported that the administration of topical tobramycin was rated more convenient than fusidic acid which accounted for greater treatment adherence among patients (strength of recommendation A; quality of evidence I). (Jackson et al., 2002).
8. A controlled trial of povidone-iodine ophthalmic solution in pediatric patients was determined to be just as effective as neomycin-polymyxin B gramicidin for treating bacterial conjunctivitis. Because povidone-iodine ophthalmic solution can be prepared from a powder, it is inexpensive. Additionally, the solution is widely available in underdeveloped countries (strength of recommendation A; quality of evidence II-1). (Isenberg et al., 2002)
9. Although most cases of bacterial conjunctivitis are self-limiting, the addition of steroids with antibiotic treatment can lessen the patients' inflammation and duration of disease. The practitioner must distinguish between viral, hyperacute and bacterial conjunctivitis before prescribing topical steroids to prevent further damage (strength of recommendation B; quality of evidence III). (Isenberg et al., 2002; Sowka, Gurwood, & Kabat, 2000).
10. The patient and family should be educated regarding the highly contagious nature of acute bacterial conjunctivitis. Counseling should include the proper technique for cleansing the affected eye(s): wiping the eye(s) from the inner canthus outward using a single tissue/cotton ball. The tissue/cotton ball should then be discarded. The eyelashes should be cleansed several times a day with a weak solution of no-tears baby shampoo and warm water. The patient or parent should be instructed in the proper administration of ophthalmologic ointments and drops. The prescription ophthalmic solution or ointment should be instilled into the lower conjunctival sac. The patient or family should be counseled regarding the expected length of time the therapy should continue (strength of recommendation A; quality of evidence III). (Burns et al., 2004; Editorial Board, 2004; Gross, 2002; Morrow & Abbott, 1998; Uphold & Graham, 2003).
11. The patient with acute bacterial conjunctivitis should be referred to a specialist should there be no improvement within the first 24 hours after initiating therapy or should the patient develop moderate to severe ocular pain, develops severe purulent discharge, if there is diminished visual acuity or loss of vision, when conjunctivitis is associated with a sexually transmitted disease, or when infection proves to be resistant to conventional antibiotic therapy (strength of recommendation A; quality of evidence III). (Burns et al., 2004; Editorial Board, 2004; Gross, 2002; Jacobs, 2005; Mather et al., 2002; Morrow & Abbott, 1998; Uphold & Graham, 2003).
12. Antibiotics will do nothing to suppress any concurrent inflammation noted. If there is no significant corneal disruption and no contraindications exist, it is suggested that a steroid be prescribed such as Pred Forte, FML-S, or FML along with the antibiotic chosen, or a steroid-antibiotic combination such as Maxitrol (neomycin, polymyxin B, dexamethasone 0.1%), Pred-G (gentamicin 0.3%, prednisolone acetate 0.1%), or Tobradex (tobramycin 0.3%, dexamethasone 0.1%). (Sowka, Gurwood, & Kabat, 2000).

Refer to Appendix A of the original guideline document for a list of commonly used antimicrobial agents in the treatment of acute bacterial conjunctivitis along with their dosing regimens and spectrum of activity.

Definitions:

Quality of Evidence

I: Evidence obtained from at least one properly randomized-controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could be regarded as this type of evidence

III: Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees

IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Strength of Recommendations

1. There is good evidence to support the recommendation that the treatment be specifically considered in the management of acute bacterial conjunctivitis.
2. There is fair evidence to support the recommendation that the treatment be specifically considered in the management of acute bacterial conjunctivitis.
3. There is insufficient evidence to recommend for or against the inclusion of the treatment in the management of acute bacterial conjunctivitis, but recommendations may be made on other grounds
4. There is fair evidence to support the recommendation that the treatment be excluded from consideration in the management of acute bacterial conjunctivitis.
5. There is good evidence to support the recommendation that the treatment be excluded from consideration in the management of acute bacterial conjunctivitis.

None provided

The type of evidence is identified and graded for selected recommendations (see "Major Recommendations" field).

Known antibiotic sensitivities

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program

Practice Guidelines Committee

Authors: Jill Addison-Needles, RN; Micky Gonzales, RN; Kimberly Kosatka, RN; Michele Mckay, RN

Consultant: Stephanie Key, RN, PNP

Not stated

This is the current release of the guideline.

Electronic copies: None available

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499

None available

None available

This NGC summary was completed by ECRI on July 28, 2005. The information was verified by the guideline developer on August 12, 2005.

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.