Infective Conjunctivitis
NICE CKS Conjunctivitis – infective. Last revised: Oct 2022.
Background Information
Causes
- Viral conjunctivitis – 80% cases
- Most common due to adenovirus
- Other: Herpes simplex, Varicella zoster, Molluscum contagiosum, Epstein-Barr, coxsackie and enteroviruses
- Bacterial conjunctivitis
- Most common: Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae
- Contact lens users → higher risk of gram -ve organism involvement (most commonly Pseudomonas aureginosa)[Ref]
The higher risk of gram -ve organism conjunctivitis in contact lens users forms the basis for use of topical antibiotics with gram -ve coverage (e.g., topical ahminoglycosides/fluoroquinoles) in these cases.
Clinical Features
Viral Conjunctivitis
- Watery discharge (and less than bacterial conjunctivitis)
- Erythema of the conjunctiva
- Follicles on eyelid eversion
- Lid oedema
- Subconjunctival haemorrhage
Bacterial Conjunctivitis
- Purulent / mucopurulent discharge
- Crusting of the eyelids
- Eyelids stuck together on waking
Guidelines
Investigation and Diagnosis
Clinical diagnosis based on clinical features (see above).
Do not routinely take swabs (for viral PCR & bacterial culture)
Swabs
Indications
- In primary care: if the person does not require referral to ophthalmology but fails to respond to initial treatment
- In more severe or specific cases, swabbing is considered urgent and is typically performed in secondary care or upon urgent ophthalmological referral:
- Corneal Involvement
- Gonococcal infection (indicated by severe purulent discharge)
- Ophthalmia neonatorum: swabs are required urgently for conjunctivitis in neonates (red sticky eye within 30 days of birth)
Management
Viral Conjunctivitis
Avoid antibiotic prescription
Advise self-care measures
- Cold compress around the eye area
- Bathing / cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge
- Use of lubricating agents or artificial tears
Advice on the prevention of spread:
- Washing hands frequently with soap and water
- Use separate towels and flannels
- Avoid close contact with others
But there is NO NEED for exclusion from school / nursery / childminders unless an outbreak or cluster of cases occurs.
Bacterial Conjunctivitis
Advise the person that most cases of bacterial conjunctivitis are self-limiting and resolve within 5–7 days without treatment
If severe / require rapid solution / symptoms not resolved within 3 days: offer topical antibiotics
- Chloramphenicol, or
- Fusidic acid (preferred in pregnancy)
There is NO NEED for exclusion from school / nursery / childminders unless an outbreak or cluster of cases occurs.
Although topical chloramphenicol for eye use is NOT absolutely contraindicated in pregnancy, the BNF states that it should be ‘avoided unless essential‘.[Ref]
NB – oral chloramphenicol is contraindicated in pregnancy due to the risk (especially with use in the 3rd trimester) of ‘grey-baby’ syndrome.
Contact Lens Conjunctivitis
If there is no suspicion/confirmed corneal involvement (i.e, no corneal defect on topical fluorescein) and no red flags:
- Stop contact lens use immediately and avoid until all symptoms have resolved
- Bathing / cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge
- Consider topical antibiotic effective against gram -ve organisms
- Aminoglycoside (e.g. gentamycin)
- Fluoroquinolone (e.g. levofloxacin, moxifloxacin)