Bacterial conjunctivitis

Prescribing Notes:

• Most cases of acute bacterial conjunctivitis are self-limiting and resolve within 5-7 days without treatment. Treat with topical antibiotics if severe. A delayed treatment strategy may be appropriate - advise the person to initiate topical antibiotics if symptoms have not resolved within 3 days.
• Self care is the recommended first line treatment for conjunctivitis. Bathe clean eyelids with cotton wool dipped in sterile saline or boiled and cooled water to remove crusting.
• Fusidic acid does not give Gram-negative cover.
• Chloramphenicol ointment and drops are available to buy in pharmacies to treat bacterial conjunctivitis. The pharmacist will assess the patient to ascertain suitability before deciding whether to supply the medicine.
• Refer to NICE CKS guidance on infective conjunctivitis for advice on when to refer to ophthalmology and for conjunctivitis in contact lens wearers.
• Antibacterials are not helpful in managing viral conjunctivitis. Viral (non-herpetic) conjunctivitis usually resolves within 1-2 weeks without treatment.
• Simple lubricants are often helpful for comfort.
• Bacterial keratitis and cellulitis require treatment by or under instruction of a consultant ophthalmologist.

Prescribing Notes:

Neonates

• Refer to local board guidance on the management and investigation of neonatal conjunctivitis (within 28 days of birth).
• Most cases are mild, however, untreated infection (for example with gonococcus, chlamydia, pseudomonas, or herpes) can lead to serious complications including sight loss and death.
• Consider empirical treatment with chloramphenicol ointment in neonates in line with local board guidance. Change to systemic treatment based on swab results.
• Refer to hospital antimicrobial guidance for the treatment of gonococcal eye infection.
• If swab results are positive for chlamydia/gonorrhoea refer parents to sexual health.
• Erythromycin is the treatment of choice in confirmed neonatal chlamydia conjunctivitis, there is limited data available on the use of other macrolides. Erythromycin has been associated with development of pyloric stenosis if used in infants under 6 weeks of age but is still the recommended treatment of choice. Parents should be advised of this risk and infants monitored closely following treatment.

Erythromycin for the treatment of confirmed neonatal Chlamydia conjunctivitis

• There is an increased risk of infantile hypertrophic pyloric stenosis following exposure to erythromycin in infancy.
• Local specialists consider the benefit of erythromycin treatment for confirmed neonatal Chlamydia conjunctivitis (effective treatment and prevention of subsequent Chlamydial pneumonitis) outweigh the potential risk of developing infantile hypertrophic pyloric stenosis.
• Advise parents to seek advice from their doctor if vomiting or irritability with feeding occurs in infants during treatment with erythromycin.
• For more information refer to MHRA Drug safety update: Erythromycin risk of infantile hypertrophic pyloric stenosis.

Children

• Most cases of bacterial conjunctivitis are self-limiting and resolve within 5-7 days without treatment.
• Self-care is the recommended first line treatment for conjunctivitis. Bathe clean eyelids with cotton wool dipped in sterile saline or boiled and cooled water to remove crusting. Topical antimicrobial eye preparations should be reserved for severe infection. A delayed treatment strategy may be appropriate - advise the person to initiate topical antibiotics if symptoms have not resolved within 3 days.
• Watery, intermittently sticky eye in infants are often due to blocked tear ducts and do NOT require topical antibiotic treatment, unless the eye is red or hygiene measures are ineffective after 2 weeks.
• Cosmetics should be avoided.
• Massaging the tear duct, eye lids and application of a warm compress may be effective.
• Consider oral antibiotics if there are signs of meibomian gland dysfunction, or acne rosacea.
• Refer to NICE CKS: Infective conjunctivitis for advice on when to refer to ophthalmology and for conjunctivitis in contact lens wearers.
• Antibacterials are not helpful in managing viral conjunctivitis. Viral (non-herpetic) conjunctivitis usually resolves within 1-2 weeks without treatment.
• Bacterial keratitis and cellulitis require treatment by or under instruction of a consultant ophthalmologist.
• Chloramphenicol 0.5% eye drops may be prescribed as prophylaxis following surgery for squint correction. The dose is 1 drop twice daily into affected eye (s) for one week following surgery. Chloramphenicol eye ointment 1% may be considered as an alternative, although drops are preferred.

Prescribing Notes:

• Most cases of acute bacterial conjunctivitis are self-limiting. Clean away infected secretions from eyes with cotton wool soaked in cooled boiled water.
• Remove contact lenses until all symptoms have resolved and any treatment completed for 24 hours.
• Wash hands regularly and avoid sharing towels.
• If both eyes are infected, supply a separate bottle of eye drops for each eye.
• Patients with a suspected serious cause of ‘red eye’, e.g. moderate to severe eye pain, reduced and/or blurred vision, should be referred to a GP immediately.
• Patients presenting with styes should be advised to apply a hot compress to the eye lid.
• There is no benefit in using propamidine, dibrompropamidine (e.g. Brolene, Golden Eye) products in the treatment of simple bacterial conjunctivitis.
• Further information on chloramphenicol eye drops can be found on the RPS website.

Examples of Counselling Points
Keep the product in the fridge (chloramphenicol eye drops).
Once opened the eye drops / ointment should be discarded after 28 days.

When to advise patient to contact GP
Patient under 2 years of age.
Suspected foreign body in the eye or eye injury.
Pupil looks unusual i.e. irregular, dilated or non-reactive to light.
Photophobia.
Severe pain within the eye or changes in vision.
Pain or swelling around the eye or face, with or without, an associated rash.
Eye surgery or laser treatment in the past 6 months.
Pregnant or breastfeeding.
No improvement is seen after 48 hours or symptoms becoming worse.