Bacterial Conjunctivitis

Ocular irritation, conjunctival redness, and a mucopurulent discharge that is worse in the morning characterize acute bacterial conjunctivitis. The absence of itching should indicate an infectious cause of conjunctivitis such as bacterial or viral. In bacterial conjunctivitis the eyelids usually become matted to each other; this is primarily noted in the morning when the patient awakens. There is a large accumulation of polymorphonuclear cells on the surface of the eye that causes the discharge to become discolored (yellowish-green) (Fig. 4). Scraping and culturing of the palpebral conjunctiva can assist in the diagnosis and treatment with the appropriate topical antibiotic regimens.

Some forms of bacterial infection, such as inclusion conjunctivitis, that have been associated with chlamydial infections are associated with a preauricular node. Common findings of inclusion conjunctivitis include a mucopurulent discharge and follicular conjunctivitis lasting for more than 2 wk. A Giemsa stain of a conjunctival scraping may reveal intracytoplasmic inclusion bodies and will assist in confirming the diagnosis. In addition, such prolonged ocular infections are commonly associated with a conjunctival response that reveals grayish follicles on the upper palpebra. The condition can be chronic, and treatment consists of lid margin scrubs, warm compresses, and antibiotics. In general, a topical, broad-spectrum antibiotic, such as sulfacetamide, erythromycin, or a combination of polymyxin B, bacitracin, and neosporin, is appropriate. Cultures are necessary only if the conjunctivitis is severe; it would be best if they were carefully examined by an ophthalmologist. The condition should be followed carefully to ensure that the eye improves.

Fig. 4. Bacterial conjunctivitis most likely due to Staphylococcus. Note the purulent discharge. Photograph courtesy of Barbara Jennings.

Topical gentamicin and tobramycin are indicated if Gram-negative organisms are suspected or seen on Gram stain. It should be noted that all of these antibiotics have the potential to elicit an allergic reaction. A careful history for drug allergies, a time limit for therapy, and re-evaluation will minimize complications. Topical ciprofloxacin or ofloxacin offers coverage for a wide spectrum of infecting agents, but should be used only when there is the likelihood for therapeutic failure or the conjunctivitis is thought to be the result of multiple infecting organisms or Pseudomonas species. Treatment of inclusion conjunctivitis should be aggressive because there is the potential for the cornea to perforate in a short time. Both topical and systemic antibiotics should be used. The patient should be observed for other sexually transmitted diseases.

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