Bacterial conjunctivitis

Last updated: December 13, 2022

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Bacterial conjunctivitis includes neisserial conjunctivitis (hyperacute bacterial conjunctivitis), acute bacterial conjunctivitis, and chlamydial conjunctivitis (including trachoma and inclusion conjunctivitis), and it can be an ocular emergency. Factors that can help differentiate between the subtypes include severity and onset of symptoms, patient history, and associated systemic features (e.g., genitourinary symptoms). All patients with neisserial conjunctivitis, inclusion conjunctivitis, and acute bacterial conjunctivitis with severe symptoms or risk factors for severe infection (e.g., contact lens use, immunodeficiency) should undergo diagnostic studies, including a conjunctival culture. For patients with mild acute bacterial conjunctivitis or trachoma, the diagnosis may be made clinically. Antibiotic therapy is recommended for all types of bacterial conjunctivitis. Patients with neisserial or chlamydial conjunctivitis, and any patients with red flags for conjunctivitis, should be referred to ophthalmology. Undertreated or long-term infections can compromise the layers of the eye (e.g., cornea) and lead to the formation of scars and ulcers, ultimately causing blindness.

  • Most common form of conjunctivitis in children [1]
  • Most common in winter [1]

Epidemiological data refers to the US, unless otherwise specified.

Indications [4]

Patients with mild bacterial conjunctivitis or trachoma can be diagnosed clinically.

Laboratory studies [4]

Acute bacterial conjunctivitis is a common presentation in primary care; common pathogens include Streptococcus pneumoniae and Haemophilus influenzae in children and Staphylococcus aureus in adults. Neisserial conjunctivitis and chlamydial conjunctivitis manifest differently and require specialized management; these infections are covered separately in their respective sections.

Etiology [6]

Contact lens wearers are at increased risk of serious infections with gram-negative bacteria such as Pseudomonas aeruginosa. [7]

Clinical features [4]

Diagnostics [4][6]

Treatment [4]

Topical antibiotic therapy

Most cases of bacterial conjunctivitis are self-limited; however, the use of topical antibiotics speeds up recovery and may reduce the risk of transmission. [4]


Neisserial conjunctivitis, or hyperacute bacterial conjunctivitis, is a severe type of infectious conjunctivitis most commonly caused by Neisseria gonorrhoeae and characterized by an abrupt onset of quickly worsening symptoms (i.e., profuse purulent discharge, pain, and vision changes). [1][4]

Etiology [4]

Consider sexual abuse in children presenting with gonorrheal conjunctivitis. [4]

Neonatal gonococcal conjunctivitis is rare in the US because of prophylaxis at birth with erythromycin ophthalmic ointment. [11]

Clinical features [4][6]

Diagnostics [4]

  • Initiate management without waiting for diagnostic confirmation.
  • All patients require confirmatory studies, e.g.: [4][12]

Rule out N. meningitidis in patients with suspected N. gonorrhoeae infection. [4]

Treatment [4][13]

N. gonorrhoeae infection is an ocular emergency that can lead to keratitis, perforation, and blindness without prompt treatment guided by a specialist (e.g., ophthalmology, infectious diseases). [1][13]

Systemic antibiotic therapy

Do not delay antibiotics for diagnostic studies if neisserial conjunctivitis is clinically suspected. [4]

Inclusion conjunctivitis is a form of bacterial conjunctivitis caused by infection with C. trachomatis serotypes D–K, which normally cause genitourinary chlamydia.

Etiology [4]

Consider sexual abuse in children presenting with inclusion conjunctivitis. [4]

Clinical features [1][4]

Diagnostics [4][6]

Patients with suspected or confirmed chlamydia conjunctivitis should also undergo diagnostic studies for gonorrhea. [1]

Treatment [1][4]

Antibiotics should not be delayed for diagnostics if inclusion conjunctivitis is clinically suspected. [4]

Trachoma is a form of bacterial conjunctivitis seen in resource-limited settings. Repeated infection with C. trachomatis serotypes A–C leads to conjunctival scarring and blindness.

Etiology [4][16][18]

Epidemiology [4][16]

  • The most common infectious cause of blindness worldwide [1][18][19]
  • Africa is the most affected continent. [16]
  • Predominantly affects young children and women [16]
  • Transmission is more common in households with: [16]
    • Inadequate access to water and sanitation
    • Crowding

C. trachomatis serotypes A, B, and C are most common in Africa and can cause Blindness and Chronic inflammation.

Clinical features [16][18]

Infection can be recurrent or chronic; ; active and cicatricial phases may occur simultaneously.

Chronic untreated infection can lead to blindness. [1]

Diagnostics [4]

Because of the difficulties in accurately diagnosing trachoma, mass drug administration is recommended in areas with a high prevalence (> 10% in children). [18]Laboratory studies are of limited use in trachoma because they can only confirm current infection with C. trachomatis. [20]

Treatment [1]

Prevention of trachoma [16]

  • Educate patients on preventive measures (see also “Prevention of infectious conjunctivitis”). [24]
    • Advise patients to wash their face regularly.
    • Promptly seek treatment for infections.
    • Avoid sharing towels.
  • Public health measures to prevent new infections include: [16][25]
    • Mass drug administration in high-prevalence areas
    • Improved access to safe water
    • Improved sanitation (e.g., building latrines, insecticide against flies)

Trachoma is a public health issue in many resource-limited countries. The WHO has introduced the SAFE strategy for trachoma treatment and elimination: Surgery, Antibiotics, Facial cleanliness, Environmental improvement. [16]

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  12. McAnena L, Knowles SJ, Curry A, Cassidy L. Prevalence of gonococcal conjunctivitis in adults and neonates. Eye. 2015; 29 (7): p.875-880. doi: 10.1038/eye.2015.57 . | Open in Read by QxMD
  13. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and Reports. 2021; 70 (4): p.1-187. doi: 10.15585/mmwr.rr7004a1 . | Open in Read by QxMD
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