Bacterial conjunctivitis

Last updated: November 20, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, and then completing a brief evaluation, in which they will identify their question and report the impact of any information learned on their clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.

Summarytoggle arrow icon

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.

Epidemiologytoggle arrow icon

  • Most common form of conjunctivitis in children [2]
  • Most common in winter [2]

Epidemiological data refers to the US, unless otherwise specified.

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Indications [5]

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

Laboratory studies [5]

Acute bacterial conjunctivitistoggle arrow icon

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 [7]

Contact lens wearers are at increased risk of serious infections with gram-negative bacteria such as Pseudomonas aeruginosa. [8]

Clinical features [5]

Diagnostics [5][7]

Treatment [5]

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. [5]


Neisserial conjunctivitistoggle arrow icon

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). [2][5]

Etiology [5]

Consider sexual abuse in children presenting with gonorrheal conjunctivitis. [5]

Neonatal gonococcal conjunctivitis is rare in the US because of prophylaxis at birth with erythromycin ophthalmic ointment. [12]

Clinical features [5][7]

Diagnostics [5]

  • Initiate management without waiting for diagnostic confirmation.
  • All patients require confirmatory studies, e.g.: [5][13]

Rule out N. meningitidis in patients with suspected N. gonorrhoeae infection. [5]

Treatment [5][14]

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). [2][14]

Systemic antibiotic therapy

Do not delay antibiotics for diagnostic studies if neisserial conjunctivitis is clinically suspected. [5]

Chlamydial conjunctivitistoggle arrow icon

Inclusion conjunctivitis (paratrachoma)toggle arrow icon

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

Etiology [5]

Consider sexual abuse in children presenting with inclusion conjunctivitis. [5]

Clinical features [2][5]

Diagnostics [5][7]

Patients with suspected or confirmed chlamydia conjunctivitis should also undergo diagnostic studies for gonorrhea. [2]

Treatment [2][5]

Antibiotics should not be delayed for diagnostics if inclusion conjunctivitis is clinically suspected. [5]

Trachomatoggle arrow icon

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 [5][17][19]

Epidemiology [5][17]

  • The most common infectious cause of blindness worldwide [2][19][20]
  • Africa is the most affected continent. [17]
  • Predominantly affects young children and women [17]
  • Transmission is more common in households with: [17]
    • 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 [17][19]

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

Chronic untreated infection can lead to blindness. [2]

Diagnostics [5]

Because of the difficulties in accurately diagnosing trachoma, mass drug administration is recommended in areas with a high prevalence (> 10% in children). [19]Laboratory studies are of limited use in trachoma because they can only confirm current infection with C. trachomatis. [21]

Treatment [2]

Prevention of trachoma [17]

  • Educate patients on preventive measures (see also “Prevention of infectious conjunctivitis”). [25]
    • Advise patients to wash their face regularly.
    • Promptly seek treatment for infections.
    • Avoid sharing towels.
  • Public health measures to prevent new infections include: [17][26]
    • 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. [17]

Referencestoggle arrow icon

  1. Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis Preferred Practice Pattern®. Ophthalmology. 2019; 126 (1): p.P94-P169.doi: 10.1016/j.ophtha.2018.10.020 . | Open in Read by QxMD
  2. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021
  3. Azari AA, Barney NP. Conjunctivitis. JAMA. 2013; 310 (16): p.1721.doi: 10.1001/jama.2013.280318 . | Open in Read by QxMD
  4. $Contributor Disclosures - Bacterial conjunctivitis. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  5. Yeu E, Hauswirth S. A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management. Clin Ophthalmol. 2020; Volume 14: p.805-813.doi: 10.2147/opth.s236571 . | Open in Read by QxMD
  6. Rietveld RP, Riet G ter, Bindels PJE, Sloos JH, van Weert HCPM. Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms. BMJ. 2004; 329 (7459): p.206-210.doi: 10.1136/ . | Open in Read by QxMD
  7. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010; 81 (2): p.137-44.
  8. Hutnik C, Cheema. Bacterial conjunctivitis. Clin Ophthalmol. 2010: p.1451.doi: 10.2147/opth.s10162 . | Open in Read by QxMD
  9. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  10. Sheikh A et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012.doi: 10.1002/14651858.cd001211.pub3 . | Open in Read by QxMD
  11. Epling J. Bacterial conjunctivitis. BMJ Clin Evid. 2012; 2012.
  12. Kreisel K, Weston E, Braxton J, Llata E, Torrone E. Keeping an Eye on Chlamydia and Gonorrhea Conjunctivitis in Infants in the United States, 2010–2015. Sex Transm Dis. 2017; 44 (6): p.356-358.doi: 10.1097/olq.0000000000000613 . | Open in Read by QxMD
  13. 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
  14. 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
  15. Mannis MJ, Holland EJ. Cornea, E-Book. Elsevier Health Sciences ; 2021
  16. Parikh SR, Campbell H, Mandal S, Ramsay ME, Ladhani SN. Primary meningococcal conjunctivitis: Summary of evidence for the clinical and public health management of cases and close contacts. J Infect. 2019; 79 (6): p.490-494.doi: 10.1016/j.jinf.2019.10.015 . | Open in Read by QxMD
  17. Trachoma. Updated: April 1, 2017. Accessed: May 17, 2017.
  18. Bhosai SJ, Bailey RL, Gaynor BD, Lietman TM. Trachoma. Curr Opin Ophthalmol. 2012; 23 (4): p.288-295.doi: 10.1097/icu.0b013e32835438fc . | Open in Read by QxMD
  19. Bourne RRA, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990–2010: a systematic analysis. The Lancet Global Health. 2013; 1 (6): p.e339-e349.doi: 10.1016/s2214-109x(13)70113-x . | Open in Read by QxMD
  20. Solomon AW, Peeling RW, Foster A, Mabey DCW. Diagnosis and Assessment of Trachoma. Clin Microbiol Rev. 2004; 17 (4): p.982-1011.doi: 10.1128/cmr.17.4.982-1011.2004 . | Open in Read by QxMD
  21. Evans JR, Solomon AW, Kumar R, et al. Antibiotics for trachoma. Cochrane Database of Syst Rev. 2019.doi: 10.1002/14651858.cd001860.pub4 . | Open in Read by QxMD
  22. Médecins Sans Frontières. Médecins Sans Frontières Clinical guidelines: Diagnosis and treatment manual. Médecins Sans Frontières ; 2022
  23. Al-Fawaz A, Wagoner MD. Penetrating Keratoplasty for Trachomatous Corneal Scarring. Cornea. 2008; 27 (2): p.129-132.doi: 10.1097/ico.0b013e318158b49e . | Open in Read by QxMD
  24. Ejere HO, Alhassan MB, Rabiu M. Face washing promotion for preventing active trachoma. Cochrane Database of Syst Rev. 2015.doi: 10.1002/14651858.cd003659.pub4 . | Open in Read by QxMD
  25. Rabiu M, Alhassan MB, Ejere HO, Evans JR. Environmental sanitary interventions for preventing active trachoma. Cochrane Database of Syst Rev. 2012.doi: 10.1002/14651858.cd004003.pub4 . | Open in Read by QxMD
  26. Engelkirk PG, Duben-Engelkirk JL, Burton GRW. Burton's Microbiology for the Health Sciences. Lippincott Williams & Wilkins ; 2011

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer