Pediatric acute bacterial conjunctivitis is a microbial infection
involving the bulbar/palpebral conjunctiva of the eye. This infection is
usually self-limited, and is most frequently observed among infants, toddlers,
and preschool-aged children. Acute bacterial conjunctivitis affects
approximately 1 of every 8 children each year and 5 million cases occur in the
United States annually.1-3 Bacterial conjunctivitis accounts for up
to 1% of all consultations in primary care.4 The most common
causative pathogens are Haemophilus influenzae, Streptococcus
pneumoniae, and, occasionally, Streptococcus pyogenes. The
characteristic signs and symptoms of bacterial conjunctivitis and periorbital
cellulitis are similar regardless of the causative micro-organism, and although
rarely performed, bacterial culture is required to definitively identify the
specific pathogen. Polymerase chain reaction (PCR) testing for adenoviral
infection is also available.
Management of acute bacterial conjunctivitis in young children raises
a number of important questions, including:
- the epidemiology of bacterial conjunctivitis for patients of
different age groups;
- differences in management between newborns, toddlers, young
children, and adolescents;
- the use of standardized in-office treatment algorithms or
- the role of bacterial culture and testing for adenovirus;
- the relative efficacy and cost-effectiveness of different topical
- the incidence of co-infection with otitis
media and the
treatment options for children with co-infection;
- the role of bacterial vs. viral infections;
- changes in conjunctivitis epidemiology following the introduction
of the pneumococcal conjugate vaccine (PCV13).
In addition, a number of factors must be considered when evaluating
the results of clinical trials that have compared different treatment
approaches for bacterial conjunctivitis, including the median age of
participating patients, the number of young children enrolled, and differences
between natural history observational studies and those that have randomized
patients with bacterial conjunctivitis to different topical antibacterial
Diagnosis of Pediatric Acute Conjunctivitis
The presenting symptoms may suggest whether conjunctivitis is
bacterial, viral, or allergic (Table 1). Patients with bacterial conjunctivitis
tend to have bilateral involvement (present in 50% to 74% of cases) and
mucopurulent discharge.5 Conjunctival redness is common in older children and
less common in infants and toddlers. Studies have shown that approximately 50%
of children with bacterial conjunctivitis have redness with
discharge.5 Sometimes, however, the redness is experienced in the
absence of discharge. The combination of conjunctivitis and acute otitis media
(conjunctivitis-otitis syndrome) occurs in 32% to 39% of cases, mostly in
children aged 6 to 36 months.5 Viral disease is less often bilateral
(approximately 35% of cases),6 is associated with a milder, more
watery conjunctival discharge, and is usually associated with conjunctival
redness.7 Acute otitis media is uncommon in patients with viral
conjunctivitis, and the eyes are generally not pruritic. Allergic
conjunctivitis is typically bilateral and associated with conjunctival redness.
Edema palpebral or bulbar discharge is rare.7 Pruritus is common and
can be severe.
for larger version of Table 1.
Acute conjunctivitis is primarily diagnosed clinically, and treatment
is nearly always empiric. Bacterial cultures are rarely obtained because of the
relatively high cost and the 4 to 5 days before results become available.
Bacterial cultures may be obtained for refractory cases, neonates, and patients
with periorbital cellulitis. Viral cultures are rarely performed. When herpes
or adenovirus is suspected, PCR testing may be performed to confirm the
presence of these pathogens.8 Wood’s lamp examination in the
office setting may help to differentiate bacterial conjunctivitis from
suspected corneal abrasion or herpes virus. Very rare conditions that may
resemble acute conjunctivitis include ophthalmologic manifestations of Kawasaki
disease, measles, or herpes infection.
Although many clinicians believe that acute conjunctivitis accompanied
by purulent discharge is not caused by bacterial infection, several studies
have confirmed the presence of bacterial infection in the majority of these
cases. In a study published in 1981, Gigliotti and colleagues examined 99 cases
of pediatric acute conjunctivitis and found that bacterial infection accounted
for 65% of the cases, with viral infection accounting for 20%.6
Several subsequent studies reported rates of bacterial infection between 55%
and 80% among children with conjunctivitis accompanied by purulent
Patel and colleagues evaluated the usefulness of clinical signs and
symptoms to distinguish bacterial from viral conjunctivitis in 111 pediatric
patients.12 The mean age of the patients was 33 months, 78% had
positive bacterial cultures, and nontypeable H influenzae accounted for
82% of bacterial infections. A history of glued or sticky eyelids, in
combination with a physical finding of mucoid or purulent discharge, was
attributable to bacterial infection in 95% of cases.
These observations were confirmed in a more recent study of 368
patients with conjunctivitis who were between 6 months and 17 years of
age.13 Four factors were associated with bacterial infection: age
less than 6 years, onset of symptoms between December and March, “glued
eye” in the morning, and the absence of eye watering. For patients with
all 4 of these factors, 88% had a positive bacterial culture. The most common
causative organisms included H influenzae and S pneumoniae (Table
2). The relatively low rate of S pneumoniae in this study (approximately
20%) is likely due to the fact that the patients were enrolled in 2007 and
2008, when most of the population had received the highly effective
pneumococcal conjugate vaccine (PCV7).
for larger version of Table 2.
A third study, conducted in rural Kentucky between 1997 and 1998,
examined factors associated with bacterial eye infection in 250 children with
acute conjunctivitis.5 The mean age of the children was 24 months.
Bacterial cultures were positive for H influenzae in 42% of cases (69%
of which produced ß-lactamase), S pneumoniae in 30% of cases, and
were negative in 32% of cases. Erythema was present in 53% of cases, and
purulent discharge in 83%. Many children had erythema alone, therefore redness
of the eye does not definitively indicate viral conjunctivitis. In addition,
bacterial otopathogens were recovered from the eyes of 60% of patients between
the ages of 2 weeks and 2 months. Together, the results of these studies show
that the presence of purulent discharge is usually associated with bacterial
conjunctivitis even in patients as young as a few weeks of age.
Microbiology of Acute Bacterial Conjunctivitis
Nontypeable H influenzae accounts for approximately 50% to 80%
of cases of bacterial conjunctivitis after the newborn period.5,13
These cases are not preventable by H influenzae type B (Hib)
vaccination. ß-lactamase-producing bacteria are identified in
approximately 50% to 60% of cases attributed to H influenzae.
Pneumococcal infections account for approximately 20% to 30% of
cases.5 The proportion of conjunctivitis cases attributable to
pneumococcal infection varies with age and also with PCV7/13 status, which
likely reduces rates of penicillin-nonsusceptible pneumococcus (PNSP).
Moraxella catarrhalis is present in 0% to 10% of children, and 100% of these
infections are ß-lactamase producers (ie, relatively weak). Group A
streptococcal infections (eg, S pyogenes) are rare, and mostly occur in
school-aged children. Staphylococcus aureus, gonorrhea, and
meningococcus are rare causes of conjunctivitis in young children.
In neonatal patients, infection with vaginal flora (eg, Escherichia
coli, Klebsiella pneumoniae, Staphylococcus epidermidis) is a common cause
of bacterial conjunctivitis. As with older children, pediatric respiratory
bacterial pathogens (eg, H influenzae, S pneumoniae) are also
common causes of acute conjunctivitis in the newborn population.14
Although chlamydial conjunctivitis is thought to be common, in fact it is a
rare cause of conjunctivitis in most pediatric populations. Approximately 2% to
15% of mothers have chlamydia, with a 50% risk of vertical
transmission.15 Prophylactic ointments applied at birth protect
against gonorrhea but not chlamydia. In cases where chlamydia is strongly
suspected as the causative pathogen, treatment typically consists of oral
erythromycin or the better-tolerated but less well-studied
azithromycin.16 In addition to its propensity to cause notable
gastrointestinal distress, the use of erythromycin in the neonatal period is
associated with a risk of pyloric stenosis in infants, and many experts
recommend avoiding its use.17 Herpes simplex infection is a rare
cause of neonatal conjunctivitis, but should prompt an immediate referral to an
Treatment of Pediatric Acute Conjunctivitis
A Cochrane Collaboration review and meta-analysis examined the
efficacy of topical antibiotic therapy for the treatment of pediatric
conjunctivitis. Data from 5 clinical trials in which 1,034 patients were
randomized to either topical antibiotics or placebo were included in the
analysis.4 The meta-analysis demonstrated higher rates of clinical
remission (relative risk [RR], 1.24; 95% confidence interval [CI], 1.05-1.45)
and microbiological cure (RR, 1.77; 95% CI, 1.23-2.54) after 2 to 5 days for
children assigned to topical antibiotics. At 6 to 10 days, the effects of
topical antibiotic therapy were smaller but remained statistically significant
for clinical remission (RR, 1.11; 95% CI, 1.02-1.21) and microbiological cure
(RR, 1.56; 95% CI, 1.17-2.09). After 10 to 14 days, response rates were similar
for the antibiotic and placebo groups. The authors concluded that pediatric
conjunctivitis is self-limited in most cases, generally resolves spontaneously
after 10 to 14 days, and that the use of topical antibiotics significantly
increases the number of patients with early clinical and microbiological
Although acute bacterial conjunctivitis may resolve without therapy in
10 to 14 days, treatment may permit earlier return to daycare for the child and
to work for the child’s parents, reduce the likelihood of transmission to
other children, and prevent relapse. In many cases, children with
conjunctivitis are required to avoid school or daycare settings until symptoms
subside, and treatment may therefore help to minimize the socioeconomic impact
of ocular infection. In addition, untreated bacterial conjunctivitis may be
associated with complications such as keratitis and periorbital cellulitis. As
noted previously, acute otitis media is among the most common bacterial
co-infections of acute conjunctivitis, occurring in approximately 32% to 39% of
cases.5,10 Periorbital cellulitis is less common, is usually
associated with ethmoid sinusitis or trauma, and may be associated with
dacryostenosis in older children.19 Methicillin-resistant S
aureus (MRSA) is rarely found in acute bacterial conjunctivitis cultures of
children younger than 4 years of age, and is most often encountered in
association with traumatic eye infection or skin infection. Potential viral
complications include keratitis and pre-auricular lymphadenitis. Adenovirus
conjunctival infection usually presents with pharyngitis, fever, and a negative
A number of antibacterial agents are available for the treatment of
acute bacterial conjunctivitis, most of which are only approved for patients
aged 12 months and older (Table 3). Topical sulfonamides should not be
used to treat pediatric patients. Although inexpensive, these agents often
cause burning of the eye, provide minimal coverage against ocular pathogens
such as H influenzae or pneumococci, and may cause hypersensitivity
reactions. Topical aminoglycosides (eg, tobramycin, gentamicin, or neomycin)
are also relatively inexpensive, but are often not effective against S
pneumoniae and group A streptococcus. These topical agents may also cause
chemical conjunctivitis. Topical macrolides (eg, azithromycin, erythromycin)
are generally well-tolerated, are available as ointments, but they are
bacteriostatic and provide relatively weak antibacterial effects against H
influenzae, pneumococcus, and staphylococcus. Azithromycin is relatively
expensive but has a long half-life, allowing once-daily dosing.21
Polymyxin B/trimethoprim provides reasonable coverage against ocular pathogens,
especially for patients vaccinated with PCV7/13. However, polymyxin
B/trimethoprim is a bacteriostatic agent and is therefore associated with slow
clinical resolution.22 Older fluoroquinolones (eg, ciprofloxacin,
ofloxacin) are available as low-cost generics and provide good coverage against
H influenzae but only fair coverage against S
pneumoniae.23 Newer fluoroquinolones (eg, moxifloxacin,
gatifloxacin, besifloxacin, levofloxacin) are more expensive, but provide
excellent coverage against most ocular pathogens.
for larger version of Table 3.
Several studies have compared treatment outcomes for pediatric
patients receiving different topical antibiotics for acute conjunctivitis.
Bremond and colleagues compared the efficacies of azithromycin and tobramycin
in 150 patients with acute conjunctivitis.24 The average age of the
patients was 7 years, which is a much older population with acute bacterial
conjunctivitis than customarily seen in routine pediatric practice. The
principal pathogens identified included H influenzae (n = 22),
staphylococcus species (n = 34), and S pneumoniae (n = 6). The clinical
cure rates were 48% vs. 27% for the azithromycin and tobramycin groups,
respectively, at 3 days (P < .001), but were similar after 9 days
(80% vs. 82% for the azithromycin and tobramycin groups, respectively; not
statistically significant). Limitations of this study included the relatively
small sample size, the limited enrollment of younger children, and the fact
that few pathogens were recovered due to the small sample size. In addition,
staphylococcal species are often commensals in eyes, and few patients had
typical conjunctival pathogens.
A second study compared the effectiveness of bactericidal therapy with
topical moxifloxacin 3 times daily vs. bacteriostatic therapy with polymyxin
B/trimethoprim 4 times daily in 56 pediatric patients with conjunctivitis, most
of whom were between 6 and 18 years of age.22 At 48 hours, cure
rates were 81% with moxifloxacin and 44% with polymyxin B/trimethoprim
(P = .001), suggesting a more rapid early response with bactericidal
treatment compared with bacteriostatic treatment. Limitations of this study
included the enrollment of primarily older children, a very small sample size,
and minimal differences in outcome at final end-of-treatment visit.
A third study compared besifloxacin with moxifloxacin in 1,161
patients aged 1 year and older (mean age, 31.6 ± 26.2
years).25 Besifloxacin was noninferior to moxifloxacin for clinical
resolution on day 5 (58.3% vs. 59.4%, respectively) and day 8 (84.5% vs. 84.0%,
respectively) and for microbial eradication on day 5 (93.3% vs. 91.1%,
respectively) and day 8 (87.3% vs. 84.7%).
Oral antibiotics may be helpful for patients with
conjunctivitis-otitis syndrome. H influenzae is the causative pathogen
in as many as 80% of these cases, and approximately 60% to 65% are
ß-lactamase producers.26 In most cases, conjunctivitis and
otitis media are caused by the same pathogen.26 Oral antibiotics
with ß-lactamase stability are preferred such as cefdinir,
amoxicillin/clavulanate, cefpodoxime, and cefixime. In contrast, drugs with
poor ß-lactamase coverage should be avoided in these patients, including
amoxicillin, azithromycin, cefprozil, and cefaclor. Trimethoprim/sulfa may also
be reasonable, but it lacks adequate pneumococcal coverage.
Summary and Conclusions
In pediatric patients younger than 4 years of age, purulent discharge,
rather than redness, is the most common sign of bacterial conjunctivitis, and H
influenzae is the most common causative organism. The incidence of S
pneumoniae infection increases with age, and routine PCV13 vaccination may
prevent most cases of PNSP. As many as one-third of younger children with acute
bacterial conjunctivitis have concomitant acute otitis media. A thorough ear,
throat, and lung exam is important in children with acute bacterial
conjunctivitis. Topical therapy is warranted in most cases, and topical
fluoroquinolones are more potent than other classes of topical agents. Cost and
formulary restrictions may encourage clinicians to use polymyxin B/trimethoprim
or neomycin combinations as first-line agents. Sulfa drugs, aminoglycosides,
and erythromycin should not be used for the treatment of pediatric
conjunctivitis. Azithromycin may be considered for patients with
hypersensitivity reactions to other agents.
Would you advocate the use of antibiotics in children younger than 12
months of age, even if most of them have not been approved for this age group?
Stan L. Block, MD, FAAP: I would argue that any of the
antibiotics I discussed could be used in younger children despite the fact that
most are not specifically approved for children who are younger than 1 year of
age. With regard to safety issues with the fluoroquinolones, I think most
clinicians are becoming more comfortable with the use of topical
fluoroquinolones in children under the age of 12 months. Oral ciprofloxacin is
approved for children older than 12 months of age for recurrent or refractory
urinary tract infections, and its safety has not been an issue.
Please comment on the frequency of MRSA as a causative pathogen for
Block: MRSA is rare among the children who are typically seen
in primary care — those with purulent discharge, rather than those with
contacts, eye surgery, or similar conditions.
Sean P. Donahue, MD, PhD: I would say that MRSA is rare among
patients in the community setting who are presenting to the primary care
pediatrician’s office. MRSA is observed somewhat more often with orbital
signs or in patients with markedly red eye and minimal discharge. We did not
really see MRSA around the eye 5 to 10 years ago. In the pediatrician’s
office or primary care, purulent discharge from an eye is probably not caused
by MRSA. However, MRSA may be something to consider if conjunctivitis does not
Do your patients with preseptal or orbital cellulitis have MRSA very
Donahue: That is what we are seeing, including severe orbital
cellulitis in patients who have few of the typical risk factors for orbital
cellulitis. They may have a family member who had MRSA a few months ago.
Regarding preseptal cellulitis, we are observing MRSA not as often as
we do with orbital cellulitis, but it is becoming a concern. These are children
with typical bacterial conjunctivitis with purulent discharge in a relatively
Block: My contention would be that most nontraumatic preseptal
periorbital cellulitis is pneumococcal despite PCV7/13 vaccination.
Donahue: We reported data on this approximately 8 to 10 years
ago. We found that H influenzae type B was virtually eliminated by
routine Hib vaccination in orbital cellulitis, although we still saw some in
preseptal cellulitis. The nontypeable Haemophilus seems to be prominent in both
preseptal and orbital patients, although we do not culture many patients
because the majority responds to oral antibiotics, intravenous antibiotics, or
intramuscular injections of antibiotics without the need to obtain a culture.
These children usually do not have extensive sepsis.
How do the pathogens we see in children with conjunctivitis change
Block: I think more staphylococcal infections are observed in
children older than 5 to 7 years of age. In my practice, 90% to 95% of the
patients I see with purulent discharge are younger than 3 years of age. Red
eyes are more common in children older than 3 years, who are more likely to
have staphylococcal infection or, less often, streptococcal infections,
pneumococcus, or H influenzae. Pathogens become more diverse as children
enter school, and gram-positive pathogens are more likely.
Which is more important, the end-of-treatment assessment or the 24-
to 48-hour assessment?
Block: I think the critical time is the 2- to 4-day period, and
many studies show differences when evaluated at those time points.
Conjunctivitis will usually resolve eventually, but 7 days of purulent
discharge and the risk of infecting other children are usually not acceptable
for most parents, teachers, and daycare workers. Having that more rapid
response is important.
Michael E. Pichichero, MD: When patients present with pink eye,
I do not watch and wait. I administer a topical antibiotic.
Considering your observations from your own patients, the literature,
and the types of pathogens that may be involved, what is your approach to
first-line therapy of pediatric conjunctivitis?
Block: My first-line option is usually the polymyxin
B/trimethoprim combination. In some cases, I may administer neomycin
combinations. I never use amoxicillin for patients with concomitant acute
otitis media, but will select either cefdinir or amoxicillin-clavulanate. I
would expect a 70% to 80% cure rate with those options. For second-line
therapy, I usually prescribe the fluoroquinolones. Which fluoroquinolone I
choose depends on the patient’s insurance status. For patients on
Medicaid, we are required to use ofloxacin or ciprofloxacin for cost reasons.
Options for patients not on Medicaid include broad-spectrum antibiotics such as
levofloxacin, besifloxacin, or moxifloxacin. I do not implement tobramycin or
gentamicin because we have published data showing that the MIC90
values for H influenzae and S pneumoniae were µg/mL and 16
µg/mL, respectively.5 I avoid azithromycin except for true
allergies to multiple agents.
Donahue: I usually start with gentamicin, which provides
approximately 99% coverage for H influenzae and about 90% coverage for
staphylococcus species, although streptococcus species are not
well-covered.27 The limited coverage of pneumococcal species may not
be a significant issue, however, due to the availability of pneumococcal
immunization. When choosing a second-line agent, I usually look at the
treatment history to see what the patient has already received. Usually by the
time they are referred to me they have been to a pediatrician and had 1 or 2
antibiotics and they have had conjunctivitis for 10 to 12 days. I typically
reserve fluoroquinolones for more severe cases (ie, for those who have already
had several antibiotics, or for cases where vision is threatened). I would
usually choose a newer fluoroquinolone to avoid the possibility of resistance.
Many of the patients I treat have some toxic conjunctivitis from medication or
from allergic responses. For a patient with some purulent discharge, red eye,
and light sensitivity, I may consider stopping the medications or replacing it
with artificial tears.
Block: In a study that my colleagues and I published in which
we examined the susceptibility of commonly encountered micro-organisms to
different antibiotics, we found that the MIC90 for H influenzae was 8
µg/mL with gentamicin/tobramycin vs. 1 µg/mL with polymyxin
B/trimethoprim.5 Although there may be differences in the antibiotic
concentration delivered with different eye drop formulations, we felt that this
greater susceptibility of H influenzae made polymyxin B/trimethoprim a
reasonable option for first-line treatment.
When do you obtain cultures?
Block: I will obtain a culture for a small percentage of
patients who fail first-line or second-line therapy and have an eye that
appears severely affected. I obtain cultures for children younger than 2 weeks
of age, or for children with any kind of periorbital cellulitis.
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