• Prescribe chloramphenicol first-line for empirical treatment of infective conjunctivitis when a topical ocular antibiotic is considered necessary.
• Fusidic acid is an alternative empirical treatment. It is preferred for people who:
• Are pregnant.
• Have a personal or family history of blood dyscrasias, such as aplastic anaemia.
• Are intolerant of chloramphenicol.
• Prefer a twice-a-day treatment for infective conjunctivitis.

Basis for recommending chloramphenicol first-line and fusidic acid as an alternative:

• Chloramphenicol has a relatively broad spectrum of action against most Gram-positive and Gram-negative bacteria, is generally well tolerated, and is widely recommended by UK experts as the drug of choice [HPA, 2006; BNF 54, 2007].
• There is no evidence of significant systemic absorption or serious adverse effects from topical chloramphenicol, but because of these theoretical risks chloramphenicol is not recommended for people with a personal or family history of blood dyscrasias, or women who are pregnant [Walker et al, 1998; ABPI Medicines Compendium, 2008; ABPI Medicines Compendium, 2007b; ABPI Medicines Compendium, 2007a].
• In selecting a suitable alternative empirical option to chloramphenicol, topical fusidic acid has been in several comparative trials to be equally as effective as topical chloramphenicol in treating people with infective conjunctivitis [Hvidberg, 1987; Horven, 1993; Carr, 1998], and it is less expensive than other topical antibiotic preparations available. However, adverse effects may be more common with fusidic acid [Epling and Smucny, 2006].
• Note: most randomized controlled trials comparing antibiotics with each other found no significant difference in their clinical or microbiological cure rates between, for more information, see Supporting evidence.