Acute infective conjunctivitis:

• Advise on self-care measures to relieve symptoms.
• Consider prescribing a topical ocular antibiotic.
• Advise when to reconsult if symptoms deteriorate or persist.

Persistent infective conjunctivitis:

• Advise on self-care measures to relieve symptoms.
• Arrange investigations to determine the cause.
• Manage cause, guided by microbiological investigations.

Neonatal conjunctivitis:

• Refer for specialist assessment all infants who have conjunctivitis in the first 28 days of life.

Acute infective conjunctivitis is a self-limiting condition that may last up to 3 weeks but usually resolves within 2 weeks. When acute infective conjunctivitis persists longer than 2 weeks see Managing persistent conjunctivitis.

Advise people with infective conjunctivitis:

• That infective conjunctivitis is a self-limiting illness that, for most people, settles without treatment within 1–2 weeks. If symptoms persist for longer than 2 weeks they should reconsult for investigation of the cause.
• To urgently seek medical attention if they develop marked eye pain or photophobia, loss of visual acuity, or marked redness of the eye.
• To remove contact lenses, if worn, until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours.
• That lubricant eye drops may reduce eye discomfort; these are available over the counter, as well as on prescription.
• To clean away infected secretions from eyelids and lashes with cotton wool soaked in water.
• To wash their hands regularly, particularly after touching infected secretions, and to avoid sharing pillows and towels to avoid spreading infection.

• These are common sense recommendations widely supported by expert opinion [NGC, 2005].

• Advise people with clinical features of infective conjunctivitis that:
• Most people with infective conjunctivitis get better, without treatment, within 1–2 weeks.
• For most people, use of a topical ocular antibiotic make little difference to recovery from infective conjunctivitis.
• Up to 10% of people treated with topical ocular antibiotics complain of adverse reactions to treatment.
• The risk of a serious complication from untreated infective conjunctivitis is low.
• Consider offering a topical ocular antibiotic to a person with infective conjunctivitis when:
• Infective conjunctivitis is severe, or likely to become severe, providing serious causes of a red eye can be confidently excluded.
• Schools and childcare organizations require treatment before allowing a child to return.
• They understand the limitations of treatment but still prefer treatment.
• When a topical ocular antibiotic is prescribed because of the person's preference for treatment, consider advising them to delay starting treatment for 7 days to see if the condition will resolve spontaneously without treatment.

• There are no agreed definitions of mild, moderate, or severe conjunctivitis. It would seem reasonable to consider infective conjunctivitis to be severe when the person considers the symptoms to be distressing or signs are judged to be severe from clinical experience.

These recommendations are based upon evidence from randomized controlled trials. Trials carried out in secondary care show that people with microbiologically-proven bacterial conjunctivitis benefit modestly from treatment with topical ocular antibiotics. However, the likelihood of people with clinically diagnosed infective (bacterial or viral) conjunctivitis responding to treatment is small. Based upon this evidence it seems reasonable:

• To avoid prescribing a topical ocular antibiotic for people with mild-to-moderate infective conjunctivitis where the potential benefits of treatment are limited and the risks of harms from untreated infective conjunctivitis are small:
• Advice to delay the use of antibiotics, given to people who are prescribed treatment principally because they prefer treatment, is a strategy proven to reduce antibiotic usage in primary care [Everitt et al, 2006].
• To prescribe a topical ocular antibiotic for people with more severe infective conjunctivitis because:
• They have a greater potential for benefit from treatment than people with mild-to-moderate conjunctivitis.
• They are probably at greater risk of a complication from infective conjunctivitis and it seems reasonable to try and reduce this risk.

• 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.

• Advise parents that it is not necessary to exclude a child from school or childcare if they have infective conjunctivitis, unless there is an outbreak of infective conjunctivitis. Then, advice should be sought from the Health Protection Agency by the school or childcare centre. This advice is included in Health Protection Agency (pdf) guidance on infection control in schools and other childcare settings.

These recommendations are based upon advice issued by the Health Protection Agency (HPA) [HPA, 2006b].

• Attendance at school results in children catching and spreading numerous mild, self-limiting, infectious illnesses. The HPA does not recommend excluding children with infective conjunctivitis from school because:
• It is widely accepted that it is not desirable to exclude children from schools or childcare centres with other mild infectious illnesses (such as the common cold). There is no more reason to exclude children with infectious conjunctivitis than to exclude a child with a common cold.
• The requirement to exclude a child until they have received a topical ocular antibiotic is equally flawed as there is no evidence to suggest that this reduces their risk of spreading infection, especially when infective conjunctivitis often has a viral cause.

Advise people with infective conjunctivitis:

• To urgently seek medical attention if they develop marked eye pain or photophobia, loss of visual acuity or marked redness of the eye.
• To remove contact lenses, if worn, until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours.
• That lubricant eye drops may reduce eye discomfort; these are available over the counter, as well as on prescription.
• To clean away infected secretions from eyelids and lashes with cotton wool soaked in water.
• To wash their hands regularly, particularly after touching infected secretions, and to avoid sharing pillows and towels to avoid spreading infection.

• These are common sense recommendations widely supported by expert opinion [NGC, 2005].

If suspected infective conjunctivitis persists for longer than 2 weeks:

• Reassess the diagnosis — see Diagnosing infective conjunctivitis.
• Assess features suggestive of blepharitis and see the CKS topic on Blepharitis if they are present. Features include:
• Swollen eyelids: the defining sign of staphylococcal blepharitis, but unusual when it is less severe.
• Inflamed lid margins: usually present.
• Altered eyelash appearance: including misdirection, crusting, and eyelash loss.
• Altered eyelid surfaces: may be scaly, oily, or greasy. Ulceration of the anterior lid indicates infection.
• Take swabs for bacteria and chlamydia.
• Consider prescribing a topical ocular antibiotic while awaiting results of swabs.

Basis for taking swabs to identify the pathogen causing infective conjunctivitis lasting longer than 2 weeks:

• Microbiological investigations are not considered necessary in primary care when a person presents with a short history of infective conjunctivitis because most cases will settle spontaneously. However, management of chronic infections requires microbiological identification of the causative organism.
• The recommendation to swab people with infective conjunctivitis that persists for longer than 2 weeks is pragmatic and based upon the established pathophysiology of infective causes of conjunctivitis published in authoritative texts [Yanoff and Duker, 2004].
• Most bacterial and viral infections resolve spontaneously within 2 weeks.
• Chlamydial infections, and some bacterial infections, can cause chronic conjunctivitis lasting for weeks or months if untreated.

For people with:

• Blepharitis associated with chronic conjunctivitis, see the CKS topic on Blepharitis.
• A positive bacterial culture, prescribe a topical ocular antibiotic directed by sensitivity results if they are still symptomatic.
• A positive chlamydial culture, refer for testing of sexual contacts and systemic treatment.
• A negative bacterial and chlamydial culture, consider repeating the test if symptoms persist for longer than 3 weeks.

Basis for recommending treatment of microbiologically-proven bacterial infective conjunctivitis:

• Evidence from good quality trials has shown that treating people with proven bacterial conjunctivitis with a topical ocular antibiotic modestly reduces the severity and duration of conjunctivitis [Sheikh and Hurwitz, 2001].

Basis for repeating swabs if initial swab is negative but symptoms persist for longer than 3 weeks:

• A negative swab result in a person with conjunctivitis of less than 3 weeks' duration occurs most commonly when there is a viral cause for the conjunctivitis.
• Infective conjunctivitis lasting longer than 3 weeks is unlikely to be due to viral infection but may be due to a false negative result for a chronic bacterial or chlamydial infection.

[Yanoff and Duker, 2004]

• Urgently refer all infants in the first 28 days of life with conjunctivitis for same day assessment and management of their conjunctivitis.

• It is important to distinguish neonatal conjunctivitis, when the conjunctiva is inflamed and red, from a simple sticky eye (when there are no signs of conjunctival inflammation). A simple sticky eye does not usually require specialist assessment.

• Neonatal conjunctivitis may result in a severe and rapidly progressive eye infection, or be associated with a potentially serious systemic infection, both of which require urgent investigation and management in secondary care.
• Chlamydia is the commonest cause of neonatal conjunctivitis in the United States. An infant born to a mother with chlamydia has a 30–40% chance of developing conjunctivitis, and a 10–20% chance of developing pneumonia.
• Gonorrhoea infection typically results in a rapidly developing severe conjunctivitis associated a profuse purulent discharge within 48 hours of birth. Corneal ulceration and perforation may occur.

[Yanoff and Duker, 2004]