Bacterial Conjunctivitis in Children and Adults: Diagnosis and Treatment Options

1. Bacterial Conjunctivitis in Children and Adults A.KHALILIAN Farabi Hospital Drkhalilian.com

2. Bacterial Conjunctivitis in Children and Adults • Bacterial conjunctivitis is less common than viral conjunctivitis in adults • In an adult with unilateral bacterial conjunctivitis >>> NLDO (R/O)

4. Acute purulent conjunctivitis • Purulent discharge < 3 weeks’ duration • S pneumoniae, • Streptococcus viridans, • S aureus, (acute blepharoconjunctivitis) • H influenzae (biotype III previously called H aegyptius)

6. H influenzae conjunctivitis • Young children, sometimes with otitis media, • Adults, particularly those chronically colonized with H influenzae(smokers, COPD). • Conjunctival membranes do not develop, peripheral corneal epithelial ulcers and stromal infiltrates occur more commonly. • H influenzaepreseptal cellulitis may be associated with fulminant Haemophilus Meningitis (up to 20% long-term neurologic sequelae)

7. Gram-stained smears and culture of the conjunctiva in: • Neonatesor debilitated or immunocompromisedindividuals, to assess the risk of local and systemic complications • Severe cases of purulent conjunctivitis, to differentiate it from hyperpurulentconjunctivitis,whichgenerally requires systemic therapy • Unresponsive to initial therapy

8. Rx acute bacterial conjunctivitis • Delaying treatment until day 3 or 4 would significantly reduce the unnecessary use of antibiotics and would not affect outcomes • If the conjunctivitis is improving on day 4, then antibiotics may not be necessary at all.(limited benefit)

9. PolymyxinB/trimethoprim (Haemophilusspecies) • Aminoglycosides or fluoroquinolone drops, • Bacitracin or ciprofloxacin ointment. • 4–6 times daily for approximately 5–7 days

10. Supplemental oral antibiotics are recommended for patients with • Acute purulent conjunctivitis associated with pharyngitis, • Conjunctivitis-otitis syndrome, • Haemophilus conjunctivitis in children.

11. Cultures of the nose or throat: • Associated sinusitis or pharyngitis • Relapsing conjunctivitis Because organisms persisting in and colonizing the respiratory mucosa may be the source of infection.

12. Hyperacutegonococcal conjunctivitis

13. Hyperacutegonococcal conjunctivitis • Explosive onset and very rapid progression of severe purulent conjunctivitis • Massive exudation; severe chemosis; eyelid edema; marked conjunctivalhyperemia,cornealinvolment • N gonorrhoeae (STD, maternal–neonate transmission in NVD)

14. N gonorrhoeaeconjectivitis • Preauricularlymphadenopathy • Conjunctivalmembranes. • Keratitis,theprincipal cause of sight-threatening complications (15%–40%): • Diffuse epithelial haze, • Epith defects, • Marginal infiltrates, • Ulcerative keratitis • Corneal melting &perforation

15. N gonorrhoeae grows well on chocolate agar and Thayer-Martin media

17. Rx • Patients with penicillin allergy can be given spectinomycin (2 g IM) • Oral fluoroquinolones (ciprofloxacin 500 mg or ofloxacin 400 mg orally twice daily for 5 days) • Patients should be instructed to refer their sex partners for evaluation and treatment.

19. Bacterial conjunctivitis in neonatesophthalmianeonatrum • Chlamydia trachomatis • S viridans • S aureus • H influenzae • group D Streptococcus • Moraxella catarrhalis • E coli and other gram-negative rods • N gonorrhoeae

20. Neonatal gognococcalconjectivitis1% • Bilateral conjunctivaldischarge typically develops 3–5 days after parturition. • The discharge may be serosanguinousduring the first several days, with a copious purulent exudate, severe corneal complications, and endophthalmitis developing later • Disseminated gonococcal infection with arthritis, meningitis, pneumonia, and sepsis

21. Rx • For nondisseminated infections, a single IM or IV ceftriaxone injection (up to 125 mg or a dose of 25–50 mg/kg) or cefotaxime at a single dose of 100 mg/kg IV or IM • For disseminated infection, treatment should be augmented according to infectious disease consultation.

22. Hourly saline irrigation of the conjunctiva until discharge is eliminated. • If corneal involvement is suspected, application of topical erythromycin or gentamicin ointment or frequent application of a topical fluoroquinoloneshould be considered. • Topical cycloplegia

23. Neonatal chlamydia conjectivitis • There is no follicular response in newborns. • The gretaeramount of mucopurulent discharge • Pseudomembranes • Intracytoplasmic inclusions • The infection in newborns is more likely to respond to topical medications.

24. Gramand Giemsa stains of conjunctival scrapings are recommended in neonates with conjunctivitis to identify C trachomatis and N gonorrhoeae, as well as other bacteria

25. Rx of Neonatal chlamydia conjectivitis • Other Chlamydia-associated infections, such as pneumonitis and otitis media, can accompany inclusion conjunctivitis in the newborn. 1- Topical erythromycin or sulacetamide+ 2- Systemic erythromycin (12.5 mg/kg oral or IV 4 times daily for 14 days)

26. Chlamydial conjunctivitis Chlamydia trachomatis: • Trachoma: serotypes A–C • Adult and neonatal inclusion conjunctivitis: serotypes D–K • Lymphogranulomavenereum: serotypes L1, L2, and L3

27. Adult chlamydialconjunctivitis • Adult chlamydial conjunctivitis is a sexually transmitted disease often found in conjunction with chlamydial urethritis or cervicitis.( systemic disease) • Other modes of transmission may include shared eye cosmetics and swimming pools.

28. Scant mucopurulent discharge • Follicular conjunctival response that is most prominent in the lower palpebral conjunctiva and fornix, • Preauricularadenopathy. • Follicles in the bulbar conjunctiva and semilunar fold( specific sign)

29. Fine or coarse epithelial infiltrates, occasionally associated with subepithelial infiltrates.( sup) • Micropannus ( < 3mm. Sup)

30. Rx • Adult chlamydial conjunctivitis often resolves spontaneously in 6–18 months. • Azithromycin 1000 mg single dose • Doxycycline100 mg twice daily for 7 days • Tetracycline250 mg 4 times daily for 7 days • Erythromycin500 mg 4 times daily for 7 days

31. Patients and their sexual contacts should be evaluated for coinfection with other sexually transmitted diseases, such as syphilis or gonorrhea