EM@3AM – Bacterial Conjunctivitis

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 22-year-old male presents to the emergency department with right eye redness, pain, and discharge. The patient notes the onset of his symptoms as 24 hours prior to arrival, and progressively worsening (eye pain: dull, aching, 10/10; “pus constantly running down my cheek”). The man is not a contact lens wearer. He reports an ophthalmologic examination one year prior: “20/20 in both eyes.” He denies eye trauma, fever, headache, ear pain, hearing loss, and sick contacts. He reports recent sexual activity with one new female partner.

Initial VS: BP 121/77, HR 62, T 98.4F Oral, RR 12, SpO2 99% on room air.

OD: 20/200 OS: 20/20 OU: 20/50

OD: conjunctival injection, chemosis, copious purulent discharge

What’s the next step in your evaluation and treatment?

Answer: Bacterial Conjunctivitis1,2

  • Presentation and Pathogens: Often begins with unilateral eye redness and crusting +/- irritation/pain. Infection frequently spreads to include both eyes within 48 hours of onset. Most common pathogens: S. aureus, S. pneumoniae, H. influenzae.
    • Hyperacute presentation: Rapid progression of symptoms (within hours), copious purulent drainage +/- chemosis +/- pre-auricular lymphadenopathy. Pathogens: N. gonorrhoeae or C. trachomatis.1
  • Evaluation:
    • Perform a thorough H&P:
      • Question regarding sexual activity.
      • Neonate: question regarding place of birth (U.S. – erythromycin ophthalmic ointment administered following delivery to prevent gonococcal conjunctivitis) or maternal infections during pregnancy.
    • Examination:
      • Visual Acuity
      • Fluorescein stain => specifically for contact lens wearers and for patients in whom gonococcal conjunctivitis is a concern (corneal ulceration).1
      • Evert eyelids to evaluate for foreign body.
      • Evert the lower eyelid to evaluate for bulbar or palpebral hyperemia, edema, or discharge (consistent with conjunctivitis).
      • Consider slit lamp examination if suspicion for gonococcal conjunctivitis (keratitis) or if diagnosis is unclear.
  • Treatment:
    • Numerous therapies available (e.g. neomycin/polymyxin B/gramicidin ophthalmic solution, polymyxin B and trimethoprim ophthalmic solution, erythromycin ophthalmic, etc.)
    • Special considerations:
      • Contact lens wearers: antibiotic therapy directed towards pseudomonas (e.g. ciprofloxacin ophthalmic, moxifloxacin ophthalmic, etc.). Advise patient to dispose of current contact lenses and resume wear of new lenses only upon the completion of therapy/resolution of infection.
      • Gonorrhea conjunctivitis: rocephin 1g IM (in addition to oral azithromycin for chlamydia treatment) + ophthalmology consultation (may require intraocular antibiotics/admission for parenteral antibiotics and monitoring) + treatment of sexual partners1,2
      • Chlamydia conjunctivitis: erythromycin 250mg PO QID x 14 days, doxycycline 100 mg PO BID x 14 days, or azithromycin 1g PO + ophthalmology consultation + treatment of sexual partners1,2
  • Pearls:
    • Viral conjunctivitis is the most common etiology of eye redness (members of the Adenovirus family).1 Patients with viral conjunctivitis often present with bilateral eye redness, watery eye discharge, +/- pre-auricular lymphadenopathy.
      • Topical antibiotics have historically been prescribed to prevent bacterial superinfection in this setting, however, it is important to recognize that no presenting sign/symptom has demonstrated specificity for the diagnosis of viral vs. bacterial conjunctivitis.1
    • Neonates: Gonococcal conjunctivitis: presents 2-4 days following birth. Chlamydial conjunctivitis: most common etiology of infectious conjunctivitis in the newborn; occurs 1 week to 2 months following birth.1
    • Chlamydial infection may cause concomitant pneumonia (staccato cough), otitis media, proctitis, and vulvovaginitis in patients presenting with conjunctivitis.
    • Ophthalmology consultation is paramount in the setting of presumed gonorrhea or chlamydial infection => sight threatening.
      • Conjunctival scraping is recommended => Gram stain and bacterial culture2



  1. Bope E, and Kellerman M. Disease of the Head and Neck. In Conn’s Current Therapy. Philadelphia, Saunders. 2015; 7: 441-478.
  2. Barnes S, Kumar N, Pavan-Langston D, Azar D. Microbial Conjunctivitis. In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, Updated Edition. Philadelphia, Saunders. 2015; 114: 1392-1401.e1.


For Additional Reading:

Ophthalmologic Medications: Pearls & Pitfalls for the ED

Ophthalmologic Medications: Pearls & Pitfalls for the ED

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