Bacterial conjunctivitis

o ces [2]. Most cases are spread through direct contact with infected persons or equipment [3]. Health care workers are encouraged to wear gloves, practice good hand washing, and clean instruments after patient contact [3]. Patients should also be encouraged to promote good hand washing and to separate towels of infected and noninfected family members [5]. Treatment is supportive, with symptoms lasting 1 to 3 weeks. Cold compresses, artificial tears, and topical vasoconstrictors may provide some relief [2]. A randomized, double-blind placebo-controlled trial with topical ketorolac versus artificial tears for the treatment of viral conjunctivitis failed to show any statistical di erence in patient symptom score (discomfort, itching, foreign-body sensation, tearing, or eyelid swelling) or sign score (conjunctival injection, chemosis, mucous, or eyelid edema) [23]. Topical antibiotics are rarely needed because superinfection with bacterial pathogens is a rare occurrence [2].

Viral etiologies for conjunctivitis other than adenoviruses include ECHO virus, herpesviruses, enteroviruses, Epstein-Barr virus, influenza A virus, human coxsackieviruses, and Kawasaki disease. Patients present with conjunctival injection, watery discharge, conjunctival swelling, a tender preauricular node, and possibly foreign-body sensation [2]. Both eyes may be concurrently infected or the second eye may become involved a few days later; an associated upper respiratory infection may accompany the conjunctivitis [2].

Viral conjunctivitis caused by recurrent herpes simplex virus (HSV) can be vision threatening. Although primary infection usually has a self-limited course, recurrent disease can result in corneal opacification and loss of vision [1]. Primary infection peaks between age 1 and 5 years [3]. Recurrent disease primarily strikes in adulthood [24]. Most ocular infections in children are caused by HSV-1 as opposed to neonatal herpes eye disease, whereby HSV-2 is acquired at delivery [1]. Presentation of eye disease in primary HSV infection may be a nonspecific conjunctivitis (follicular response, serous discharge, and preauricular adenopathy) with or without vesicles of the surrounding skin (Fig. 3) [1]. Without these vesicles present, disease may not be distinguishable from other infectious forms of conjunctivitis. A helpful clue is that most herpetic conjunctivitis (80%) is unilateral [3]. The virus is transmitted from inoculation through direct contact with another individual who is shedding the virus or from autoinoculation of the conjunctiva from a primary infection elsewhere [3]. On examination, involvement of the cornea with the classic dendritic appearance is found in 50% of patients (Fig. 4) [5].

Secondary HSV disease may occur if the trigeminal ganglion is invaded during primary disease. Physical stress may precipitate the second outbreak. These patients now present with a di erent clinical picture: unilateral red eye with severe pain and sensation of a foreign body but without history of trauma or contact with a foreign body [1]. On examination, a dendritic ulcer on the corneal epithelium is a characteristic feature. Identification can be facilitated by the use of fluorescein dye and by examination with filtered cobalt

children aged 1 month to 18 years. By day 8, both groups were cured (no significant P value). Treatments with topical antibiotics led to a faster cure and a greater likelihood of clearing the organism.

As previously stated, most causes of bacterial conjunctivitis are caused by gram-positive and gram-negative organisms, and treatment should be tailored accordingly. Options include trimethoprim-polymixin B (Polytrim), which has broad-spectrum antibiotic coverage, is inexpensive, and has minimal side e ects (ocular irritation) (Table 1) [25]. Sodium sulfacetamide 10% (Bleph-10) is also an inexpensive option covering gram-positive organisms but causes significant stinging on application [25]. Topical fluoroquinolones such as ciprofloxacin 0.3% (Ciloxan) and ofloxacin (Ocuflox) have broadspectrum coverage against gram-positive and gram-negative organisms but are more expensive choices [1]. Aminoglycosides are frequently prescribed for bacterial conjunctivitis; gentamicin and tobramycin have good gram-negative coverage but do not cover organisms such as Chlamydia, and corneal epithelial toxicity may be seen with extensive use [25]. Erythromycin is another inexpensive option with good gram-positive and Chlamydia coverage; however, it has poor activity against Haemophilus species, B catarrhalis, gram-negative organisms, and staphylococcal species [25]. Administration may be by drops or with ointment. Ointments tend to blur vision, which may be a consideration in school-aged children [1]. Overall, the side e ects of topical agents, including hypersensitivity, are local in nature, with systemic e ects being rare [25]. Neomycin preparations should be avoided because there is a higher likelihood of cell-mediated sensitivity to these agents [6].

Recently, fourth-generation topical fluoroquinolones have been introduced for the treatment of bacterial conjunctivitis. These agents, including gatifloxacin 0.3% and moxifloxacin 0.5%, have increased e cacy against gram-positive organisms and reduced the potential for bacterial resistance [27]. Moxifloxacin is the only fluoroquinolone that can be administered in the less frequent, three-times-daily dosing schedule. The relatively low minimum inhibitory concentration of moxifloxacin for isolates of the common pathogens that cause pediatric conjunctivitis in addition to the high conjunctival tissue levels reached compared with other topical antibiotics make it ideal for eradicating the organism quickly and for subsequent rapid clinical cures [28]. A recent study demonstrated the need to exclude children with infectious conjunctivitis from school until clinical signs and symptoms are resolved. Treatment of bacterial conjunctivitis with the fourth-genera- tion fluoroquinolones may provide the opportunity to get children back to school the next day following initiation of treatment [29].

Combination therapies of antibiotics and corticosteroids are available. These therapies are not generally recommended unless a firm diagnosis is obtained because they are able to increase intraocular pressure with prolonged use and cause aggravation of ocular HSV infections (causing the virus to proliferate) [1].