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Clinical Summary

Bacterial conjunctivitis is characterized by the acute onset of conjunctival injection and a thick yellow, white, or green mucopurulent drainage. Lid edema, erythema, and chemosis may also be seen. S aureus is the most common causative bacteria. S pneumoniae and Haemophilus influenzae occur more frequently in children.

Hyperacute bacterial conjunctivitis, the most severe form of acute purulent conjunctivitis, is associated with N gonorrhoeae. Symptoms are hyperacute in onset, and findings include a purulent, thick, copious discharge; eyelid swelling and tenderness; marked conjunctival hyperemia; chemosis; and preauricular adenopathy. The condition is serious and threatens sight because Neisseria species are capable of invading an intact corneal epithelium. Corneal findings include epithelial defects, marginal infiltrates, and an ulcerative keratitis that can progress to perforation. A Gram stain can be performed, but NAAT or polymerase chain reaction (PCR) testing is highly sensitive in confirming gonococcal or Chlamydia infection.


Bacterial Conjunctivitis. Mucopurulent discharge, conjunctival injection, and lid swelling in a 10-year-old with H influenzae conjunctivitis. (Photo contributor: Frank Birinyi, MD.)

Management and Disposition

Encourage frequent hand washing and warm moist compresses. Empiric antibiotic choices include polymyxin/trimethoprim drops and erythromycin ophthalmic ointment. Other options include bacitracin, sulfacetamide, or polymyxin-bacitracin ointments or fluoroquinolone or azithromycin drops. Improvement should be noted in 1 to 2 days. Patients who do not improve should be referred to an ophthalmologist.


Bacterial Conjunctivitis. Mucopurulent discharge and conjunctival injection in an adult with conjunctivitis. (Photo contributor: Lawrence E. Heiskell, MD.)

Fluoroquinolones should be prescribed for contact lens wearers (and keratitis ruled out) due to concern for Pseudomonas infection. Hyperacute bacterial conjunctivitis requires immediate ophthalmologic consultation and hospitalization.


  1. Conjunctivitis is a common presentation of the red eye and should be considered after more serious causes, such as acute angle-closure glaucoma (ACG), iritis, and infectious keratitis, have been ruled out.

  2. Red flags include a significantly decreased visual acuity, ciliary flush, corneal opacity, and rapid progression.

  3. Worsening symptoms during topical treatment with Neosporin or a sulfonamide suggest a contact allergic reaction.

  4. N gonorrhoeae conjunctivitis must be considered in the sexually active adult with a prominent, thick, copious discharge. Urethritis is usually present.

  5. Fluoroquinolones should be prescribed for contact lens wearers because of concern for Pseudomonas infection in these patients.


Gonococcal Conjunctivitis. Right eye chemosis, purulent discharge, and pain in young adult male with urethritis. (Photo contributor: Catherine Burger, MD.)

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