The dogma has been to prescribe a topical antibiotic agent for acute bacterial conjunctivitis regardless of the exact causative bacteria or age of the patient.^1,2 Historically, antibacterial topical therapy has been the preferred method of treatment because it will usually shorten the course of the disease slightly and allow the early re-admittance of children to school and adults to the workplace.¹ Exceptions to this practice occur when it’s important to avoid specific drugs (including oral medications), especially when they are contraindicated because of age or the potential for allergic reaction.

Without hesitation, H. influenza conjunctivitis, Gonococcal conjunctivitis and any other severe forms of conjunctivitis with scleral extension need to be treated systemically due to their extraocular involvement and potential for devastating consequences.^1,2

The Case for Not Prescribing
Fortunately, most infective (viral and bacterial) conjunctivitis resolves spontaneously without treatment. So, should topical antibiotics routinely be used? One study concluded that infective conjunctivitis should be managed conservatively with antibiotics prescribed either after a delayed period, if symptoms do not improve within three days of onset (generally when we see them), or not at all.³ More physicians have recently been successful in promoting conservative treatment for upper respiratory infections (initially avoiding antibiotic treatment) and changing management expectations of parents and patients. Likewise, some authorities feel that it might be time to take a close look at our prescribing patterns for acute infective conjunctivitis, where the patient has relatively few signs and symptoms, except for the redness and minor irritation. Most cases of acute infectious conjunctivitis are viral in etiology. But, viral and bacterial etiologies are sometimes difficult to distinguish in clinical measures alone. So, the real uncertainty rests in the decision on whether to prescribe when there is high probability that the infection is bacterial.

The Opposing View
Acute bacterial conjunctivitis is generally a self-limiting condition, but the use of topical antibiotics is associated with a significantly improved rate of early (days two to five) clinical remission and early and late microbiological remission in bacterial disease.^1-3 Any additional benefit is marginal for later remission (days six to 10).⁴ Although unanswered questions about serious risk or adverse events that may occur in those who do not receive treatment for bacterial conjunctivitis linger, on balance, topical antibiotics offer at least marginal benefit in improving clinical outcomes.^1,3

Make it Personal
Whether or not to treat acute bacterial conjunctivitis will remain a highly personal decision. The optimal way to handle these cases from a socioeconomic and medical perspective needs to be thoughtfully evaluated on a case-by-case basis by every clinician who encounters acute infectious conjunctivitis. Keep in mind that the effects of a non-prescribing attitude on transmission rates of various bacterial pathogens in the community remain uncertain.¹

For now, I will continue to prescribe antibiotics with confidence when conditions warrant, such as in early presentations of suspected bacterial conjunctivitis and when severe infections present where a bacterial etiology is confirmed. I would like to again acknowledge the value of the Cochrane Library.⁵ The Library is an invaluable collection of databases in medicine and other health care-related topics by the Cochrane Collaboration. The core of the Library is the Cochrane Reviews, a database for systematic reviews and meta-analyses that summarize and interpret the results of quality medical research. It serves as a key source of evidence-based medicine, an invaluable tool to evaluate and attempt to answer difficult questions in health care.  

1. Ehlers JP, Shah CP. Acute Conjunctivitis. In: Ehlers JP and Shah CP, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia, PA. Wolters/Kluwer/JB Lippincott. 2008:104-07.
2. Hovding G. Acute bacterial conjunctivitis. Acta Ophthalmol. 2008 Feb;86(1):5-17.
3. Visscher KL, Hutnik CM, Thomas M. Evidence based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing. Can Fam Physician. 2009 Nov;55(11):1071-5.
4. Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update. Br J Gen Pract. 2005 Dec;55(521):962-4.
5. The Cochrane Collaboration. Available at: www.cochrane.org/reviews. (Accessed Dec 2009).