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What is This?
Clinical Pediatrics
Abstract
Bacterial conjunctivitis, one of the most common eye diseases in children, is highly contagious and rapidly transmitted
in day-care centers and schools. Empiric treatment with a broad-spectrum, ocular topical antibiotic has been shown
to shorten the course of the disease and reduce the risk for contagion. However, recent studies have documented a
pattern of growing drug resistance among the pathogens that cause bacterial conjunctivitis. Because drug resistance
occurs to each of the classes of ocular antibiotics (aminoglycosides, polymyxin B combination therapies, macrolides,
and fluoroquinolones), the selection of an effective anti-infective agent has become very difficult.
Keywords
bacterial conjunctivitis, fluoroquinolones, antibiotics, bacterial resistance
Table 1. Common Pathogens of Bacterial Conjunctivitis5 Treatment of acute bacterial conjunctivitis with a broad-
spectrum, preferably bactericidal, antibacterial is often
Neonates
<1 week Neisseria gonorrhoeae initiated empirically because the rapid kill of bacteria
1-2 weeks Chlamydia trachomatis shortens the time to recovery1,2,13; limits the spread of
Haemophilus influenzae disease2; relieves a financial burden by speeding up a
Streptococcus pneumoniae child’s return to day care or school and, consequently,
Older infants and toddlers (1-5 years) the parents’ return to work; and reduces the risk of
Without otitis sight-threatening complications. For acute bacterial
H influenzae
conjunctivitis with otitis media, treatment with an oral
S pneumoniae
Moraxella catarrhalis antibiotic is recommended.14 For uncomplicated acute
Staphylococcus aureus bacterial conjunctivitis, topical ophthalmic agents are
With otitis preferred over systemic agents because the concentra-
H influenzae tion of antibiotic achieved on the eye following topical
S pneumoniae administration is higher than that achieved in the blood
School-aged children/adolescents following oral administration and systemic side effects
S aureus
of orally administered antibiotics are avoided. Also, the
H influenzae
S pneumoniae concentration of antibiotic achieved on the surface of
the eye following topical administration is expected
to exceed both the minimum inhibitory concentration
(MIC) required to inhibit 90% of tested isolates (MIC90)
and the minimum bactericidal concentration at the target
hyperacute, or chronic).5 Exposure to other children/ tissue site.15 To date there has only been one study com-
adults at home, school, or day care with similar symp- paring the efficacy of oral treatment with that of topical
toms should be noted, as should a history of allergies treatment. Wald et al16 showed that oral cefixime and
and whether the conjunctivitis is unilateral or bilateral. topical polymyxin B/bacitracin were equally effective
The physical exam should include an assessment of in achieving clinical cure in children aged 2 months to
the external structural parts of the eye (eyelids, lashes) 6 years with acute bacterial conjunctivitis. From this study
as well as the cornea and bulbar palpebral conjunctiva. one might infer that an effective oral antibiotic with activ-
The surrounding skin should be examined and ity against ocular pathogens should be sufficient therapy
enlarged regional lymph nodes should be noted. In addi- and the addition of an ocular antibiotic unnecessary. when
tion, patients should be checked for comorbid otitis both conjunctivitis and otitis media are present.
media. Considerations in choosing the appropriate topi-
Signs and symptoms specific to allergic conjunctivi- cal antibiotic for bacterial conjunctivitis include broad
tis include itching, stringy or ropy discharge, lid edema, coverage of ocular Gram-positive and Gram-negative
chemosis, red, hyperemic conjunctiva, and comorbid bacteria,17 rapid kill rate, low bacterial resistance, mini-
allergic rhinitis. Viral conjunctivitis is characterized by mal toxicity to the eye, patient comfort, and a convenient
watery discharge and conjunctival injection. The pres- dosing schedule to encourage patient adherence. Cur-
ence of preauricular and/or submandibular lymphade- rently, the most commonly used topical ophthalmic anti-
nopathy can confirm viral conjunctivitis. Children with infective options are from one of the following classes:
viral conjunctivitis may be febrile and/or have associ- aminoglycosides, polymyxin B combination therapies,
ated pharyngitis. macrolides, or fluoroquinolones.9 Sulfonamides and
Acute bacterial conjunctivitis begins abruptly with chloramphenicol are no longer favored in the United
early symptoms of irritation or foreign body sensation States because of tolerability/safety concerns of severe
and tearing. Mucopurulent or purulent discharge, fre- stinging on instillation with sulfonamides and aplastic
quently occurring with morning crusting, swelling, and anemia with chloramphenicol and are not addressed in
comorbid otitis media are the most common indicators this review. Table 2 presents a brief summary of the
of acute bacterial conjuctivitis.2,6 currently used topical anti-infectives for bacterial con-
Cultures may be used to confirm or deny the etiology; junctivitis with their dosage regimens. Most of these
however, these are rarely obtained, unless the conjunc- antibiotics are approved for children 1 year and older.
tivitis is recurrent or severe. In children, nontypeable H
influenzae is the predominant organism in acute bacterial
conjunctivitis followed by S pneumoniae.3,12 Figure 1 Aminoglycosides
depicts an algorithm for evaluating conjunctivitis based Aminoglycosides (gentamicin, tobramycin, neomycin) are
on the age of the child.5 most active against Gram-negative bacteria, particularly
Pseudomonas aeruginosa (with the exception of neo- note, little to no aminoglycoside resistance was seen in
mycin), and are active against methicillin-sensitive S H influenzae.10
aureus (MSSA) but offer little coverage of streptococci
and methicillin-resistant S aureus (MRSA).18 Studies of
tobramycin 0.3% and gentamicin 0.3% in patients of all Polymyxin B Combination Therapy
ages found clinical cure rates ranging from 46% to 77% Polymyxin B exerts activity against Gram-negative organ-
and 39% to 70%, respectively.7 One study demonstrated isms only and is, therefore, administered in combination
significantly improved clinical cure rates with tobramy- with other antibiotics with complementary modes of
cin compared with gentamicin (P = .038).19 Results of a action to provide a broader spectrum of coverage. Com-
study in children (<20 years) demonstrated bacterial monly used polymyxin B combination products include
eradication rates identical to those in patients of all ages polymyxin B/trimethoprim, polymyxin B/bacitracin,
with bacterial eradication rates of 85% and 65% for and polymyxin B/neomycin/bacitracin. Trimethoprim
tobramycin and gentamicin, respectively.20 has activity against most staphylococci, streptococci,
and some Gram-negatives such as Haemophilus. Most
staphylococci and streptococci are susceptible to bacitra-
Resistance to Aminoglycosides cin. Double-masked, randomized comparisons did not
Studies of bacterial conjunctivitis isolates conducted from identify any significant differences between the poly-
the late 1990s through the mid-2000s have shown an myxin B combination regimens in clinical resolution
increasing degree of resistance to gentamicin and tobra- or bacterial eradication rates when tested in patients of
mycin among Gram-positive pathogens. The first annual all ages.12
survey of Ocular TRUST, describing data collected from
October 2005 through June 2006 showed 65.3% resis-
tance among S pneumoniae isolates to tobramycin.10 Resistance to Polymyxin B
Tobramycin was active against MSSA, but 63.6% of Combination Therapy
MRSA were resistant to tobramycin. Additional analysis In 2000, a pediatric surveillance study by Block et al12
of archived isolates of S pneumoniae and H influenzae showed that polymyxin B was ineffective against both
obtained between 1999 and 2006 further showed 59.9% PSSP and PNSP isolates. Although both polymyxin B/
of penicillin-sensitive S pneumoniae (PSSP) isolates were neomycin and polymyxin B/trimethoprim combinations
resistant to tobramycin compared with 73.1% of peni- were more active against S pneumoniae isolates than
cillin-nonsusceptible S pneumoniae (PNSP) isolates. Of polymyxin B, only the combination of polymyxin B/
Table 2. Summary of Commonly Used Topical Antimicrobial Agents for Bacterial Conjunctivitis
trimethoprim achieved MIC90 values considered predic- Trimethoprim was effective against PSSP, but 74% of
tive of clinical efficacy and then only against penicillin- PNSP were resistant to trimethoprim.10
susceptible S pneumoniae.12 In contrast, most strains of
H influenzae remained susceptible to polymyxin B
alone or in combination with neomycin or trimethoprim Macrolides
regardless of β-lactamase status. Ocular TRUST 1 data Macrolides are active primarily against Gram-positive
reported 100% resistance among S pneumoniae and cocci with the exception of enterococci and are generally
MSSA to polymyxin B, but no resistance by H influenzae.10 bacteriostatic. Erythromycin has been used as an ocular
photophobia, negative effects on corneal epithelium) than 10. Asbell PA, Colby KA, Deng S, et al. Ocular TRUST:
other ophthalmic antibacterial classes.18,32,33 nationwide antimicrobial susceptibility patterns in ocular
isolates. Am J Ophthalmol. 2008;145:951-958.
11. Asbell PA, Sahm DF, Shaw M, Draghi DC, Brown NP.
Choosing an Appropriate Ophthalmic Increasing prevalence of methicillin resistance in serious
Antibiotic for Bacterial Conjunctivitis ocular infections caused by Staphylococcus aureus in the
The ideal topical anti-infective for the treatment of acute United States: 2000 to 2005. J Cataract Refract Surg.
bacterial conjunctivitis should be a well-tolerated, broad- 2008;34:814-818.
spectrum, highly potent, and a bactericidal agent with a 12. Block SL, Hedrick J, Tyler R, et al. Increasing bacterial
high concentration on the ocular surface and rapid kill resistance in pediatric acute conjunctivitis (1997-1998).
time. Although there are many classes of topical antibiotic Antimicrob Agents Chemother. 2000;44:1650-1654.
treatment options available to primary care physicians, dif- 13. Sheikh A, Hurwitz B. Antibiotics versus placebo for acute
ferences among them as well as emerging bacterial resis- bacterial conjunctivitis. Cochrane Database Syst Rev.
tance should be considered in selecting the appropriate 2006;19(2):CD001211.
antibiotic. In addition, agents with convenient dosing regi- 14. Bodor FF. Systemic antibiotics for the treatment of the
mens are likely to promote treatment compliance. When conjunctivitis otitis media syndrome. Pediatr Infect Dis J.
local antibiotic resistance to ocular pathogens warrants 1989;8:287-290.
the increased cost, use of newer fluoroquinolones might 15. Mah FS. New antibiotics for bacterial infections. Ophthal-
be considered. mol Clin North Am. 2003;16:11-27.
16. Wald ER, Greenberg D, Hoberman A. Short-term oral
cefixime therapy for treatment of bacterial conjunctivitis.
Declaration of Conflicting Interests
Pediatr Infect Dis J. 2001;20:1039-1042.
The author(s) declared no conflicts of interest with respect to 17. Cavuoto K, Zutshi D, Karp CL, Miller D, Feuer W. Update
the authorship and/or publication of this article. on bacterial conjunctivitis in South Florida. Ophthalmol-
ogy. 2008;115:51-56.
Funding 18. Gwon A; for the Ofloxacin Study Group. Topical ofloxa-
The author(s) received no financial support for the research cin compared with gentamicin in the treatment of ocular
and/or authorship of this article. infection. Br J Ophthalmol. 1992;76:714-718.
19. Cagle G, Davis S, Rosenthal A, Smith J. Topical tobramy-
cin and gentamicin sulfate in the treatment of ocular infec-
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