Conjunctivitis (bacterial)

Eye & Ear

Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.

Clinical features

Can be unilateral or bilateral (one eye affected first, then other) with a purulent/mucopurulent discharge

Allergic and viral conjunctivitis are discussed separately under the headings 'conjunctivitis (allergic)' and 'conjunctivitis (viral)'. [Allergic conjunctivitis both eyes usually affected, they are red and usually feel itchy and gritty. Other allergy symptoms and a positive personal or family history may be present. Viral tends to be associated with a watery discharge and other symptoms such as an upper respiratory tract infection.]

Bacterial conjunctivitis

General point: if complications affect vision (potentially resulting in a loss of vision), it is vital that such referrals are urgent/prompt and possibly to hospital rather than the GP

Marked redness of the whole eye or redness/signs of damage specifically around pupil (particularly in a contact lens wearer)

Unsure if straightforward/uncomplicated (for example, if patient has an existing eye condition or recent injury or surgery in the last 6 months)

Irritant conjunctivitis (acid or alkali burns or exposure to irritating substance)

Primary angle closure glaucoma (eye pain; headache, nausea and vomiting caused by pain, red eye, impaired vision, lights seen with surrounding halos, pupil dilation impaired)

Uveitis (eye pain, impaired/blurred vision, watering, photophobia, floaters, unreactive or irregular-shaped pupil, possible red eye)

Keratitis or corneal ulcer (unilateral, painful, photophobia, contact lens wearer). Be mindful that contact lens wearers are at risk of developing giant papillary conjunctivitis (GPC) which can present with conjunctivitis-type symptoms but requires referral to an optometrist for further investigation

Scleritis (pain, headache, association with other inflammatory diseases, vision reduced)

Should resolve within 5-7 days in most cases (medical attention sought if not). See also specific product time frame information

Non-pharmacological advice

Hygiene measures: bathe the eyelids with tepid water to remove discharge. The Royal Pharmaceutical Society recommend wiping the eye from the bridge of the nose to the outer corner with a fresh piece of cotton wool/gauze

Discuss ways to minimise the spread of infection: wash hands regularly, particularly after touching eyes/discharge, avoid sharing towels and pillows, facecloths, discard contaminated make up etc. and reiterate good contact lens practice if relevant (following the specified cleaning and wearing guidance, having regular eye examinations, should not typically be worn in the shower, hot tubs, or during water sports)

According to NHS "patients don't need to stay away from work or school unless they are feeling particularly unwell. If there are a number of conjunctivitis cases at your child's school or nursery, you may be advised to keep them away until their infection has cleared up. Generally, adults who work in close contact with others, or share equipment such as phones and computers, shouldn't return to work until the discharge has cleared up."

Pharmacological advice

OTC chloramphenicol: the latest evidence suggests that it does speed up resolution time and is unlikely to cause serious side-effects. However, as the condition is self-limiting, this may be considered an unnecessary expense/hassle/exposure to medication and could contribute to the wider problem of antibiotic resistance

Two OTC chloramphenicol formulations (drops and ointment) under various brand names, each having specific dosage instructions which should be followed. Explain how to use and differences in formulations: frequency of application (ointment less) and the eye drops require fridge storage. In the UK, these OTC products are not suitable for children aged under 2 years (at the time of writing) and so if antibacterial therapy is warranted, a suitable prescriber will need to initiate this

5 day course; if no improvement within the first 48 hours of use, discontinue and seek medical advice

Contact lens wearers: various manufacturers recommend that if the patient wears contact lenses, they should seek advice from their contact lens practitioner (optician, optometrist) or doctor BEFORE using OTC chloramphenicol (there is also specific guidance from the manufacturer about removal and re-insertion

Pregnancy: provide non pharmacological advice. OTC chloramphenicol not licensed; if an antibacterial is deemed necessary, this will have to be obtained via a prescription