Conjunctivitis

Most infections are viral and/or self-limiting and do not require antibiotics.

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is conjunctivitis.

Treatments of conjunctivitis are cheap to buy and are readily available OTC along with advice from pharmacies. Please click here for further information, exceptions, and a patient leaflet.

Bacterial conjunctivitis is usually bilateral, one eye may be affected before the other (by one or two days), and is characterised by red eye with mucopurulent, not watery, discharge. The condition is self-limiting and will normally settle in 5-10 days. Therefore, avoidance of drug treatment is an option if a patient wishes, for example during pregnancy.

Patients should be encouraged to use self-care including the following measures: cleansing the eye lids with a cotton wool ball moistened with boiled and cooled water, paying attention to hand hygiene, and avoiding sharing towels. Patients should be aware of the red flag symptoms and be advised to seek medical advice if they emerge.

Red flag symptoms: eye pain or photophobia, marked redness in one eye, reduced visual acuity or purulent conjunctivitis in a new-born infant (see below)

Conjunctivitis in neonates: Neonates with severe conjunctivitis should be referred urgently to secondary care

Public Health England advises that exclusion of single cases from school/nursery is not generally necessary but may be required if an outbreak occurs. Some institutions may apply their own exclusion policies.

Treatment options

See section 11.3 anti-infective eye preparations

Chloramphenicol 0.5% drops

• Apply every 2 hours during day for first 48 hours, then four times a day until 48 hours after resolution (5-7 day course)
• A link between aplastic anaemia and chloramphenicol eye drops has not been proven but topical chloramphenicol should be avoided in patients with a personal or family history of blood dyscrasia.
• Neonates with severe conjunctivitis should be referred urgently to secondary care
• MHRA Drug Safety Update (July 2021): Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years
  Chloramphenicol eye drops can be safely administered to children aged 0 to 2 years where antibiotic eye drop treatment is indicated.
  • Some licences for chloramphenicol eye drop products containing borax or boric acid buffers were recently updated to restrict use in children younger than 2 years of age to reflect warnings on maximum daily limits for boron exposure
  • The MHRA has reviewed the available evidence and sought independent expert advice. The MHRA has concluded that the benefits of chloramphenicol eye drops containing borax or boric acid outweigh the potential risks for children, including those aged 0 to 2 years
  • The product information for affected chloramphenicol products is being updated to reflect the revised advice and remove restrictions for use in infants – in the meantime the MHRA asks healthcare professionals to reassure parents and carers that these products can be safely given to children aged 0 to 2 years as prescribed
  • For more information and advice for parents and carers, see the Drug Safety Update

Chloramphenicol 1% eye ointment

• Apply 3-4 times daily until 48 hours after resolution (5-7 day course)
• Neonates with severe conjunctivitis should be referred urgently to secondary care

If treatment with chloramphenicol fails take swabs and consider viral cause or incorrect administration. Fusidic acid eye drops have a narrow spectrum of activity and should not be used for reasons of convenience. Fusidic acid eye drops should only be used if indicated by antimicrobial sensitivity or on specialist recommendation for an individual patient.