g logo ipb green


  • Bacterial infection of the conjunctiva, typically by:
    • Staphylococcus species
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella catarrhalis

Predisposing factors

  • Children and the elderly have an increased risk of infective conjunctivitis (NB bacterial conjunctivitis in the first 28 days of life is a serious condition that must be referred urgently to the ophthalmologist.See Clinical Management Guideline on Ophthalmia Neonatorum )
  • Contamination of the conjunctival surface
  • Superficial trauma
  • Contact lens wear (NB infection may be Gram-negative)
  • Secondary to viral conjunctivitis
  • Recent cold, upper respiratory tract infection (NB refer also to Clinical Management Guideline on Conjunctivitis (viral, non-herpetic) or sinusitis)
  • Diabetes (or other disease compromising the immune system)
  • Steroids (systemic or topical, compromising ocular resistance to infection)
  • Blepharitis (or other chronic ocular inflammation)


  • Acute onset of:
    • redness
    • discomfort, usually described as burning or grittiness
    • discharge (may cause temporary blurring of vision)
    • crusting of lids (often stuck together after sleep and may have to be bathed open)
  • Usually bilateral—one eye may be affected before the other (by 1 or 2 days)


  • Lid crusting
  • Purulent or mucopurulent discharge
  • Conjunctival hyperaemia—maximal in fornices
  • Tarsal conjunctiva may show mild papillary reaction
  • Cornea: usually no involvement (occasionally superficial punctate keratitis (SPK)—mainly in lower third of cornea). If cornea significantly involved, consider possibility of gonococcal infection
  • Pre-auricular lymphadenopathy: usually absent

Differential diagnosis

  • Other forms of conjunctivitis:
    • epidemic keratoconjunctivitis (e.g. adenovirus)
    • herpes (simplex or zoster)
    • chlamydial infection
    • allergy
  • Other causes of acute red eye:
    • angle closure glaucoma
    • infective keratitis
    • anterior uveitis

Management by optometrist

  • Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

  • Often resolves in 5–7 days without treatment
  • Bathe/clean the eyelids with lint or cotton wool dipped in sterile saline or boiled (cooled) water to remove crusting
  • Advise patient that condition is contagious (e.g. do not share towels)


  • Treatment with topical antibiotic may improve short-term outcome and render patient less infectious to others
  • Chloramphenicol 0.5% drops 2-hourly for 2 days, then four-times daily for 5 days
  • Chloramphenicol 1% ointment four-times daily for 2 days, then twice-daily for 5 days
  • Fusidic acid 1% eye drops twice-daily for 7 days
  • Contact lens wearers with a diagnosis of bacterial conjunctivitis should be treated with a topical antibiotic effective against Gram-negative organisms, e.g. gutt ofloxacin 0.3% q.d.s. for up to 10 days. Contact lenses should not be worn during the treatment period
  • Advise patient to return/seek further help if symptoms persist beyond 7 days

Management Category

  • Refer if condition fails to resolve, or if there is corneal involvement

Possible management by ophthalmologist

  • If resistant to treatment, or recurrent:
    • conjunctival swabs taken for microscopy and culture and/or PCR analysis
    • treatment with other antibiotics, based on culture results

full guideline available from…
The College of Optometrists, 42 Craven Street, London, WC2N 5NG

The College of Optometrists. Conjunctivitis (bacterial)—clinical management guidelines
First included: March 2016.