Conjunctivitis Treatment Considerations

Child greater than 8 weeks of age

Clinical Question #4: In children greater than 8 weeks presenting with acute conjunctivitis, are there clinical signs or symptoms to help distinguish between bacterial and viral etiologies?

We STRONGLY RECOMMEND based on low quality evidence consideration of supportive care or alternative diagnosis to bacterial conjunctivitis for patients that do not present with mucopurulent discharge or a history of glued eyelids upon awakening in the morning.

Rationale and Evidence Base

Rietveld et al performed a systemic literature review published in British Medical Journal in 2003 concluding that classic textbook teaching on the different clinical signs and symptoms between viral and bacterial disease appear to be expert opinion and not evidence based (Rietveld, van Weert et al. 2003). Since that review, two prospective observational cohort studies in pediatric patients have attempted to identify signs and symptoms to assist the practitioner in which patients require treatment. Patel et al evaluated 111 patients over one year and found that patients were more likely to have a positive bacterial culture with a history of gluey or sticky eyelids in the morning (OR, 5.0; 95% CI=1.8 to 13.7), exam findings of mucoid or purulent eye discharge (OR, 4.8; 95% CI=1.8 to 12.6) and eyelids or eyelashes crusting or gluing (OR, 3.0; 95% CI=1.2 to 7.5). The combination of gluey or sticky eyelids in the morning and purulent or mucoid discharge on physical exam had a sensitivity of 85% (95% CI=76%-91%) with a specificity of 73% (95% CI=40%-93%) and a positive likelihood ratio of 3.1 (95% CI= 1.5-8.8). Interestingly, no association was identified between age, daycare attendance, exposure to other patients with a "pink eye" and a positive culture results (Patel, Diaz et al. 2007).

Meltzer et al performed a similar study in 2010, enrolling 368 patients with the goal to identify patients at low risk of having acute bacterial conjunctivitis. Five variables were associated with negative culture: age 6 years and older, presentation in April through November (study performed in Bronx, NY), absence of a glued eye in the morning and absence of photophobia. Overall results found that 92.3% (95%CI: 66.1-98.2%) of patients had negative culture if all four variables were present. With three variables, percentage decreased to 76.4% (95%CI: 63.6-85.6%). For children less than 6 years, two variables were associated with odds of negative culture including no or watery discharge and no glued eye in the morning. Findings not associated with difference in culture results included chemosis, erythema and household member with conjunctivitis (Meltzer, Kunkov et al. 2010).


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

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