Bacterial Conjunctivitis

Imagine waking up with eyelids stuck together, a gritty feeling in your eye, and a noticeable redness staring back at you in the mirror. These are common indicators of conjunctivitis, an inflammation of the conjunctiva – the thin, transparent membrane that lines the inner surface of the eyelids and covers the white part of the eyeball (sclera). 

While conjunctivitis can have various causes, including viral infections, allergies, and irritants, bacterial conjunctivitis, often referred to as "pink eye" or "red eye" due to its characteristic redness, is a common and contagious form caused by bacterial invasion.

Bacterial conjunctivitis is an inflammation of the conjunctiva caused by a bacterial infection. The conjunctiva's role is to lubricate and protect the eye by producing mucus and tears. When bacteria invade this membrane, it triggers an inflammatory response, leading to the characteristic signs and symptoms of bacterial conjunctivitis.

The infection occurs when bacteria come into contact with the conjunctiva and multiply. These bacteria can originate from various sources, including:

• Direct contact with infected individuals: This can happen through hand-to-eye contact after touching someone with the infection or surfaces they have contaminated.
• Contaminated objects: Sharing personal items like towels, pillowcases, eye makeup, or contact lenses can spread the bacteria.
• Spread from other infections: Bacteria from nearby infections, such as a bacterial ear infection or sinusitis, can sometimes spread to the eye.
• Inadequate hygiene: Poor handwashing practices significantly contribute to the transmission of bacterial infections, including those affecting the eye.

Bacterial conjunctivitis is a common condition worldwide, affecting individuals of all ages, although it is particularly prevalent in children due to their close contact in school and daycare settings and potentially less rigorous hygiene practices.

• Staphylococcal conjunctivitis: Caused by Staphylococcus species, commonly Staphylococcus aureus. This can often present with a milder, more chronic form of bacterial conjunctivitis, sometimes associated with blepharitis (inflammation of the eyelids).
• Streptococcal conjunctivitis: Caused by Streptococcus species, including Streptococcus pneumoniae and Streptococcus pyogenes. This can sometimes be associated with a more mucopurulent (containing mucus and pus) discharge.
• Haemophilus influenzae conjunctivitis: Despite its name, Haemophilus influenzae is a bacterium, not a virus. It is a common cause of bacterial conjunctivitis, particularly in children, and often produces a sticky, watery discharge.
• Moraxella catarrhalis conjunctivitis: This bacterium is another common cause, often associated with a subacute or chronic form of conjunctivitis.
• Gonococcal and Chlamydial conjunctivitis: These are less common but more serious forms of bacterial conjunctivitis, often sexually transmitted. Neisseria gonorrhoeae and Chlamydia trachomatis can cause severe eye infections that can lead to serious complications if not treated promptly and aggressively. These often present with a copious purulent discharge and may be associated with systemic symptoms or genital infections.

Bacterial conjunctivitis is caused by various types of bacteria that can infect the conjunctiva. The most common culprits include:

• Staphylococcus aureus: A common bacterium found on the skin and in the nose. It can easily be transferred to the eyes through hand contact.
• Streptococcus pneumoniae: A bacterium known for causing pneumonia and ear infections, it can also infect the conjunctiva.
• Haemophilus influenzae: As mentioned, a common cause, especially in children.
• Moraxella catarrhalis: Another frequently implicated bacterium.

Less common but potentially more serious causes include:

• Neisseria gonorrhoeae: The bacterium responsible for gonorrhoea, it can cause a severe and rapidly progressive conjunctivitis that can lead to corneal ulceration and vision loss if not treated immediately. This is often acquired through genital-to-hand-to-eye contact or during childbirth in newborns of infected mothers.
• Chlamydia trachomatis: The bacterium that causes chlamydia, a sexually transmitted infection. Chlamydial conjunctivitis can present with a more chronic course and may be associated with genital infection. In newborns, it can be acquired during birth.

The transmission of these bacteria to the conjunctiva typically occurs through:

• Direct contact: Touching an infected eye or surfaces contaminated with the bacteria and then touching your own eye.
• Indirect contact: Sharing contaminated personal items like towels, washcloths, eye makeup, or contact lenses.
• Spread from other infections: Bacteria from a nearby infection, such as a staphylococcal skin infection or a streptococcal throat infection, can sometimes spread to the eye.
• Vertical transmission: In the case of gonococcal and chlamydial conjunctivitis in newborns, the infection can be transmitted from the mother during childbirth.

Understanding these modes of transmission is crucial for implementing effective hygiene practices to prevent the spread of bacterial conjunctivitis.

The symptoms of bacterial conjunctivitis can vary in severity but typically include one or more of the following:

• Redness in the white of the eye (sclera) and inner eyelid: This is a hallmark sign, giving rise to the term "pink eye" or "red eye". The redness can range from mild to intense.
• Thick, yellow, green, or white discharge from the eye: This purulent discharge is a key characteristic of bacterial conjunctivitis and helps distinguish it from viral or allergic conjunctivitis, which usually produce a clearer, watery discharge. The discharge can be continuous or intermittent.
• Stickiness of the eyelids: The discharge can cause the eyelids to stick together, especially upon waking in the morning, making it difficult to open the eyes.
• Gritty feeling in the eye: Many individuals describe a sensation of having sand or grit in their eye.
• Increased tearing: While the discharge is thick, there may also be an increase in tear production as the eye tries to flush out the infection.
• Itching or burning sensation: Some people may experience mild itching or a burning feeling in the affected eye.
• Blurred vision: Vision may be temporarily blurred, often due to the discharge coating the surface of the eye. Blinking or wiping the eye may temporarily improve clarity.
• Swollen eyelids: The eyelids may become slightly swollen due to inflammation.
• Crusting around the eyelids and eyelashes: Dried discharge can form crusts around the eyelids and eyelashes, particularly after sleep.

Typically, bacterial conjunctivitis starts in one eye and can easily spread to the other eye through hand contact. The symptoms usually develop within 24 to 72 hours of exposure to the bacteria. While the symptoms can be bothersome, bacterial conjunctivitis usually resolves with appropriate treatment within a week to ten days. However, prompt diagnosis and treatment are important to prevent complications and limit its spread.

Diagnosing bacterial conjunctivitis is usually based on a clinical examination of the eye and a review of the patient's symptoms and medical history. Further testing is typically not required for mild to moderate cases. The doctor will look for the characteristic signs, such as redness of the conjunctiva and the presence of a thick, purulent discharge.

The diagnostic process may involve:

• Medical history: The doctor will ask about the onset and duration of symptoms, any recent exposure to individuals with conjunctivitis, and any other relevant medical conditions or allergies.
• Physical examination: The doctor will examine the affected eye(s), looking at the conjunctiva, eyelids, and surrounding tissues. They will assess the colour and consistency of the discharge.
• Differentiation from other types of conjunctivitis: The doctor will try to differentiate bacterial conjunctivitis from viral conjunctivitis (which often has a more watery discharge and may be associated with a recent cold or sore throat) and allergic conjunctivitis (which typically involves significant itching and watery discharge, often affecting both eyes and associated with allergy symptoms).

In certain situations, the doctor may decide to take a sample of the eye discharge for laboratory analysis (culture and sensitivity testing). This is usually reserved for:

• Severe or persistent infections that do not respond to initial treatment.
• Cases of suspected gonococcal or chlamydial conjunctivitis.
• Neonatal conjunctivitis (eye infection in newborns), as this can be serious.
• Recurrent infections.

Culture and sensitivity testing can identify the specific bacteria causing the infection and determine which antibiotics will be most effective for treatment. However, for most common cases of bacterial conjunctivitis, empirical treatment (treatment based on the most likely causative bacteria) is usually initiated without laboratory confirmation.

The primary treatment for bacterial conjunctivitis is with antibiotic medications to eradicate the bacterial infection. The most common forms of treatment include:

• Antibiotic eye drops: These are usually the first-line treatment for most cases of bacterial conjunctivitis. Various types of antibiotic eye drops are available, including broad-spectrum antibiotics that are effective against a range of common bacteria. Examples include chloramphenicol, fusidic acid, ofloxacin, ciprofloxacin, moxifloxacin (Brand available: Moxicip) and tobramycin. The specific choice of eye drops may depend on local prescribing guidelines and the severity of the infection. The drops are typically instilled into the affected eye(s) several times a day for about five to seven days. It is important to complete the full course of antibiotics as prescribed, even if symptoms improve, to ensure the infection is completely cleared.
• Antibiotic eye ointment: Antibiotic ointments are another effective treatment option. They have the advantage of staying in contact with the eye for a longer period compared to eye drops, which can be particularly helpful for nighttime use, especially if eyelids are sticking together upon waking. Common antibiotic ointments include chloramphenicol and tetracycline. However, ointments can sometimes cause temporary blurring of vision.
• Oral antibiotics: In some cases, particularly for more severe infections, suspected gonococcal or chlamydial conjunctivitis, or if there is associated systemic infection, oral antibiotics may be prescribed in addition to or instead of topical treatments. For gonococcal and chlamydial infections, systemic treatment is crucial to address potential systemic involvement and prevent complications.

Supportive measures can also help to relieve symptoms:

• Warm compresses: Applying warm compresses to the affected eye(s) several times a day can help to soothe discomfort and loosen any crusting around the eyelids, making it easier to wipe away discharge.
• Artificial tears: Over-the-counter artificial tears can help to relieve dryness and irritation associated with the infection.
• Good hygiene practices: Frequent handwashing with soap and water is essential to prevent the spread of the infection to the other eye and to other people. Avoid touching your eyes as much as possible.

It is generally advised to avoid wearing contact lenses until the infection has completely cleared and for at least 24 hours after the last dose of antibiotic medication. Contaminated contact lenses should be discarded to prevent reinfection. Eye makeup should also be avoided during the infection and any potentially contaminated makeup should be replaced.

• Close contact with infected individuals: Being around someone with bacterial conjunctivitis increases your risk of getting it.
• Poor hygiene practices: Not washing hands properly makes it easier for bacteria to spread to your eyes.
• Sharing personal items: Sharing items like towels or eye makeup can transfer bacteria that cause eye infections.
• Contact lens wear: Improper contact lens care or overuse increases the risk of bacterial eye infections.
• Underlying eye conditions: Conditions like blepharitis make the eyes more prone to bacterial infections.
• Weakened immune system: A compromised immune system lowers the body’s defense against eye infections.
• Recent eye infection or injury: Previous eye issues can leave the eye vulnerable to new bacterial infections.
• Exposure to contaminated environments: Unsanitary conditions or water can expose the eyes to harmful bacteria.
• Age: Children are more susceptible due to close contact and developing hygiene habits.

• Keratitis: Infection spreading to the cornea can cause pain, vision issues, and light sensitivity.
• Corneal ulcer: Untreated infections can lead to open sores on the cornea, risking vision loss.
• Preseptal cellulitis: Severe infections may spread to eyelid tissues, needing urgent antibiotic treatment.
• Chronic conjunctivitis: Persistent or recurring symptoms may develop if not treated properly.
• Spread of infection: Some bacterial forms are highly contagious and can spread through contact or bodily fluids.
• Scarring of the conjunctiva: Severe or prolonged inflammation can lead to rare but serious scarring of the eye lining.

While you have bacterial conjunctivitis, these tips can help manage your symptoms and prevent further spread:

• Follow your doctor's instructions: Use antibiotic eye drops or ointment exactly as prescribed and complete the full course of treatment.
• Wash your hands frequently and thoroughly: This is the most important step in preventing the spread of the infection.
• Avoid touching your eyes: Resist the urge to rub or touch your eyes. If you need to touch them, wash your hands immediately before and after.
• Use warm compresses: Apply warm compresses to your eyes several times a day to soothe irritation and help loosen any crusting.
• Gently clean your eyelids: Use a clean, damp cloth to gently wipe away any discharge or crusting around your eyelids. Wash your hands immediately after.
• Avoid wearing contact lenses: Do not wear contact lenses until your infection has completely cleared and for at least 24 hours after finishing your antibiotic treatment. Discard any disposable lenses used during the infection and thoroughly clean and disinfect reusable lenses before wearing them again. It may be safest to discard reusable lenses as well to prevent reinfection.
• Do not share personal items: Avoid sharing towels, washcloths, eye makeup, and eye drops with others.
• Use a separate towel and pillowcase: Use a clean towel and pillowcase each day to avoid re-contaminating your eyes.
• Avoid eye makeup: Do not use eye makeup while you have an active infection, and discard any makeup used during this time to prevent reinfection.
• Stay home from school or work: To prevent spreading the infection, it is advisable to stay home from school or work until the discharge has stopped, typically 24-48 hours after starting antibiotic treatment. Check with your doctor or local guidelines for specific recommendations.
• Avoid swimming pools: Refrain from swimming in public pools while you are contagious.

Misconception: You can get pink eye just by looking at someone who has it.

Reality: Bacterial conjunctivitis is spread through direct or indirect contact with the infected eye's secretions. Simply looking at someone with pink eye will not cause you to get the infection.

Misconception: Pink eye will go away on its own without treatment.

Reality: While mild cases of bacterial conjunctivitis might sometimes resolve spontaneously, antibiotic treatment can shorten the duration of the infection, reduce the severity of symptoms, and decrease the period of contagiousness, thereby limiting its spread and the risk of complications.

Misconception: All red eyes are pink eye (bacterial conjunctivitis).

Reality: Redness of the eye can be caused by various conditions, including viral conjunctivitis, allergic conjunctivitis, dry eyes, eye irritation, or more serious eye problems. It's important to have a proper diagnosis to determine the cause and receive appropriate treatment.

It is advisable to see a doctor if you experience any symptoms of conjunctivitis, especially if you suspect it might be bacterial. Seek medical attention promptly if you experience any of the following:

• Significant eye pain.
• Sensitivity to light (photophobia).
• Blurred vision that does not improve with blinking.
• Intense redness of the eye.
• Copious or persistent thick, yellow, or green discharge.
• Symptoms that do not improve within 24-48 hours of home care measures (like warm compresses).
• If you wear contact lenses.
• If you have a weakened immune system.
• If a newborn develops symptoms of conjunctivitis. Neonatal conjunctivitis can be serious and requires immediate medical attention.
• If you suspect exposure to gonorrhoea or chlamydia.

When you see your doctor for suspected bacterial conjunctivitis, consider asking the following questions:

• What is the likely cause of my red eye? Do you think it's bacterial conjunctivitis?
• What type of treatment do you recommend? Will I need antibiotic eye drops or ointment?
• How often and for how long should I use the medication?
• Are there any potential side effects of the medication?
• How long will it take for my symptoms to improve?
• When is it safe for me to return to work or school?
• When is it safe for me to wear contact lenses again? Should I discard my current lenses?

Supporting someone with bacterial conjunctivitis involves understanding their discomfort and helping to prevent the spread of the infection:

• Encourage good hygiene: Gently remind them about the importance of frequent handwashing and avoiding touching their eyes.
• Avoid sharing personal items: Do not share towels, washcloths, eye makeup, or eye drops with them.
• Offer help: If their vision is temporarily blurred, offer assistance with tasks that require clear vision.
• Be mindful of contagion: Follow preventative measures yourself, such as frequent handwashing, especially after being in close contact.
• Encourage them to follow doctor's instructions: Remind them to use their medication as prescribed and to complete the full course.
• Offer comfort: Warm compresses can be soothing. You can offer to help prepare these.
• Avoid judgment: Bacterial conjunctivitis is common and can happen to anyone. Avoid making them feel self-conscious.
• Support their need to stay home: Understand that they may need to stay home from school or work to prevent spreading the infection.

Bacterial conjunctivitis is a common eye infection characterised by redness, discharge, and discomfort. It is typically mild and treatable with antibiotics. By practicing good hygiene, avoiding the sharing of personal items, and seeking timely medical attention, individuals can effectively manage bacterial conjunctivitis and protect their own health and the health of those around them.