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Summary Table

Category	Details
Risk Factors	Contact lens wear (especially extended-wear soft lenses), recent upper respiratory infection, close-contact settings (schools, daycares, dormitories), poor hand hygiene, ocular trauma, sexually active adults (gonococcal/chlamydial), neonates born to infected mothers
Etiology	Staphylococcus aureus (most common in adults), Streptococcus pneumoniae and Haemophilus influenzae (children), Moraxella catarrhalis, Pseudomonas aeruginosa (contact lens wearers), Neisseria gonorrhoeae (hyperacute), Chlamydia trachomatis (chronic/neonatal)
Patient Presentation	Red eye with thick, purulent, mucopurulent discharge; eyelids matted shut on awakening; foreign body or gritty sensation; onset often unilateral then becomes bilateral within 1 to 2 days
Classic Physical Exam	Diffuse conjunctival injection, crusting of lashes, yellow-green discharge re-accumulating after wiping, preserved visual acuity, no photophobia, no preauricular lymphadenopathy (distinguishes from viral), normal pupil and cornea
Key Diagnostic Results	Primarily a clinical diagnosis. Gram stain and culture reserved for hyperacute, severe, refractory, contact lens-related, or neonatal cases. Gram-negative intracellular diplococci suggests gonococcal disease. Giemsa stain shows intracytoplasmic inclusion bodies in chlamydial disease
Management	Topical antibiotics (trimethoprim-polymyxin B drops, erythromycin ointment, or fluoroquinolone drops). Contact lens wearers require antipseudomonal fluoroquinolone. Gonococcal disease requires intramuscular ceftriaxone 1 g single dose plus saline irrigation. Chlamydial disease requires oral azithromycin 1 g single dose or doxycycline 100 mg twice daily for 7 days
Keywords	"Eyelids stuck together in the morning," "mucopurulent discharge," "yellow-green crusting," "hyperacute red eye with copious discharge" (gonococcal), "contact lens wearer with red eye" (Pseudomonas), "neonate with conjunctivitis at day 5 to 14" (Chlamydia)

1. Pathophysiology

Bacterial conjunctivitis develops when pathogenic bacteria breach the normal ocular surface defenses, which include the tear film (containing lysozyme, lactoferrin, and immunoglobulin A), constant mechanical clearance by blinking, and the intact conjunctival epithelium. Once organisms adhere to and colonize the conjunctiva, they trigger an acute neutrophil-predominant inflammatory response, which explains the characteristic purulent (pus-filled) discharge. The accumulation of neutrophils, fibrin, and cellular debris overnight is what causes the eyelids to be matted shut on awakening, a classic vignette clue.

The conjunctival vasodilation produces the diffuse bulbar and palpebral injection, distinguishing it from the perilimbal "ciliary flush" of keratitis or iritis. Because the inflammation remains superficial and does not involve the cornea, iris, or deeper structures, visual acuity is preserved and photophobia is absent. This is a high-yield discriminator: any red eye with vision loss, severe pain, or photophobia is not simple conjunctivitis and warrants urgent evaluation for sight-threatening pathology.

Different organisms produce distinct clinical patterns. Neisseria gonorrhoeae is unique because it can penetrate intact corneal epithelium, making it a true ophthalmologic emergency that can cause corneal perforation within 24 to 48 hours. Chlamydia trachomatis is an obligate intracellular pathogen that produces a more indolent, chronic follicular reaction. In contact lens wearers, Pseudomonas aeruginosa secretes proteolytic exotoxins that can rapidly progress to bacterial keratitis with corneal ulceration, which is why these patients always require antipseudomonal coverage.

2. Classification and Clinical Manifestation

Classification	Timing	Organisms	Clinical Features
Acute (most common)	Symptoms less than 3 to 4 weeks; resolution typically within 1 to 2 weeks	S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis	Mucopurulent discharge, matted lids, mild irritation, self-limited
Hyperacute	Rapid onset within 12 to 24 hours	N. gonorrhoeae, N. meningitidis	Copious, profuse purulent discharge, marked lid edema, preauricular lymphadenopathy, risk of corneal ulceration and perforation
Chronic	Symptoms more than 4 weeks	C. trachomatis serotypes D to K (inclusion conjunctivitis); serotypes A to C (trachoma)	Follicular reaction on upper tarsal conjunctiva, scanty discharge, often coexisting genital infection
Neonatal (ophthalmia neonatorum)	Onset depends on pathogen	Chemical (day 1), Gonococcal (day 2 to 5), Chlamydial (day 5 to 14)	Bilateral discharge in newborn; gonococcal causes severe lid edema and risk of corneal perforation; chlamydial may progress to pneumonia

3. Diagnostic Workup

Test	Indication	Finding
Clinical evaluation	Best initial approach for routine cases	Purulent discharge, matted lids, no vision change, no photophobia
Gram stain	Hyperacute presentation, neonates, contact lens wearers, refractory cases	Gram-negative intracellular diplococci (gonococcal), Gram-positive cocci in clusters (Staph)
Bacterial culture	Same indications as Gram stain; confirmatory	Identifies organism and sensitivities
Giemsa stain / NAAT	Suspected chlamydial disease	Intracytoplasmic inclusion bodies (Giemsa); nucleic acid amplification is most sensitive
Fluorescein staining	Any concern for keratitis or corneal involvement	Should be negative in uncomplicated conjunctivitis; positive uptake suggests keratitis

For the routine, otherwise healthy patient with a typical mucopurulent red eye, bacterial conjunctivitis is a clinical diagnosis and no laboratory testing is required. Empiric topical antibiotic therapy is appropriate.

The best initial test when laboratory workup is indicated is Gram stain of conjunctival scrapings, which provides rapid information about the likely organism and allows targeted therapy. The most accurate/confirmatory test is bacterial culture on blood and chocolate agar, which identifies the organism definitively and provides antimicrobial sensitivities. Laboratory workup is indicated in any of the following: hyperacute presentation (rule out gonococcal disease), neonatal conjunctivitis, contact lens wearers (rule out Pseudomonas), immunocompromised patients, severe or refractory disease, and any patient with vision changes or suspected keratitis.

For suspected chlamydial conjunctivitis, the test of choice is nucleic acid amplification testing of conjunctival swabs, which is more sensitive than Giemsa stain. Coexisting genital infection should be evaluated. Fluorescein staining should always be performed if there is any concern for corneal involvement; a positive uptake pattern (especially dendritic or ulcerative) changes the diagnosis to keratitis and changes management entirely.

4. Management and Treatment

Clinical Scenario	First-Line Treatment	Duration
Routine acute bacterial conjunctivitis	Trimethoprim-polymyxin B drops, 1 to 2 drops every 3 to 6 hours OR erythromycin 0.5% ointment, applied to lower fornix four times daily	5 to 7 days
Contact lens wearer	Topical fluoroquinolone (moxifloxacin 0.5% or ciprofloxacin 0.3%), 1 drop every 2 to 4 hours initially; discontinue lens wear	7 days
Gonococcal (hyperacute)	Ceftriaxone 1 g intramuscular single dose plus saline lavage; treat for coexisting chlamydial infection empirically	Single dose; hospital admission often required
Chlamydial (adult inclusion)	Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily	Single dose or 7 days
Neonatal gonococcal	Ceftriaxone 25 to 50 mg/kg intravenous or intramuscular single dose (maximum 125 mg) plus saline irrigation	Single dose
Neonatal chlamydial	Oral erythromycin 50 mg/kg/day divided four times daily	14 days
Neonatal prophylaxis	Erythromycin 0.5% ointment to both eyes at birth	Single application

For the otherwise healthy patient with routine acute bacterial conjunctivitis, topical antibiotic therapy shortens the duration of symptoms and reduces transmission, although most cases would resolve spontaneously within 1 to 2 weeks. Trimethoprim-polymyxin B drops and erythromycin ointment are the typical first-line agents because of cost, efficacy, and minimal resistance concerns. Adjunctive measures include warm compresses to loosen crusting, frequent handwashing, avoiding eye rubbing, and discarding contaminated cosmetics.

Contact lens wearers require a fluoroquinolone such as moxifloxacin or ciprofloxacin because of the risk of Pseudomonas aeruginosa, which can rapidly cause bacterial keratitis and corneal melt. Contact lens use must be discontinued until the infection has cleared and the patient is asymptomatic for at least 24 hours after completing antibiotics.

Hyperacute gonococcal conjunctivitis is an ophthalmologic emergency. The next best step is intramuscular ceftriaxone 1 g as a single dose along with copious saline lavage to remove the purulent discharge. Empiric coverage for coexisting chlamydial infection with azithromycin should also be given, and the patient should be evaluated for other sexually transmitted infections. Failure to treat promptly can result in corneal perforation and permanent vision loss.

Chlamydial conjunctivitis in adults is treated with oral azithromycin 1 g single dose or doxycycline 100 mg twice daily for 7 days. Topical therapy alone is inadequate because of the systemic nature of the infection and the presence of concurrent genital tract infection in most patients. Sexual partners require evaluation and treatment.

In neonatal conjunctivitis, the timing of onset narrows the differential. Onset on day 1 suggests chemical conjunctivitis from silver nitrate prophylaxis (now largely replaced). Onset on day 2 to 5 suggests gonococcal disease, treated with parenteral ceftriaxone. Onset on day 5 to 14 suggests chlamydial disease, treated with oral erythromycin because topical therapy does not prevent the associated chlamydial pneumonia. Important contraindication: oral erythromycin in neonates carries a risk of infantile hypertrophic pyloric stenosis, particularly in those under 2 weeks of age, so parents should be counseled to watch for projectile vomiting.

Topical corticosteroids should never be prescribed empirically for a red eye because they can worsen undiagnosed herpetic keratitis and lead to corneal scarring or perforation.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It's Similar	Key Discriminator
Viral conjunctivitis (adenovirus)	Red eye, conjunctival injection, often bilateral, contagious	Watery (serous) discharge, preauricular lymphadenopathy, antecedent upper respiratory infection, gritty sensation more than purulence
Allergic conjunctivitis	Red, irritated eyes, often bilateral	Intense itching (the cardinal feature), watery or stringy mucoid discharge, history of atopy, seasonal pattern, cobblestone papillae on upper tarsal conjunctiva
Bacterial keratitis	Red eye, contact lens wearer, possibly with discharge	Pain, photophobia, decreased vision, positive fluorescein uptake showing corneal ulcer or infiltrate
Herpes simplex keratitis	Unilateral red eye, foreign body sensation	Dendritic ulcer on fluorescein staining, decreased corneal sensation, history of cold sores, do not give steroids
Anterior uveitis (iritis)	Red eye, photophobia	Ciliary flush (perilimbal injection), small or irregular pupil, photophobia worse with consensual light reflex, no discharge
Acute angle-closure glaucoma	Acute red eye, eye pain	Severe pain with nausea/vomiting, fixed mid-dilated pupil, hazy cornea, markedly elevated intraocular pressure, vision loss with halos around lights
Subconjunctival hemorrhage	Acute red eye	Painless, no discharge, blood under conjunctiva with sharp borders, normal vision
Dacryocystitis	Red, painful area near eye, possible discharge	Tender swelling over the lacrimal sac (medial canthus), purulent material expressed from punctum on pressure

6. Traps and High-Yield Pearls

The single most common error on this topic is failing to recognize the red flags that move the diagnosis away from simple conjunctivitis. A patient with a red eye who has vision loss, photophobia, severe pain, or ciliary flush does not have conjunctivitis, and choosing topical antibiotics for such a patient is the wrong answer regardless of how attractive the bacterial features appear. The core competency tested here is the ability to triage the red eye and recognize sight-threatening pathology (keratitis, uveitis, angle-closure glaucoma) hiding behind a vignette that looks superficially like a routine conjunctivitis.

The second classic trap is the contact lens wearer with a red eye. Even if the vignette emphasizes mucopurulent discharge and looks like standard bacterial conjunctivitis, the correct management is a fluoroquinolone with Pseudomonas coverage, not erythromycin or trimethoprim-polymyxin. Missing this leads to bacterial keratitis and corneal perforation. The question stem will often plant subtle clues such as "wears soft contact lenses overnight" or "rinses lenses with tap water."

The third high-yield trap is the hyperacute presentation. A vignette describing onset over hours with profuse, copious purulent discharge in a sexually active adult or in a neonate at day 2 to 5 is gonococcal conjunctivitis, which requires systemic ceftriaxone, not topical drops. The distinction matters because gonococcus can penetrate intact corneal epithelium and cause perforation within 24 to 48 hours.

Fourth, the discharge type is the highest-yield differentiating feature between the three common conjunctivitides: purulent and matted equals bacterial, watery with preauricular node equals viral, and itchy with stringy mucus equals allergic. If the vignette says "itchy," the answer is allergic, even if some bacterial features are mentioned as distractors.

Finally, in neonatal conjunctivitis, the timing of onset is the discriminator, and the chlamydial neonate requires oral erythromycin (not topical) because of concurrent pneumonia risk, while remembering the association with infantile hypertrophic pyloric stenosis is a frequent secondary testing point.

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