How should I manage a patient with bacterial conjunctivitis who has not improved after 48 hours of treatment?

Management of bacterial conjunctivitis not improved after 48 hours of treatment:

• If a patient with bacterial conjunctivitis has not improved after 48 hours of treatment, consider sending swabs for bacterial culture and viral PCR (for adenovirus and Herpes simplex virus) to identify the causative organism and guide further treatment.
• If topical antibiotics have not yet been tried, consider offering empirical topical antibiotics such as chloramphenicol 0.5% drops (1 drop 2 hourly for 2 days, then reduce frequency) or fusidic acid 1% eye drops (1 drop twice daily), continuing treatment until 48 hours after infection clearance.
• Advise the patient on self-care measures including cleaning eyelids with sterile saline or cooled boiled water and avoiding contact lens use if applicable.
• If symptoms persist beyond 7 to 10 days despite treatment, consider referral to ophthalmology for further assessment.

This approach balances the self-limiting nature of most bacterial conjunctivitis cases with the need for targeted treatment and specialist referral if symptoms persist or worsen.

References: NICE CKS