Conjunctivitis and Conjunctivitis-Otitis Syndrome


Have you recently heard anyone say the following statement: “Around 80% of conjunctivitis is due to viruses. We often treat them with antibiotics, but it is more so the kid can go back to daycare.”  I certainly was taught that… and it really irritates me when I was taught incorrectly!

As with everything in Pediatrics, it depends on age.

  • Neonatal period (see Ophthalmia neonatorum (Jan. 28, 2011 Morsel):
    • Chemical irritant often presents in 1st day and is mild (and not that common now)
    • Big concern is for GC and Chlamydia, but other bacteria and viruses also possible.
  • Beyond neonate up to school age:
    • Acute Conjunctivitis is TWICE as likely to be due to BACTERIA than to viruses.
      • Non-typeable H. influenzae is the most common culprit
      • S. pneumoniae and B. catarrhalis are also encountered frequently
      • Should still consider GC and Chlamydia in the patient with abrupt onset of copious, purulent discharge, eyelid edema, and fever.
  • School-aged and older:
    • Most often is viral or allergic
    • ~20% of all conjunctivitis is due to adenovirus.
    • More prevalent in Fall and Winter
    • Epidemic keratoconjunctivitis more commonly afflicts adolescents and adults.
    • Don’t forget about HSV!


  • For Ophthalmia neonatorum, see Jan. 28, 2011 Morsel
  • For everyone else, recall that there is NO Reliable way to discern between bacterial vs viral etiologies.
  • Certainly, you can play the odds and diagnose viral conjunctivitis in the adolescent, but I definitely wouldn’t do that for the younger pre-school group.
  • Additionally, acute bacterial conjunctivitis is a SELF-LIMITED disease… so why bother at all?
    • We know that topical or systemic antibiotics lead to quicker clinical improvement and eradicate the bacteria from the conjunctiva when compared to placebo.
  • Bacitracin-polymyxin (Polysporin) or trimethoprim-polymyxin (Polytrim) are good first-line therapies as they cover the most common bacterial.

Conjunctivitis-Otitis Syndrome – special consideration

  • ~25% of patients with conjunctivitis have a concurrent otitis media, even in the ABSENCE of ear pain.
  • Every patient with conjunctivitis needs to have an examination of his/her TMs, as your management may change.
  • Non-typeable H. influenzae is the most common recovered bacterial. Identical pathogens are seen in the middle ear effusion and the purulent conjunctival discharge.
  • Younger children and those with multiple AOM that year had higher risk for developing Otitis media associated with the conjunctivitis.
  • For these patients, systemic (oral) antibiotics are recommended and the topical ophthalmic antibiotics are NOT necessary.
  • Antibiotics should cover beta-lactamase producing organisms.


Teoh DL, Reynolds S. Diagnosis and management of pediatric conjunctivitis. Pediatric Emergency Care: 2003; 19(1), pp. 48-55.

Ward ER. Conjunctivitis in infants and children. Pediatric Infectious Disease Journal: 1997; 16(2), pp.S17-S20.

Harrison CJ, Hendrick JA, Block SL, Gilchrist MJR. Relation of the outcome of conjunctivitis and the conjunctivitis-otitis syndrome to identifiable risk factors and oral antimicrobial therapy. Pediatric Infectious Disease Journal: 1987; 6(6), pp. 536-540.

Bodor FF, Marchant CD, Shurin PA, Barenkamp SJ. Bacterial etiology of conjunctivitis-otitis media syndrome. Pediatrics: 1985; 76(1), pp.26-28.

Bodor FF. Conjunctivitis-Otitis Syndrome. Pediatrics: 1982; 69(6), 695-698.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 580


  1. I agree with most of what you have written. I do question the ability for caregivers to get eyedrops in the eyes of young children. If I treat, I prefer erythromycin ointment for conjunctivitis without OM.

Comments are closed.