Evidence-based treatment of acute infective conjunctivitis

Case description

A 5-year-old boy presents with a 3-day history of watery discharge from his right eye. The eye is red. Similar findings have been demonstrated in his left eye as of that morning. He is not particularly photophobic and his eyes are not itchy. He is healthy, but just got over an upper respiratory tract infection approximately 3 days ago.

On examination, the patient is not in acute distress. He is afebrile, has normal visual acuity, and demonstrates moderate bilateral conjunctival injection and tender preauricular nodes.

The patient’s father wants a prescription for ophthalmic antibiotics because they have worked before; the boy needs 24 hours of treatment before he can return to school.

Sources of information

MEDLINE (from January 1950), EMBASE (from January 1980), and the Cochrane Database of Systematic Reviews (from January 1950) were searched until May 2009 using the following MeSH terms: conjunctivitis with bacterial, diagnosis, epidemiology, and drug therapy; conjunctivitis with viral, diagnosis, epidemiology, and drug therapy; family practice with standards, statistics, and numerical data; and physician practice patterns. Also, for information on patient education materials, the MeSH terms searched were patient education with methods, pamphlets, family practice, organization and administration, and primary health care. The results of the searches were limited to full-text articles from core clinical journals in the English language. The term conjunctivitis, bacterial was searched in Clinical Evidence using the full review list option; the results used in this paper are based on a January 2007 search. Finally, the Guidelines Advisory Committee was searched using the terms conjunctivitis, red eye, and pink eye, but no results were found. All research cited in this paper is based on level I or II evidence, and the information cited from Clinical Evidence is based on moderate-quality evidence.

Main message

According to the evidence, antibiotics are not particularly necessary for the resolution of bacterial conjunctivitis, at least not for most patients presenting in primary care. A Clinical Evidence summary of a Cochrane review of 3 randomized controlled trials (RCTs) and 1 subsequent RCT suggests there is moderate-quality evidence that topical antibiotics are no more effective than placebo at increasing clinical cure rates in people with suspected bacterial conjunctivitis at days 5 to 7.6 Further, level I evidence shows high spontaneous remission rates, marginal benefits, and low risk of adverse outcomes in patients not treated with antibiotics.2,4,6,7,10 Although there is empirical evidence to suggest topical antibiotics might have marginal benefits as well,6 the recommended management strategy is to delay antibiotic use and promote supportive care, such as frequent eye cleansing with sterile water and cotton balls, warm water compresses, proper hand and eyelid hygiene, and temporary use of artificial tears for comfort. If the symptoms of conjunctivitis do not begin to improve within 2 days of proper supportive management, the recommendation is to then begin a topical antibiotic.6

This “delay” style of management was evaluated in an RCT by Everitt et al that involved 307 adults and children with acute bacterial conjunctivitis diagnosed clinically by general practitioners in southern England.7 The study compared outcomes among patients prescribed antibiotic drops immediately, not at all, or in a delayed fashion. The delayed approach was to give a prescription that could be filled 2 to 3 days after diagnosis at the patient’s discretion for worsening or persistent symptoms. The findings indicated that this approach reduced antibiotic use compared with immediate prescribing, despite similar duration and severity of symptoms. Also, the approach helped to prevent the medicalization of conjunctivitis, thereby reducing medical consultations for future episodes. The success of the delayed approach is consistent with results found in the treatment of upper and lower respiratory tract infections.11–13 The disadvantage, however, is the added time necessary to effectively educate patients on the self-limiting nature of the condition.

Case resolution

A focused history and physical examination should be done to make a clinical diagnosis of acute infective conjunctivitis and to rule out any red flags that might indicate a different and potentially more serious condition (Table 1).

The parent or patient should be given a well-designed pamphlet that uses simple language and pictures to outline a description of the condition, how it is treated, reasons to make a follow-up appointment, and when to fill the postdated antibiotic prescription (if applicable).

The physician should quickly go over the most important aspects of the pamphlet with the parent or patient and answer any questions. If the delayed prescribing method is chosen, then a postdated prescription for antibiotics can be provided that the patient can use should the symptoms worsen over the next 3 days.

Conclusion

Acute infective conjunctivitis is the most common ocular complaint dealt with in family practice. This condition has both viral and bacterial causes, which can be difficult to differentiate on clinical grounds. Regardless of the cause, however, evidence suggests that the most reasonable approach to treatment in primary care is patient education and supportive management, with delayed or no prescribing of antibiotics. The patient education component, although often time-consuming, is important for changing the management expectations of parents, schools, and day cares, thereby decreasing the pressure on general practitioners to prescribe antibiotics. To help, evidence suggests that properly designed information pamphlets are a cost-effective and safe way to facilitate education and increase patient satisfaction. Further, the empowering effects of education will give parents enough confidence to manage this simple ailment at home, thereby improving the community’s efforts to prevent antibiotic resistance.