Child greater than 8 weeks of age
Clinical Question #4: In children
greater than 8 weeks presenting with acute conjunctivitis, are
there clinical signs or symptoms to help distinguish between
bacterial and viral etiologies?
We STRONGLY RECOMMEND based on low
quality evidence consideration of supportive care or alternative
diagnosis to bacterial conjunctivitis for patients that do not
present with mucopurulent discharge or a history of glued eyelids
upon awakening in the morning.
Rationale and Evidence Base
Rietveld et al performed a systemic literature review published
in British Medical Journal in 2003 concluding that classic
textbook teaching on the different clinical signs and symptoms
between viral and bacterial disease appear to be expert opinion and
not evidence based (Rietveld, van Weert et al. 2003). Since that
review, two prospective observational cohort studies in pediatric
patients have attempted to identify signs and symptoms to assist
the practitioner in which patients require treatment. Patel et al
evaluated 111 patients over one year and found that patients were
more likely to have a positive bacterial culture with a history of
gluey or sticky eyelids in the morning (OR, 5.0; 95% CI=1.8 to
13.7), exam findings of mucoid or purulent eye discharge (OR, 4.8;
95% CI=1.8 to 12.6) and eyelids or eyelashes crusting or gluing
(OR, 3.0; 95% CI=1.2 to 7.5). The combination of gluey or sticky
eyelids in the morning and purulent or mucoid discharge on physical
exam had a sensitivity of 85% (95% CI=76%-91%) with a specificity
of 73% (95% CI=40%-93%) and a positive likelihood ratio of 3.1 (95%
CI= 1.5-8.8). Interestingly, no association was identified between
age, daycare attendance, exposure to other patients with a "pink
eye" and a positive culture results (Patel, Diaz et al. 2007).
Meltzer et al performed a similar study in 2010, enrolling 368
patients with the goal to identify patients at low risk of having
acute bacterial conjunctivitis. Five variables were associated with
negative culture: age 6 years and older, presentation in April
through November (study performed in Bronx, NY), absence of a glued
eye in the morning and absence of photophobia. Overall results
found that 92.3% (95%CI: 66.1-98.2%) of patients had negative
culture if all four variables were present. With three variables,
percentage decreased to 76.4% (95%CI: 63.6-85.6%). For children
less than 6 years, two variables were associated with odds of
negative culture including no or watery discharge and no glued eye
in the morning. Findings not associated with difference in culture
results included chemosis, erythema and household member with
conjunctivitis (Meltzer, Kunkov et al. 2010).
These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.
It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.