Clinical Question #5: In children
greater than 8 weeks with suspected bacterial conjunctivitis, is
delayed treatment a valid option?
We RECOMMEND based on low quality
evidence consideration for delayed treatment or delayed
prescription option for patients with suspected bacterial
Rationale and Evidence Base
Everitt et al published a randomized controlled trial on the
management strategies for treatment of acute infective
conjunctivitis comparing immediate antibiotic prescriptions on
initial presentation to a provider, delayed prescription for three
days and no prescription in the British Medical Journal in
2006. The authors advocate for a delayed prescribing strategy for
treatment of acute conjunctivitis in the primary care setting
identifying that delayed prescribing had an almost 50% reduction in
antibiotic use with patients experiencing similar symptom control
and fewer second visits to providers for continued symptoms
(Everitt, Little et al. 2006). The overall self limiting nature of
conjunctivitis in addition to the difficulty in determining viral
or bacterial etiologies makes delayed prescribing a viable
Clinical Question #6: In children
greater than 8 weeks presenting with acute conjunctivitis, what
therapy options are recommended?
We DO NOT RECOMMEND based on high
quality evidence specific treatment options for patients with
suspected bacterial conjunctivitis as various therapies have
demonstrated similar outcomes and available ophthalmic antibiotic
options are variable among pharmacies and insurance plans.
Rationale and Evidence Base
A Cochrane review published in 2009 reviewed five trials with a
total of 1034 adult and pediatric patients to determine the
literature support for antibiotics versus placebo in acute
bacterial conjunctivitis (Sheikh and Hurwitz 2006). Included
studies were heterogeneous in terms of treatment options utilized
and meta-analyses of data found that treatment with topical
antibiotics were beneficial in improving early (days 2-5) clinical
and microbiological remission. Late remission (days 6-10) also
showed a benefit, but the results were only marginally improved
compared to placebo. Overall, most cases resolved spontaneously
with clinical remission in 65% of patients on days 2-5 receiving
placebo with no serious outcomes reported in either treatment or
placebo group. Sight threatening complications were also
infrequently reported. Treatment options of the various studies
included: polymyxin and bacitracin, ciprofloxacin, norfloxacin,
fusidic acid and chloramphenicol.
Two studies published in the Journal of Pediatric
Ophthalmology and Strabismus argue that moxifloxacin is the
superior antibiotic choice in the treatment of conjunctivitis. When
comparing moxifloxacin to other antibiotic solutions, two reasons
provided in these articles are: 1) a faster rate of kill of S.
pneumonia in vitro (Lichtenstein, Dorfman et al. 2006) 2) a
quicker reduction in clinical symptoms (Granet, Dorfman et al.
2008). However, significant limitations were present in both of
these studies: 1) both were funded by the manufacture of
moxifloxacin, 2) the structure of the studies found an incomplete
description of the blinding and randomization process and 3) power
calculations and confidence intervals were not reported. These
limitations raise concerns for significant bias and therefore, do
not allow us to recommend a broad spectrum fluoroquinolone
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.