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Delayed Treatment Option

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 conjunctivitis.

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 option.

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 ophthalmic antibiotic.

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.