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Delayed Treatment

Is delayed treatment an option?

 

Rationale, current evidence, and consensus statement:

Everitt et al (2006) 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.  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.  The overall self-limiting nature of conjunctivitis in addition to the difficulty in determining viral or bacterial etiologies makes delayed prescribing a viable option, but there is limitations to this study in that it did not include patients < 1 year of age. 

In a review of bacterial conjunctivitis, Hovding (2008) established “pros and cons” for delay or no-treatment options for the infant or child with suspected bacterial conjunctivitis.  Caregivers may be provided the pros and cons of delayed treatment or no treatment based on their personal circumstances relating to work and job requirements as well as daycare or school attendance.
 

Delayed antibacterial treatment


Pros:

  • Reduced use of topical antibiotics

  • Reduced medicalization of an ‘innocent’ condition

  • Improved patient ‘education’ and responsibility

Cons:

  • Little or no reduction of health service attendance

  • Increased time out of work/education/kindergarten

 

No antibacterial treatment


Pros:

  • Very high percentage of spontaneous clinical cure ≤ 1 week

  • Less antibiotic ‘load’ on patient and society

  • No adverse events related to topical antibiotics

Cons:

  • Increased time out of work/education/kindergartens

  • Possible increased risk of transmitting the infection

  • At least a theoretically increased risk of complications

 

Based on current literature the Care Process Model team recommends consideration to delay treatment or provide a delayed prescription option for the infant or child with suspected bacterial conjunctivitis, with the knowledge that each situation will warrant a pragmatic approach by the healthcare provider in conjunction with the child’s caregiver.

 

References:

Everitt, H. A., Little, P. S., & Smith, P. W. (2006). A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. BMJ, 333(7563), 321. doi:10.1136/bmj.38891.551088.7C

Hovding G. (2008). Acute bacterial conjunctivitis. Acta Ophthalmol; 86: 5 – 17.

 

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.