Vol 55: noVember
Canadian Family Physician
Le Médecin de famille canadien
Evdece-based treatmet f acute fectve cjuctvts
On examination, the patient is not in acute dis-tress. He is aebrile, has normal visual acuity, anddemonstrates moderate bilateral conjunctival injec-tion and tender preauricular nodes.The patient’s ather wants a prescription or oph-thalmic antibiotics because they have worked beore;the boy needs 24 hours o treatment beore he canreturn to school.
Surces f frmat
MEDLINE (rom January 1950), EMBASE (rom January 1980), and the Cochrane Database o SystematicReviews (rom January 1950) were searched until May 2009 using the ollowing MeSH terms:
physician practice patterns.
Also, or inormation on patient education materials,the MeSH terms searched were
methods, pamphlets, family practice, organization
primary health care.
The resultso the searches were limited to ull-text articles romcore clinical journals in the English language. Theterm
was searched in
using the ull review list option; the resultsused in this paper are based on a January 2007 search.Finally, the Guidelines Advisory Committee wassearched using the terms
but no results were ound. All research citedin this paper is based on level I or II evidence, and theinormation cited rom
is based onmoderate-quality evidence.
According to the evidence, antibiotics are notparticularly necessary or the resolution o bacterialconjunctivitis, at least not or most patients present-ing in primary care. A
summary o a Cochrane review o 3 randomized controlled tri-als (RCTs) and 1 subsequent RCT suggests there ismoderate-quality evidence that topical antibiotics areno more eective than placebo at increasing clinicalcure rates in people with suspected bacterial conjunc-tivitis at days 5 to 7.
Further, level I evidence showshigh spontaneous remission rates, marginal bene-fts, and low risk o adverse outcomes in patients nottreated with antibiotics.
Although there is empir-ical evidence to suggest topical antibiotics might havemarginal beneits as well,
the recommended man-agement strategy is to delay antibiotic use and pro-mote supportive care, such as requent eye cleansingwith sterile water and cotton balls, warm water com-presses, proper hand and eyelid hygiene, and tempo-rary use o artifcial tears or comort. I the symptomso conjunctivitis do not begin to improve within 2 dayso proper supportive management, the recommenda-tion is to then begin a topical antibiotic.
This “delay” style o management was evaluated inan RCT by Everitt et al that involved 307 adults and chil-dren with acute bacterial conjunctivitis diagnosed clini-cally by general practitioners in southern England.
Thestudy compared outcomes among patients prescribedantibiotic drops immediately, not at all, or in a delayedashion. The delayed approach was to give a prescrip-tion that could be flled 2 to 3 days ater diagnosis at thepatient’s discretion or worsening or persistent symp-toms. The fndings indicated that this approach reducedantibiotic use compared with immediate prescribing,despite similar duration and severity o symptoms.Also, the approach helped to prevent the medicaliza-tion o conjunctivitis, thereby reducing medical consul-tations or uture episodes. The success o the delayedapproach is consistent with results ound in the treat-ment o upper and lower respiratory tract inections.
The disadvantage, however, is the added time necessary to eectively educate patients on the sel-limiting natureo the condition.
Unnecessary antibiotic prescription.
This might beold news or many amily physicians, given that theguidelines and evidence or conservative managemento conjunctivitis with judicial antibiotic use have beenavailable or almost a decade. However, the problem iscompliance.In a retrospective study involving 195 amily medi-cine practitioners and more than 390 000 patients inthe Netherlands, 5213 new and recurrent episodes o inectious conjunctivitis were reported and 80% wereprescribed ophthalmic antibiotics over a 12-monthperiod.
This occurred even though the Dutch Collegeo General Practitioners had been widely distributing
Levels of evidence
At least one properly conducted randomizedcontrolled trial, systematic review, or meta-analysis
Other comparison trials, non-randomized,cohort, case-control, or epidemiologic studies, andpreerably more than one study
Expert opinion or consensus statements
Further research is very unlikely to change confdence in the estimate o eect
Further research islikely to aect confdence in the estimate o eectand might change that estimate
Further research is very likely to aect confdence in the estimate o eectand is likely to change that estimate