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Bacterial Conjunctivitis … Does It Always Need Antibiotics?: Wise Use of Antibiotics

Column Author & Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

 

Acute infectious conjunctivitis affects 1 in 8 children annually, impacting 6 million people every year in the United States. The illness is estimated to result in over $1 billion in costs annually in the U.S. with $800 million in direct health care cost alone.1 Most cases of conjunctivitis are managed by primary care providers. Although the American Academy of Ophthalmology has guidance recommending avoiding topical antibiotics for most cases of pink eye,2 ophthalmic antibiotics continue to be one of the most commonly prescribed topical antibiotics, with nearly 60% of patients with conjunctivitis filling at least one topical antibiotic prescription.3

What are the most common causes of infectious conjunctivitis?

In adults, over 90% of infectious conjunctivitis cases are viral and occur predominantly in the summer. In children, however, viral conjunctivitis is much less frequent; bacterial conjunctivitis is responsible for 50%-75% of cases, and is observed mostly December through April.4 Common pathogens include Haemophilus influenzae (most commonly, non-typable H. influenzae), followed by Moraxella catarrhalis and Streptococcus pneumoniae.5,6 Other bacterial pathogens such as Staphylococcus aureus are much less frequent. Adenovirus, the most common cause of viral conjunctivitis, is highly contagious, and is associated with pharyngoconjunctivitis, as well as epidemic keratoconjunctivitis, a syndrome that has resulted in multiple outbreaks in schools and child care centers. 

How to differentiate different types of infectious conjunctivitis?

The clinical presentation of infectious conjunctivitis is often nonspecific. In 2003, a large meta-analysis failed to find any clinical studies correlating the signs and symptoms of conjunctivitis with the underlying cause.7 The same authors later conducted a prospective study and found that three signs (bilateral matting of the eyelids, lack of itching, and no history of conjunctivitis) can be used as predictors of bacterial conjunctivitis, though that study excluded children.8 A more recent systematic review that included both children and adults from 32 studies found no reliable differentiating sign or symptom.9 A purulent or mucopurulent discharge was more commonly encountered in cases of bacterial conjunctivitis (67% in bacterial vs. 21% in viral), while a watery discharge was more commonly seen in viral conjunctivitis (77% viral vs. 26% bacterial); bilateral symptoms were seen slightly more frequently in bacterial infections (59% vs. 44% viral).9 

Are topical antibiotics necessary to treat bacterial conjunctivitis?

Contrary to common practice, the vast majority of bacterial conjunctivitis cases are self-limiting and do not require antimicrobials to resolve.4 A recent randomized clinical trial of 88 children 6 months-7 years of age with acute infective conjunctivitis showed no difference in the time to clinical cure between moxifloxacin and placebo (difference 0.2, CI -2.2 to 1.6). However, both moxifloxacin eye drops and placebo shortened the time to clinical cure relative to no intervention, possibly from a washout effect or lubrication. Additionally, relapse at 14 days was higher in the antibiotic group (17% vs. 7.4%).10 A meta-analysis including that clinical trial and three previous randomized controlled trials of 584 children 1 months-18 years of age showed reduction in symptoms at days 3 and 6 in the topical antibiotic group compared to placebo, although the effect was modest (OR 0.59, CO 0.39-0.91).10 More importantly, antibiotics do not reduce the risk of severe complications, which are exceedingly rare, except in patients who use contact lenses. Topical antibiotics are not without adverse events, and result in changes to the protective microbiome and increase antimicrobial resistance, along with the risk of contamination to the contralateral eye. Finally, although antibiotic therapy used to be considered essential to reduce transmission in conjunctivitis, data suggest that transmission is in fact rare among household contacts of children with conjunctivitis.5 The American Academy of Ophthalmology’s conjunctivitis preferred practice plan therefore recommends avoiding use of topical antibiotics as most mild bacterial conjunctivitis cases are likely to be self-limited.2

What would happen if we stopped prescribing topical antibiotics for bacterial conjunctivitis?

A recent quality improvement project in Denver, Colorado, did just that! Using a multi-faceted approach, clinicians reduced the use of ophthalmic antibiotics in children with conjunctivitis from a baseline of ~50% to as low as 25% with no increase in failure rates.11

In conclusion, although bacterial conjunctivitis is more common in children than viral conjunctivitis, differentiating the two etiologies is difficult, and both conditions are self-limited. Thus topical antibiotics are rarely necessary for treating pediatric conjunctivitis. In the absence of statewide policies, child care center policies for return to school often dictate our managements.12 The American Academy of Pediatrics and the Centers for Disease Control and Prevention specify no exclusion from child care unless the patient has systemic symptoms. Improving our guidance and policies rather than exposing children to unnecessary possibly harmful antibiotics should be the focus of nationwide antimicrobial stewardship efforts.  

 

References:

  1. Pepose JS, Sarda SP, Cheng WY, et al. Direct and indirect costs of infectious conjunctivitis in a commercially insured population in the United States. Clin Ophthalmol. 2020;14:377-387. doi:10.2147/OPTH.S233486
  2. Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis preferred practice pattern®. Ophthalmology. 2019;126(1):P94-P169. doi:10.1016/j.ophtha.2018.10.020
  3. Shekhawat NS, Shtein RM, Blachley TS, Stein JD. Antibiotic prescription fills for acute conjunctivitis among enrollees in a large United States managed care network. Ophthalmology. 2017;124(8):1099-1107. doi:10.1016/j.ophtha.2017.04.034
  4. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721-9. doi:10.1001/jama.2013.280318
  5. Rose PW, Harnden A, Brueggemann AB, et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet. 2005;366(9479):37-43. doi:10.1016/S0140-6736(05)66709-8
  6. Mahoney MJ, Bekibele R, Notermann SL, Reuter TG, Borman-Shoap EC. Pediatric conjunctivitis: a review of clinical manifestations, diagnosis, and management. Children (Basel). 2023;10(5). doi:10.3390/children10050808
  7. Rietveld RP, van Weert HC, ter Riet G, Bindels PJ. Diagnostic impact of signs and symptoms in acute infectious conjunctivitis: systematic literature search. BMJ. 2003;327(7418):789. doi:10.1136/bmj.327.7418.789
  8. Rietveld RP, ter Riet G, Bindels PJ, Sloos JH, van Weert HC. Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms. BMJ. 2004;329(7459):206-10. doi:10.1136/bmj.38128.631319.AE
  9. Johnson D, Liu D, Simel D. Does this patient with acute infectious conjunctivitis have a bacterial infection?: the rational clinical examination systematic review. JAMA. 2022;327(22):2231-2237. doi:10.1001/jama.2022.7687
  10. Honkila M, Koskela U, Kontiokari T, et al. Effect of topical antibiotics on duration of acute infective conjunctivitis in children: a randomized clinical trial and a systematic review and meta-analysis. JAMA Netw Open. 2022;5(10):e2234459. doi:10.1001/jamanetworkopen.2022.34459
  11. Sebastian T, Durfee J, Wittmer N, et al. Reducing ophthalmic antibiotic use for non-severe conjunctivitis in children. J Pediatric Infect Dis Soc. 2023;12(9):496-503. doi:10.1093/jpids/piad065
  12. Sebastian T, Frost HM. A qualitative evaluation of pediatric conjunctivitis medical decision making and opportunities to improve care. J AAPOS. 2022;26(3):113 e1-113 e6. doi:10.1016/j.jaapos.2021.12.008

 

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