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Physicians disagree with conjunctivitis study results
A study suggests that because conjunctivitis often does not respond to antibiotics, the infection should not be treated. Some physicians disagree.
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Childhood acute infective conjunctivitis should be allowed to improve on its own without use of antibiotics, a new British study has suggested. Some U.S. pediatric ophthalmologists say the study’s conclusions may be flawed.
The study, conducted by Peter Rose, MD, and colleagues, suggests that because the infection often does not respond to antibiotic treatment, antibiotics should not be prescribed unless the infection does not clear. They cite the growing cases of antibiotic resistance and reduction of prescriptions for other childhood conditions, such as sore throat and otitis media.
The study’s authors also said that the health economic argument against antibiotic prescription for acute conjunctivitis is “compelling.” They said the cost of 1 million general practice consultations and prescriptions every year is substantial.
Dr. Rose and colleagues recommended that instead of administering antibiotics in every case of conjunctivitis, parents should cleanse their children’s infected eyes if drugs are not prescribed.
“Doctors should certainly now consider the evidence that antibiotics make little difference to the outcome, and give parents the option not to have treatment,” Dr. Rose said in an e-mail interview with Ocular Surgery News. “That is what I do, and a larger proportion of parents are relieved that the conjunctivitis will resolve by itself and that antibiotics are not essential.”
Cure rate
The study, published in the June 21 online edition of The Lancet, examined 326 children aged 6 months to 12 years with a clinical diagnosis of conjunctivitis. They were recruited from 12 general medical practices in the United Kingdom. One hundred and sixty-three children randomly received chloramphenicol eye drops and 163 received placebo eye drops. All children were followed up to 6 weeks to identify relapse. Adverse events were rare and evenly distributed between each group.
The study defined the primary outcome as clinical cure at day 7. The difference between the placebo and chloramphenicol groups was 3%. In the placebo group, 83% of 155 children were cured, while in the chloramphenicol group, 86% of 162 children were clinically cured. For children with bacterial pathogen, 80% of the placebo group and 85% of the chloramphenicol group were clinically cured in that time span.
For microbiological cure, the numbers fell significantly, with only 23% of the placebo study and 40% of the chloramphenicol groups cured in a week.
According to the study, those percentages make a difference of about a half-day more for conjunctivitis in children who do not take antibiotic drops. The study authors cast doubt on the possibility of another drug being more effective; studies of other drugs have not consistently shown benefits compared with chloramphenicol, they said.
Some physicians disagree with the study’s conclusions. They say that 7 days is an extended time period for curing conjunctivitis with antibiotics, suggesting that use of different drugs, such as fluoroquinolones, might have produced different results.
Rudolph S. Wagner, MD, OSN Pediatrics/Strabismus Section member, said conjunctivitis is usually cured in 3 days by antibiotics commonly used in the United States.
“The signs and symptoms of acute bacterial disease can be ameliorated with topical antibiotic therapy,” he said. “In addition, the use of some topical fluoroquinolones, particularly the [newest] generation, have been shown to shorten the course of the disease to 3 days or less in many cases.”
Loss of work, school days
According to Robert S. Gold, MD, OSN Pediatrics/Strabismus section editor, the fact that acute conjunctivitis is a self-limiting process, as the study states, is not “new news.” He said parents in this country want their children cured of conjunctivitis quickly, a standard met by physicians through antibiotics.
“Our society demands return to our daily routines as soon as possible and any disease process, including a possible contagious conjunctivitis, can delay this process by many days,” Dr. Gold said.
Dr. Rose and colleagues acknowledge in their article that allowing conjunctivitis to clear up without antibiotics has one major drawback: Many schools and day care centers exclude children from attending while infected. As a result, substantial school and workdays are lost, he said. While the study collected data totaling lost days, those numbers have not yet been published, Dr. Rose said.
“Until child care institutions and schools will allow children with conjunctivitis who are untreated to attend, this will still be a difficult area for working parents,” he stated.
Those lost work and school days could become a compounded problem, Dr. Wagner said, if untreated and infected children were sent back to school and day care centers before they were cured of conjunctivitis.
“If you’re not getting a more significant microbiological cure at day 7 or sooner, then you may have a higher likelihood of having an epidemic or spread of the conjunctivitis among contacts in the schools,” he said.
The study was not designed to assess the effect of nonprescription drugs on transmission rates, according to Dr. Rose and colleagues. They acknowledged that acute infective conjunctivitis is potentially transmissible, especially in children younger than 5 years.
“Despite our results, antibiotic treatment might still reduce the absolute number, and hence transmissibility of pathogens, and further research might be necessary if antibiotics cease to be prescribed for this disorder,” the study stated.
Placebo vs. chloramphenicol
The study used 0.5% chloramphenicol and a placebo of distilled water with the excipients boric acid 1.5% and borax 0.3%. While chloramphenicol is not commonly used in the United States for childhood conjunctivitis, it is the most popular drug for the infection in the United Kingdom, according to the study.
“Our microbiology results confirm that chloramphenicol does reduce the number of pathogenic bacteria in the eye, but eradication is not essential for a clinical cure,” the study stated. “Follow-up for 6 weeks after diagnosis showed that complications and relapse were uncommon, even without treatment.”
Dr. Wagner said he was concerned that the study’s placebo might not be a neutral treatment, as boric acid has been used for years as an eyewash. He said the placebo might have changed the study’s findings as a result.
“There may be some antiseptic effect in that,” he said. “Not only that, when you’re putting a drop in, you’re actually washing out the eye. You may be clearing out some organisms based on that, so that could account for some of the clinical improvement, just on that basis.”
Dr. Rose said he could not comment on the placebo or controls, which were made by Moorfields Eye Hospital pharmacy.
For Your Information:Reference:
- Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407-767-8160; e-mail: rsgeye@aol.com.
- Peter Rose, MD, a university lecturer, can be reached at the Department of Primary Health Care, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, England; 01865-226766 or 01491-838286; e-mail: peter.rose@public-health.oxford.ac.uk.
- Rudolph S. Wagner, MD, can be reached at Children’s Eye Center of New Jersey, 495 N. 13th St., Newark, NJ 07107; 973-485-3186; fax: 973-497-5674; e-mail: wagdoc@comcast.net.
- Rose P, Harnden A, et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: A randomized double-blind placedo-controlled trial. Lancet. 2005;366 (1):37-43.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.