Researcher analyzes over-prescription of antibiotics for acute conjunctivitis

COLORADO SPRINGS, Colo. — Acute conjunctivitis is typically managed by all types of health care providers, not just ophthalmologists. Even though the American Academy of Ophthalmology Preferred Practice Pattern guidelines state that “viral conjunctivitis will not respond to antibacterial agents and mild bacterial conjunctivitis is likely to be self-limited,” one study of U.S. health care claims data from a managed care plan found a preponderance of prescribing topical antibiotics, according to a study.

Six million cases per year of acute conjunctivitis represent hundreds of millions of dollars spent per year, Nakul Shekhawat, MD, told colleagues at the American Ophthalmological Society meeting here.

Nakul Shekhawat

“The purpose of our study was to determine the extent to which patients diagnosed with acute conjunctivitis are treated with topical antibiotics and also to determine factors associated with this antibiotic use,” Shekhawat said.

To be included, patients had an initial ICD-9 diagnosis of unspecified conjunctivitis, unspecified acute conjunctivitis or adenoviral conjunctivitis, and had to be continuously enrolled in the managed care plan for at least 14 days after initial diagnosis.

Outcome measures were topical antibiotic use of one or more prescriptions of all major antibiotic classes filled within 14 days of diagnosis. Fluoroquinolones, macrolides, aminoglycosides, sulfonamides, polymyxins and antibiotic-steroid combinations were considered.

Of 340,630 patients included in the study, 58% (198,511 patients) filled prescriptions for antibiotics within 14 days of diagnosis.

“Of note, among this group of patients, the majority, 98%, filled their prescriptions within 3 days of the diagnosis, not within 14 days,” Shekhawat said.

Fluoroquinolones were prescribed in 33% of cases, non-fluoroquinolones were prescribed in 51% of cases, and antibiotic-steroid combinations were prescribed in 20% of cases, “which are contraindicated in most cases of acute conjunctivitis,” Shekhawat said.

Of patients diagnosed with acute conjunctivitis by an ophthalmologist, 37% filled a prescription for topical antibiotics within 14 days of diagnosis. Of patients seen by an optometrist, that number was 45%; for family practitioners, 56%; for internists, 58%; for pediatricians, 59%; for urgent care physicians, 68%; and for other providers, 64%.

Sociodemographic factors influenced use, Shekhawat said, with younger, white, more affluent, more educated patients having higher odds of filling prescriptions for topical antibiotics; however, health factors, such as diabetes or HIV infection, did not appear to influence use.

“Interestingly, patients with end organ damage from diabetes, such as retinopathy or nephropathy, were less likely to receive antibiotics,” Shekhawat said.

Strengths of the study included a large sample size and an “unparalleled glimpse into real-world practice patterns,” Shekhawat said. The key limitation of the study was its inability to determine more information than was coded by the diagnosing physician.

“No doubt some patients in our study were appropriate candidates for antibiotics,” Shekhawat said. “Although high-quality epidemiological data regarding the relative incidence of bacterial vs. viral conjunctivitis is limited, it is very difficult to believe that 58% of red eyes presenting to primary outpatient facilities across the U.S. have a severe, unremitting bacterial infection that warrants immediate antibiotic therapy.” – by Patricia Nale, ELS

Reference:

Shekhawat N. Substantial over-prescription of antibiotics for acute conjunctivitis in the United States. Presented at: American Ophthalmological Society, May 19-22, 2016; Colorado Springs, Colo.

Disclosure: Shekhawat reports no relative financial disclosures.