Stewardship in the pediatrician’s office: Antibiotic prescribing for conjunctivitis

Asif Noor

Ulka Kothari

Pediatricians often face the challenge of diagnostic accuracy in conjunctivitis cases. Compared with the common clinical syndromes of otitis media and pharyngitis, conjunctivitis presents less frequently and does not require systemic antibiotics. Nonetheless, not every single red or pink eye needs antibiotic drops.

Conjunctivitis, or pink eye, is the inflammation of conjunctiva. It is the leading cause of day care and school absenteeism. It accounts for 1% of all primary care visits. The cause of conjunctivitis can be infectious (viral, bacterial) or noninfectious (allergens, irritants). Most cases in children are bacterial — 65% and 80% reported in two separate studies conducted in 1981 and 1993, respectively.

 

Eye drops are frequently prescribed in cases of pink eye. A large study in a managed care network found that 60% of patients filled antibiotic prescriptions when it was seldom necessary. Even when used appropriately for bacterial conjunctivitis, topical eye drops provide minimal benefit of shortening clinical recovery. In this column, we will discuss clinical features that can help differentiate between bacterial, viral and allergic causes of conjunctivitis.

Confronting the conundrum of appropriate antibiotic prescription

Acute conjunctivitis, or inflammation of conjunctiva, has an abrupt onset and lasts for less than 10 to 14 days. Symptoms of conjunctivitis include itching, burning, foreign body sensation and photophobia. Signs consist of hyperemia, epiphora, discharge (either watery or purulent), chemosis and regional lymphadenopathy (preauricular, submandibular).

Etiology

The three common causes of childhood conjunctivitis are bacterial, viral and allergic. Acute bacterial conjunctivitis is generally seen in preschool children. It is associated with mucopurulent discharge with matting of eyelids. The course is shorter compared with viral conjunctivitis. Typically, it is unilateral; however, it can be bilateral at onset. It does not cause adenopathy. Conjunctivitis due to nontypeable Haemophilus influenzae has an association with otitis media.

On the other hand, viral conjunctivitis is often seen in older children. It starts in one eye and involves the contralateral eye within a week. It is associated with regional adenopathy.

Prevalence of allergic conjunctivitis coincides with allergy season. It has a protracted course, waxing and waning throughout the allergy season. Symptoms highly suggestive of allergic conjunctivitis are itchiness, allergic shiners (dark circles), chemosis (swelling of conjunctiva) and rhinitis. Occasionally, allergic conjunctivitis is associated with asthma and eczema.

Other uncommon causes of conjunctival injection include vasculitis, such as Kawasaki disease or multisystem inflammatory syndrome in children due to COVID-19.

Microbiology

The three common bacteria responsible for conjunctivitis in children are nontypeable H. influenzae, Streptococcus pneumoniae and Moraxella — accounting for 54% to 73% of all cases.

Several viruses cause acute follicular conjunctivitis, such as:

• adenovirus type 3 and 7, which are associated with pharyngeal conjunctivitis;
• adenovirus 8, 19 and 37, which cause epidemic keratoconjunctivitis;
• herpes simplex virus; and
• picornaviruses, such as enterovirus 70 and coxsackie A 24, which cause hemorrhagic acute conjunctivitis.

Diagnostic approach

Clinical signs and symptoms can help differentiate between the causes of acute conjunctivitis, but often it can be challenging with overlapping features. See the Table comparing the three common causes of conjunctivitis in children.

Diagnostic tests

Most of cases of conjunctivitis do not require testing. Conjunctival swabs should be reserved for neonates, immunocompromised patients and those with suspected HSV infection. In a child with suspected adenoviral infection, a nasopharyngeal multiplex PCR swab can help provide definitive diagnosis. A bacterial swab/conjunctival scraping is high yield; however, it does not help in the decision of an empiric antibiotic. When bacterial conjunctivitis is suspected, the few choices are:

• Infants can be treated with polymyxin B/bacitracin or erythromycin ointment for 5 to 7 days.
• Older children can be given polymyxin B/trimethoprim solution, sodium sulfacetamide, tobramycin (which carries an increased risk of Streptococcus resistance) and fluoroquinolones (which are expensive and also increase the risk of drug resistance).

Schools and child care facilities often require children to be symptom free or on antibiotics for at least 24 hours before returning to school. In cases of bacterial conjunctivitis, ocular antibiotics might lessen transmission; however, it does not affect transmission in viral conjunctivitis. Conjunctivitis without fever does not necessitate exclusion from child care centers or schools.

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