#167 Keeping our eye on the ball for infectious conjunctivitis management

CLINICAL QUESTION

Do topical antibiotics benefit infectious conjunctivitis?

BOTTOM LINE

Nonvenereal infectious conjunctivitis is self-limited, with very low rates of complications. Topical antibiotics, compared to placebo, will lead to the resolution of symptoms in an additional ~1 in 12 patients at ~7 days. Delayed prescriptions (for three days) reduce overall antibiotic use with similar outcomes.

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EVIDENCE

Statistically significant unless otherwise mentioned.

- Topical antibiotics versus placebo.
  - Systematic review, 11 Randomized Controlled Trials (RCTs), 3,673 patients with clinically suspected or culture confirmed bacterial conjunctivitis, (nine specialty clinics, two in primary care).¹
    - Clinical resolution, antibiotics versus placebo:
      - At 2-5d (2,116 patients): 40% versus 30%, Number Needed to Treat (NNT)=10.
      - At 6-10d (2,353 patients): 50% versus 41%, NNT=12.
  - Systematic review, three primary care RCTs, 622 patients with clinically suspected infectious conjunctivitis.²
    - Cure rate at day seven, antibiotics versus placebo:
      - 80% versus 74%, NNT=17.
      - When no treatment is used (instead of placebo drops) greater absolute benefit are seen with antibiotics.³
- Delayed versus immediate antibiotics versus no prescription.³
  - Primary care RCT, 307 patients with clinically suspected infectious conjunctivitis.
  - Mean duration of moderate symptoms 4.8 days if no prescription.
    - Decreased by 1.5 days if immediate antibiotics.
    - Decreased by 0.9 day if delayed antibiotics.
    - Antibiotics were used by: 99% receiving immediate antibiotics, 53% delayed (three days), 30% no prescription.
    - No difference in symptom scores on days 1-3 following consultation.

Context:

The two main primary care RCTs used “infectious/acute conjunctivitis” as their inclusion criteria, suggesting that making a diagnosis of bacterial conjunctivitis (versus viral) is not essential when deciding to prescribe (or not) antibiotic drops.^3,4
No complications of acute bacterial conjunctivitis were reported in a systematic review of 11 RCTs.¹
Evidence does not demonstrate clear superiority of one topical antibiotic over another,^1,5 therefore practical considerations such as dosing and cost should be considered if antibiotics are prescribed.