Hong Kai Lim, BA, MB BChir1 Contact, Ashton Z. Lau2, Walton N. Charles, BSc (Hons), MBBS3, Roselin C. Charles, BSc (Hons), MBBS, FRCOphth4.
1Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK.
2The Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.
3Department of Surgery and Cancer, Imperial College London, London, UK.
4Department of Ophthalmology, Maidstone Hospital, Maidstone, UK.
Conflicts of Interest and Source of Funding: The author has no financial or conflicts of interest to disclose. No funding was sought or received for this work.
Infective conjunctivitis is a common ophthalmic condition encountered in general practice. Topical antibiotics are often routinely prescribed in primary care for this generally self-limiting condition, despite evidence-based guidance consistently recommending otherwise. Injudicious antimicrobial prescribing has important social, economic, and public health consequences. This review discusses the evidence-based management of infective conjunctivitis and the implications of overprescribing antibiotics for this condition in primary care.
Infective conjunctivitis describes conjunctival inflammation of viral or bacterial aetiology and is frequently encountered by general practitioners (GPs) within the UK and worldwide, accounting for approximately 1–2% of all consultations (1, 2). Common clinical features of infective conjunctivitis include conjunctival injection, watery or purulent discharge, foreign body sensation, and mild photophobia.
In most cases, infective conjunctivitis is mild and self-limiting, with remission occurring within 5–7 days. It generally resolves without medical intervention and evidence-based guidelines consistently advocate for limited and judicious antimicrobial usage (3). However, the antibiotic prescription rate for infective conjunctivitis is inappropriately high among GPs worldwide (4–6). This prescribing behaviour is multi-factorial and has important social, economic, and public health implications. This review discusses the evidence-based management of infective conjunctivitis, the prescribing behaviours of GPs, and the benefits of improving antimicrobial stewardship in primary care.
Pathogenic ambiguity between bacterial and viral causes of conjunctivitis, coupled with beliefs that bacterial infections require prescription antibiotics, has meant that topical antibiotics have traditionally formed the standard treatment for infective conjunctivitis (7, 8). Since then, several landmark randomised controlled trials and systematic reviews have confirmed high rates of resolution without treatment and only modest benefit conferred by antibiotics in bacterial conjunctivitis (1, 2, 9–11).
A strategy of delayed antibiotic prescribing for 3 days was observed to rationalise antibiotic use, reduce reattendance, and prevent ‘medicalisation’ of the self-limiting condition, while offering symptom management comparable to immediate prescribing (9). The UK Royal College of General Practitioners subsequently recommended the uptake of this strategy alongside conservative management, such as reassurance and self-care measures for symptomatic relief (3).
Caution is however emphasised regarding specific patient populations, including conjunctivitis in neonates and contact lens wearers demonstrating conjunctivitis-like symptoms, due to the potentially sight threatening complications of delayed treatment (3).
Evidence-based guidelines consistently advocate against routine antibiotic prescribing for infective conjunctivitis, but prescription rates remain high in primary care. Approximately, 900,000 and 3.4 million annual prescriptions for topical ocular antibiotics occur in the Netherlands and the UK, respectively (6).
In a study of over 390,000 patients in the Netherlands, 80% of infectious conjunctivitis cases were prescribed antibiotics over 12 months (4). Similarly, an Australian study of GP registrars reported that antibiotics were prescribed in 74% of new cases (5). Although currently there is no recognised benchmark recommendation regarding antibiotic prescription for infective conjunctivitis in primary care, these rates can be considered in excess of what is justified by guidelines.
Overprescribing may contribute to public misapprehension of the disease, generate unnecessary costs, and delay care for more serious conditions resembling conjunctivitis (12). Several studies have investigated barriers to changing prescribing practices among GPs. A network of contributary factors was established from a qualitative survey of GPs, parents of children with infective conjunctivitis, and schools and childcare facilities in the UK (13). Parents’ desire to return their children to school and views regarding the necessity of antibiotics for preventing serious consequences were key drivers in seeking antimicrobials (13).
Furthermore, healthcare providers are poor discriminators of viral from bacterial aetiology in conjunctivitis. A Dutch study of 177 adults highlighted this, demonstrating the diagnosis can be incorrect in approximately 50% of cases despite identification of ‘classical’ features of bacterial conjunctivitis (8).
Suboptimal ophthalmic teaching in medical school, as reported by a recent national survey, may also contribute (14). Over 90% of GPs are reported to prescribe antibiotics for conjunctivitis even for cases considered to be of viral origin, often using diagnostic ambiguity to justify prescription, which reinforces patients’ beliefs (7). This is further complicated by regulatory policy including the UK Medicines and Healthcare Products Regulatory Agency’s decision to allow topical chloramphenicol to be sold over-the-counter for infective conjunctivitis, which is reported to have caused a 48% usage increase (1).
Improving Prescribing Practices
The appropriate management of infective conjunctivitis in primary care depends substantially on medical education. Resource sharing between professional organisations may improve ophthalmology’s presence in training curricula and so improve diagnostic confidence, awareness of best-practice guidelines, and establish rational prescribing habits at an earlier stage.
However, such approaches may still be limited by the inherent difficulty in differentiating viral and bacterial conjunctivitis clinically. Cost-effective microbiological testing may be the only way to tackle diagnostic uncertainty at the point of care. This is recommended for severe or atypical cases but its utility is somewhat limited in routine practice due to a lack of perceived therapeutic impact and the potential for further ‘medicalising’ a self-limiting illness (3, 9).
With sufficient organisational restructuring, one possibility is to implement the current framework for simple urinary tract infections in the UK, namely Pharmacy First, where low-risk cases may be managed at selected pharmacies, thereby facilitating appropriate triage (15). Regardless, informed clinicians should recognise the importance of reassurance and educating patients about the self-limiting nature of the condition, which a delayed prescribing strategy permits.
Qualitative research indicates patients’ lack of awareness of the largely benign natural history of conjunctivitis as an important factor underlying attendance for antibiotics (9). When adequately informed, patients were prepared to forego a prescription, with their satisfaction further improved by the provision of information leaflets (9). This highlights the importance of patient education in managing medical expectations, which becomes increasingly relevant with the greater availability of over-the-counter ocular antimicrobials. While empowering patients to manage their own health, these policy changes also contradict public antibiotic stewardship efforts (1).
Although prudent antibiotic prescribing is high on the public health agenda and is reflected in established evidence-based guidelines, antibiotics continue to be used injudiciously for infective conjunctivitis in primary care.
Determinants of prescribing patterns are complex and interrelated, including both clinical and non-clinical factors such as diagnostic confidence, patient beliefs, and public health policy. Greater clarity in guidelines, confidence in prescribing, and management of patient expectations will be important to improve suboptimal rates of antibiotic prescription for infective conjunctivitis.
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