Conjunctivitis - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Next review: 02/02/2019  
Clinical Guideline
CURRENT 
ID: 2267 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Conjunctivitis

Illness

Comments

Preferred option

Alternative

Conjunctivitis
CKS
LHP1678

Most bacterial conjunctivitis self-limiting.
65% resolve on placebo by day five 1A+
Red eye with muco-purulent (not watery) discharge. Starts in one eye but may spread to both 2C
Send eye swab for C and S for persistent or severe cases.
Fusidic acid has little Gram-negative activity 3
For Neonatal Conjunctivitis:
see LHP1678

If severe: 4,5B+
Chloramphenicol electronic Medicines Compendium information on Chloramphenicol
0.5% drop, 2 hourly for 2 days
then 4 hourly (whilst awake)
AND 1% ointment, at night

for 48 hours after resolution

Fusidic acid 1% gel, twice daily
or
Gentamicin 0.3% drop
2 hourly for 2 days
then 4 hourly (whilst awake)
for 48 hours after resolution

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.  
  6. Limit prescribing over the telephone to exceptional cases.
  7. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. Co-Amoxiclav (Amoxicillin-Clavulanate), quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  9. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

Provenance

Record: 2267
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Conjunctivitis
Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

A+ = systematic review: D = informal opinion
Conjunctivitis

  1. Sheikh A and Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2006. Issue 2. Link . Accessed 23.09.14. RATIONALE: Meta-analysis of five RCTs (n=1034) found that antibiotics (one trial each of ocular polymixin plus bacitracin, ciprofloxacin, norfloxacin, fusidic acid, and chloramphenicol) improve early clinical remission rates (Risk Ratio on days 2 to 5 1.24, 95% CI 1.05 to 1.45). Clinical remission rates compared with placebo are lower if remission is assessed later (Risk Ratio on days 6 to 10 1.11, 95% CI 1.02 to 1.21). However, most cases resolve spontaneously, with clinical remission being achieved in 65% (95% CI 59 to 70%) by days 2 to 5 in those receiving placebo.
  2. American Academy of Ophthalmology Corneal/External Disease Panel. Preferred Practice Pattern Guidelines. Conjunctivitis. American Academy of Ophthalmology. 2008. Diagnosis: this guideline contains a useful table of signs and symptoms for all causes of conjunctivitis.
  3. ABPI Medicines Compendium. Summary of product characteristics for Fucithalmic. 1997. Datapharm Communications Ltd. Link . Accessed 23.09.14. RATIONALE: Fucithalmic is active against a wide range of Gram positive organisms, particularly Staphylococcus aureus. Other species against which Fucithalmic has been shown to have in vitro activity include Streptococcus, Neisseria, Haemophilus, Moraxella and Corynebacteria.
  4. Rose PW, Harnden A, Brueggemann AB, Perera R, Sheikh A, Crook D, Mant D. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet 2005;366:37-43. RATIONALE: This study (n=326) found that most children presenting with acute infective conjunctivitis in primary care will get better by themselves, and there is no statistically significant difference between using placebo or chloramphenicol. Clinical cure by day 7 occurred in 83% of children given placebo compared with 86% of children given chloramphenicol. Risk difference 3.8%, 95% CI -4.1% to 11.8%.
  5. Reitveld RP, ter Riet G, Bindels PJ, Bink D, Sloos JH, van Weert HC. The treatment of acute infectious conjunctivitis with fusidic acid: a randomised controlled trial. Br J Gen Pract 2005;55:924-930. RATIONALE: This primary care-based study (n=163) found no statistically significant difference in clinical cure rates at 7 days in people using fusidic acid (62%) compared with placebo (59%). Adjusted risk difference 5.3%, 95% CI -11% to 18%.
  6. Walker S, Daiper CJ, Bowman R, Sweeney G, Seal DV, Kirkness CM. Lack of evidence for systemic toxicity following topical chloramphenicol use. Eye 1998;12:875-879. RATIONALE: Despite widespread prescribing of topical chloramphenicol, the incidence of aplastic anaemia in the UK remains low, and epidemiological data do not suggest an association between aplastic anaemia and topical chloramphenicol. Furthermore, a study of chloramphenicol levels in 40 patients found that chloramphenicol failed to accumulate to detectable levels in serum following one and two weeks of topical treatment.

Document history

LHP version 1.0

Related information

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