Predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms

Synergism of polysaccharide polymers in antihistamine eye drops: Influence on physicochemical properties and in vivo efficacy

The incorporation of polymers into drug delivery vehicles has been shown to be a useful approach to prolong the residence time of drugs in the precorneal tear film and to improve penetration into biological membranes. The main objective of this research was to formulate novel viscous eye drops with ketotifen as the active ingredient, containing the polysaccharides: chitosan (MCH), hydroxypropyl guar gum (HPG) and hyaluronic acid (SH) alone and in combination as functional polymers. DSC and FT-IR techniques showed the compatibility between ketotifen and polymers. Physicochemical and rheological analysis at ambient and simulated physiological conditions, as well as the evaluation of mucoadhesive properties showed that vehicles containing combinations of polymers have suitable physicochemical and functional properties with demonstrated synergism between combined polymers (MCH and HPG i.e. SH and HPG). The drug permeability was successfully estimated in vitro using HCE-T cell-based models. MTT cytotoxicity assay demonstrates that the tested formulations were non-toxic and well tolerated. In vivo preclinical study on mice revealed that both vehicles containing mixed polymers enhanced and prolonged the antipruritic/analgesic-like effect of ophthalmic ketotifen. Based on these results, both combinations of polysaccharide polymers, especially SH-HPG, could be considered as potential new carriers for ketotifen for ophthalmic use.

Topical Antibiotic Therapy in the Ocular Environment: The Benefits of Using Moxifloxacin Eyedrops

Moxifloxacin is a fourth-generation fluoroquinolone antibiotic available for ophthalmic use. It inhibits two enzymes involved in bacterial DNA synthesis, covering Gram-positive and Gram-negative pathogens. This spectrum allows for the formulation of self-preserving bottle solutions, while its interesting pharmacological profile is distinguished by efficacy at low tissue concentrations and by an infrequent dose regimen due to its long duration on ocular tissues. This enhances patient compliance, promoting its use in children. The human eye hosts several microorganisms; this collection is called the ocular microbiota, which protects the ocular surface, assuring homeostasis. When choosing an antibiotic, it is appropriate to consider its influence on microbiota. A short dose regimen is preferred to minimize the impact of the drug. Moxifloxacin eyedrops represent an effective and safe tool to manage and prevent ocular infections. As healthcare providers face the complexity of the ocular microbiota and microbial resistance daily, the informed use of moxifloxacin is necessary to preserve its efficacy in the future. In this regard, it is well known that moxifloxacin has a lower capacity to induce resistance (an optimal WPC and MPC) compared to other quinolones, but much still needs to be explored regarding the impact that fluoroquinolones could have on the ocular microbiota.

Corneal Specialists' Confidence in Identifying Causal Organisms of Microbial Keratitis

PURPOSE

Microbial keratitis (MK) is a potentially blinding corneal disease caused by an array of microbial etiologies. However, the lack of early organism identification is a barrier to optimal care. We investigated clinician confidence in their diagnosis of organism type on initial presentation and the relationship between confidence and presenting features.

METHODS

This research presents secondary data analysis of 72 patients from the Automated Quantitative Ulcer Analysis (AQUA) study. Cornea specialists reported their confidence in organism identification. Presenting sample characteristics were recorded including patient demographics, health history, infection morphology, symptoms, and circumstances of infection. The association between confidence and presenting characteristics was investigated with 2-sample t-tests, Wilcoxon tests, and Chi-square or Fisher's exact tests.

RESULTS

Clinicians reported being "confident or very confident" in their diagnosis of the causal organism in MK infections for 39 patients (54%) and "not confident" for 33 patients (46%). Confidence was not significantly associated with patient demographics, morphologic features, or symptoms related to MK. MK cases where clinicians reported they were confident, versus not confident in their diagnosis, showed significantly smaller percentages of previous corneal disease (0% versus 15%, p = 0.017), were not seen by an outside provider first (69% versus 94%, p = 0.015), or had no prior labs drawn (8% versus 33%, p = 0.046), and a significantly larger percentage of cases wore contact lenses (54% versus 28%, p = 0.029).

CONCLUSION

In almost half of MK cases, cornea specialists reported lack of confidence in identifying the infection type. Confidence was related to ocular history and circumstances of infection but not by observable signs and symptoms or patient demographics. Tools are needed to assist clinicians with early diagnosis of MK infection type to expedite care and healing.

Chlamydia psittaci -Induced Reactive Infectious Mucocutaneous Eruption With Ocular Involvement

INTRODUCTION

This report highlights a postinfectious mucocutaneous inflammatory response involving the ocular surface and adnexa after Chlamydophila psittaci exposure.

CASE DESCRIPTION

A 35-year-old man presented after a prodrome of upper respiratory symptoms with rash and mucocutaneous blistering involving the ocular and oral mucosa, causing pseudomembranous conjunctivitis and corneal epithelial defects. Extensive inflammatory and infectious workup suggested recent C. psittaci infection. The patient was treated with doxycycline and supportive therapy, whereas the ocular surface was treated with lubrication and prophylactic antibiotics. In follow-up, he has retained excellent visual acuity but required scleral contact lenses to control ocular surface symptoms because of fibrotic changes of the marginal conjunctiva.

DISCUSSION

Such blistering inflammation has most commonly been described after pediatric respiratory infections because of Mycoplasma pneumoniae with additional instances related to Chlamydia pneumoniae , Epstein-Barr virus, influenza B, and other stimuli . To the best of our knowledge, this is the first reported case of C. psittaci- induced reactive infectious mucocutaneous eruption (RIME). RIME is a rare parainfectious inflammatory condition with sequelae frequently involving the periocular mucosa. Although systemic and nonocular adverse outcomes in this condition tend to be self-limited, the impact on the ocular surface may be severe, and the consequences to vision may be ongoing, especially if not treated aggressively at the outset.

Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management

Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.

Scanning Electron Microscopy of Conjunctival Scraping: Our Experience in the Diagnosis of Infectious Keratitis with Negative Culture Tests

65 consecutive patients with presumed microbial keratitis and negative culture tests for bacteria and fungi obtained by corneal curettage were evaluated. All patients had undergone local broad spectrum antibiotic therapy for at least 5 days with no clinical improvement. After 48–72 h of wash-out they underwent scraping of the superior tarsal conjunctiva for cytological examination of cellular morphology in Scanning Electron Microscopy (SEM). The presence of pathogenic microorganisms was detected with this method in 62 of these patients, towards which specific therapy was carried out. Clinical improvement and eradication of microorganisms previously detected by SEM examination were observed in all positive patients over a time between 10 and 49 days. In three patients, no microorganisms were detected, but the presence of inflammatory cells (eosinophils and mast cells) or dry eye findings. This method could be useful to detect the presence of non-isolated microorganisms at common culture tests. The resolution of the infectious keratitis and the eradication of the pathogens at the subsequent cytological examination of cellular morphology in Scanning Electron Microscopy support the validity of the proposed method.

Biopolymers in Mucoadhesive Eye Drops for Treatment of Dry Eye and Allergic Conditions: Application and Perspectives

Dry eye syndrome and allergic conjunctivitis are the most common inflammatory disorders of the eye surface. Although eye drops are the most usual prescribed dosage form, they are characterized by low ocular availability due to numerous barrier mechanisms of the eye. The use of biopolymers in liquid ophthalmic preparations has numerous advantages, such as increasing the viscosity of the tear film, exhibiting bioadhesive properties, and resisting the drainage system, leading to prolonged retention of the preparation at the site of application, and improvement of the therapeutic effect. Some mucoadhesive polymers are multifunctional excipients, so they act by different mechanisms on increasing the permeability of the cornea. Additionally, many hydrophilic biopolymers can also represent the active substances in artificial tear preparations, due to their lubrication and moisturizing effect. With the modification of conventional ophthalmic preparations, there is a need for development of new methods for their characterization. Numerous methods for the assessment of mucoadhesiveness have been suggested by the literature. This review gives an overview related to the development of mucoadhesive liquid ophthalmic formulations for the treatment of dry eye and allergic conditions.

Appropriateness of Antibiotic Prescribing for Acute Conjunctivitis: A Cross-Sectional Study at a Specialist Eye Hospital in Ghana, 2021

Most presentations of conjunctivitis are acute. Studies show that uncomplicated cases resolve within 14 days without medication. However, antibiotic prescription remains standard practice. With antimicrobial resistance becoming a public health concern, we undertook this study to assess antibiotic prescription patterns in managing acute conjunctivitis in an eye hospital in Ghana. We recorded 3708 conjunctivitis cases; 201 were entered as acute conjunctivitis in the electronic medical records (January to December 2021). Of these, 44% were males, 56% were females, 39% were under 5 years, 21% were children and adolescents (5-17 years) and 40% were adults (≥18 years). A total of 111 (55.2%) patients received antibiotics, of which 71.2% were appropriately prescribed. The use of antibiotics was more frequent in children under 17 years compared to adults (p < 0.0001). Of the prescribed antibiotics, 44% belonged to the AWaRe "Access" category (Gentamycin, Tetracycline ointment), while 56% received antibiotics in the "Watch" category (Ciprofloxacin, Tobramycin). Although most of the antibiotic prescribing were appropriate, the preponderance of use of the Watch category warrants stewardship to encompass topical antibiotics. The rational use of topical antibiotics in managing acute conjunctivitis will help prevent antimicrobial resistance, ensure effective health care delivery, and contain costs for patients and the health system.

Does This Patient With Acute Infectious Conjunctivitis Have a Bacterial Infection?: The Rational Clinical Examination Systematic Review

IMPORTANCE

Acute infectious conjunctivitis is characterized by ocular redness and discharge, and is a common clinical entity. Evidence-based tools to aid the clinical diagnosis of viral vs bacterial conjunctivitis are lacking and may contribute to overprescribing of topical antibiotics.

OBJECTIVE

To determine the relative prevalence of viral vs bacterial conjunctivitis in adults and children, and to determine which symptoms or signs are suggestive of a viral vs bacterial etiology.

DATA SOURCES

A MEDLINE search (January 1946-March 2022) yielded 1891 articles. Included articles were rated using a quality score based on a modified Rational Clinical Examination grading system. Methodological quality levels 1 through 4 required a microbiological reference standard for diagnosis, whereas quality level 5 (the lowest quality) used a clinical reference standard for diagnosis.

STUDY SELECTION

Consecutive series of patients presenting with acute infectious conjunctivitis and case series of viral or bacterial conjunctivitis alone. Thirty-two studies were included in a meta-analysis to determine prevalence and diagnostic accuracy measures; 27 used a microbiological reference standard for diagnosis and 5 used a clinical reference standard for diagnosis.

RESULTS

In studies involving children (5 studies; 881 patients; mean age, 4.7 years [age range, 1 month-18 years]), the prevalence of bacterial conjunctivitis was higher than viral conjunctivitis (71% vs 16%, respectively, P = .01). In the only study of adults (n = 207 patients; mean age, 25.7 years), the prevalence of viral conjunctivitis was higher than bacterial conjunctivitis (78% vs 16%, respectively, P < .001). For the primary analysis of level 1 (n = 6) and level 2 (n = 5) studies (1725 patients total), the clinical findings that best distinguished a viral etiology for conjunctivitis from a bacterial etiology included pharyngitis (sensitivity range, 0.55-0.58; specificity range, 0.89-0.94; positive likelihood ratio [LR] range, 5.4-9.9), preauricular lymphadenopathy (sensitivity range, 0.17-0.31; specificity range, 0.93-0.94; positive LR range, 2.5-5.6), and contact with another person with red eye (sensitivity, 0.18 [95% CI, 0.14-0.22]; specificity, 0.93 [95% CI, 0.90-0.95]; positive LR, 2.5 [95% CI, 1.6-3.7]). Mucopurulent ocular discharge (sensitivity, 0.76 [95% CI, 0.60-0.87); specificity, 0.66 [95% CI, 0.58-0.73]; positive LR, 2.1 [95% CI, 1.7-2.6]) and otitis media (sensitivity, 0.24 [95% CI, 0.20-0.29]; specificity, 0.91 [95% CI, 0.85-0.94]; positive LR, 2.5 [95% CI, 1.5-4.4]) were associated with the presence of bacterial conjunctivitis.

CONCLUSIONS AND RELEVANCE

In this review, bacterial conjunctivitis was more common than viral conjunctivitis in children and viral conjunctivitis was more common than bacterial conjunctivitis in adults, although the prevalence estimates were based on limited evidence. Symptoms and signs associated with a higher likelihood of viral conjunctivitis in adults and children included concomitant pharyngitis, an enlarged preauricular node, and contact with another person with red eye, and signs associated with a higher likelihood of bacterial conjunctivitis included the presence of mucopurulent discharge and otitis media, but no single symptom or sign differentiated the 2 conditions with high certainty.

Ocular Surface Infection Mediated Molecular Stress Responses: A Review

Infection mediated ocular surface stress responses are activated as early defense mechanisms in response to host cell damage. Integrated stress responses initiate the host response to different types of infections and modulate the transcription of key genes and translation of proteins. The crosstalk between host and pathogen results in profound alterations in cellular and molecular homeostasis triggering specific stress responses in the infected tissues. The amplitude and variations of such responses are partly responsible for the disease severity and clinical sequelae. Understanding the etiology and pathogenesis of ocular infections is important for early diagnosis and effective treatment. This review considers the molecular status of infection mediated ocular surface stress responses which may shed light on the importance of the host stress-signaling pathways. In this review, we collated literature on the molecular studies of all ocular surface infections and summarize the results from such studies systematically. Identification of important mediators involved in the crosstalk between the stress response and activation of diverse signaling molecules in host ocular surface infection may provide novel molecular targets for maintaining the cellular homeostasis during infection. These targets can be then explored and validated for diagnostic and therapeutic purposes.

Accuracy of approximations to recover incompletely reported logistic regression models depended on other available information

OBJECTIVE

To provide approximations to recover the full regression equation across different scenarios of incompletely reported prediction models that were developed from binary logistic regression.

STUDY DESIGN AND SETTING

In a case study, we considered four common scenarios and illustrated their corresponding approximations: (A) Missing: the intercept, Available: the regression coefficients of predictors, overall frequency of the outcome and descriptive statistics of the predictors; (B) Missing: regression coefficients and the intercept, Available: a simplified score; (C) Missing: regression coefficients and the intercept, Available: a nomogram; (D) Missing: regression coefficients and the intercept, Available: a web calculator.

RESULTS

In the scenario A, a simplified approach based on the predicted probability corresponding to the average linear predictor was inaccurate. An approximation based on the overall outcome frequency and an approximation of the linear predictor distribution was more accurate, however, the appropriateness of the underlying assumptions cannot be verified in practice. In the scenario B, the recovered equation was inaccurate due to rounding and categorization of risk scores. In the scenarios C and D, the full regression equation could be recovered with minimal error.

CONCLUSION

The accuracy of the approximations in recovering the regression equation varied depending on the available information.

Efficacy and safety of breast milk eye drops in infants with eye discharge

AIM

Breast milk (BM) contains various protective components, such as immunoglobulins, lactoferrin, lysozyme, oligosaccharides and immune cell subsets. We evaluated the effectiveness of BM eye drops in infants with eye discharge in a randomised controlled study.

METHODS

Subjects were breastfed infants aged ≤180 days, with eye discharge. We randomly assigned patients to receive eye drops of BM or sodium azulene sulphonate hydrate 0.02% ophthalmic solution (OS). The patients received drop of BM or OS for 7 days. Improvement score of eye discharge in the groups was compared using a non-inferiority test.

RESULTS

The number of patients improved eye discharge was 119/155 (76.8%) and 119/157 (75.8%) in BM and OS groups, respectively. There were no significant differences between groups. The improvement score in eye discharge was 1.76 ± 0.91 in the BM group and 1.71 ± 0.96 in the OS group. The BM group was considered non-inferior to the OS group.

CONCLUSIONS

This study demonstrated that BM is no less effective than OS in infants with eye discharge aged ≤6 months. The results suggested that the use of breast milk as eye drops could be considered as a first-line treatment for infants aged ≤6 months with eye discharge.

Development of antibiotic resistance in the ocular Pseudomonas aeruginosa clone ST308 over twenty years

Corneal infection caused by a bacteria Pseudomonas aeruginosa is common cause of ocular morbidity. Increasing antibiotic resistance by ocular P. aeruginosa is an emerging concern. In this study the resistome of ocular isolates of Pseudomonas aeruginosa clone ST308 isolated in India in 1997 (PA31, PA32, PA33, PA35 and PA37) and 2018 (PA198 and PA219) were investigated. All the isolates of ST308 had >95% nucleotide similarity. The isolates from 2018 had larger genomes, coding sequences, accessory and pan genes compared to the older isolates from 1997. The 2018 isolate PA219 was resistant to all antibiotics except polymyxin B, while the 2018 isolate PA198 was resistant to ciprofloxacin, levofloxacin, gentamicin and tobramycin. Among the isolates from 1997, five were resistant to gentamicin, tobramycin and ciprofloxacin, four were resistant to levofloxacin while two were resistant to polymyxin B. Twenty-four acquired resistance genes were present in the 2018 isolates compared to 11 in the historical isolates. All isolates contained genes encoding for aminoglycoside (aph(6)-Id, aph(3')-lIb, aph(3″)-Ib), beta-lactam (blaPAO), tetracycline (tet(G)), fosfomycin (fosA), chloramphenicol (catB7), sulphonamide (sul1), quaternary ammonium (qacEdelta1) and fluoroquinolone (crpP) resistance. Isolate PA198 possessed aph(3')-VI, rmtD2, qnrVC1, blaOXA-488, blaPME-1, while PA219 possessed aadA1, rmtB, qnrVC1, aac(6')-Ib-cr, blaTEM-1B, blaVIM-2, blaPAO-1, mph(E), mph(A), msr(E). In both recent isolates qnrVC1 was present in Tn3 transposon. In 219 blaTEM-1 was carried on a transposon and blaOXA-10 on a class 1 integron. There were no notable differences in the number of single nucleotide polymorphisms, but recent isolates carried more insertions and deletions in their genes. These findings suggest that genomes of P. aeruginosa ocular clonal strains with >95% nucleotide identity isolated twenty years apart had changed over time with the acquisition of resistance genes. The pattern of gene mutations also varied with more insertions and deletions in their chromosomal genes which confer resistance to antibiotics.

Microbes of the human eye: Microbiome, antimicrobial resistance and biofilm formation

BACKGROUND

The review focuses on the bacteria associated with the human eye using the dual approach of detecting cultivable bacteria and the total microbiome using next generation sequencing. The purpose of this review was to highlight the connection between antimicrobial resistance and biofilm formation in ocular bacteria.

METHODS

Pubmed was used as the source to catalogue culturable bacteria and ocular microbiomes associated with the normal eyes and those with ocular diseases, to ascertain the emergence of anti-microbial resistance with special reference to biofilm formation.

RESULTS

This review highlights the genetic strategies used by microorganisms to evade the lethal effects of anti-microbial agents by tracing the connections between candidate genes and biofilm formation.

CONCLUSION

The eye has its own microbiome which needs to be extensively studied under different physiological conditions; data on eye microbiomes of people from different ethnicities, geographical regions etc. are also needed to understand how these microbiomes affect ocular health.

Alterations in the conjunctival surface bacterial microbiome in bacterial keratitis patients

Microbial keratitis is an infectious disease of the eye, in which the cornea is inflamed. Under severe conditions, keratitis can lead to significant loss of vision and enucleation of the eye. Ocular trauma is the major risk factor causing keratitis and microorganisms viz., bacteria, fungi, viruses are the causative agents. The current study characterized the conjunctival bacterial microbiomes of healthy individuals and individuals with bacterial keratitis (BK) and assessed whether ocular microbiome dysbiosis is prevalent in BK patients. Ocular bacterial microbiomes were generated from the conjunctival swabs of healthy controls (HC-SW) and conjunctival swabs (BK-SW) and corneal scrapings (BK-CR) of BK patients using V3-V4 amplicon sequencing and data analysed using QIIME and R software. The Alpha diversity indices, diversity and abundance of different phyla and genera, heat map analysis, NMDS plots and inferred functional pathway analysis clearly discriminated the bacterial microbiomes of conjunctival swabs of healthy controls from that of BK patients. Preponderance of negative interactions in the hub genera were observed in BK-CR and BK-SW compared to HC-SW. In addition, a consistent increase in the abundance of pathogenic bacteria, as inferred from published literature, was observed in the conjunctiva of BK patients compared to HC and this may be related to causing or exacerbating ocular surface inflammation. This is the first study demonstrating dysbiosis in the ocular bacterial microbiome of conjunctiva of bacterial keratitis patients compared to the eye of healthy controls. The bacterial microbiome associated with the corneal scrapings of keratitis individuals is also described for the first time.

Assessment of the frequency and biochemical parameters of conjunctivitis in COVID-19 and other viral and bacterial conditions

Objectives

We compared the laboratory and clinical symptoms of coronavirus disease 2019 (COVID-19), other viral (beside COVID-19), and bacterial conjunctivitis patients with the values of controls.

Methods

Twenty COVID-19, 15 other viral, 15 bacterial patients, and 15 control group were included in the study. COVID-19 was diagnosed with the real time reverse transcription–polymerase chain reaction while the indirect immunofluorescent antibody test was used in the detection of other viral agents. Bacterial agents were determined with the detection of the agent. The ophthalmologic examination of all cases was carried out by direct penlight, and the anterior segment evaluation was performed. The laboratory findings of all cases included in the study were obtained from the hospital records.

Results

It was determined that 5% conjunctivitis and 5% diplopia developed in patients diagnosed with COVID-19, 20% conjunctivitis developed in patients due to other viral agents, and 66.6% conjunctivitis developed in patients due to bacterial agents.

Conclusion

The incidence of conjunctivitis in COVID-19 patients was lower than in other viral and bacterial groups. Neutrophil/lymphocyte ratio and C-reactive protein come to the forefront as precious parameters with high specificity and sensitivity that might be useful to distinguish these diseases.

Conjunctivitis: A Systematic Review

Conjunctivitis is a commonly encountered condition in ophthalmology clinics throughout the world. In the management of suspected cases of conjunctivitis, alarming signs for more serious intraocular conditions, such as severe pain, decreased vision, and painful pupillary reaction, must be considered. Additionally, a thorough medical and ophthalmic history should be obtained and a thorough physical examination should be done in patients with atypical findings and chronic course. Concurrent physical exam findings with relevant history may reveal the presence of a systemic condition with involvement of the conjunctiva. Viral conjunctivitis remains to be the most common overall cause of conjunctivitis. Bacterial conjunctivitis is encountered less frequently and it is the second most common cause of infectious conjunctivitis. Allergic conjunctivitis is encountered in nearly half of the population and the findings include itching, mucoid discharge, chemosis, and eyelid edema. Long-term usage of eye drops with preservatives in a patient with conjunctival irritation and discharge points to the toxic conjunctivitis as the underlying etiology. Effective management of conjunctivitis includes timely diagnosis, appropriate differentiation of the various etiologies, and appropriate treatment.

A Review of the Differential Diagnosis of Acute Infectious Conjunctivitis: Implications for Treatment and Management

The diagnosis of acute infectious conjunctivitis can be difficult. Clinical ambiguity exists between the acute viral and bacterial as well as the allergic forms, which can confound diagnosis. Also, discrimination between viral or bacterial origins of infectious conjunctivitis based on historical, nonspecific, clinical signs and symptoms contributes to a high rate of misdiagnosis and overuse of antibiotic treatment. Therefore, in order to effectively treat acute infectious conjunctivitis, physicians must be aware of the clinical signs and symptoms and available diagnostic tests that can provide a more accurate differential diagnosis.

Pharmacist Compliance With Therapeutic Guidelines on Diagnosis and Treatment Provision

IMPORTANCE

Misuse and overselling of over-the-counter pharmaceuticals poses a major burden on both private and public health expenditures.

OBJECTIVE

To seek evidence on whether over-the-counter medication dispensing behavior complies or conflicts with the protocols indicated in practice standards and guidelines of a national professional pharmacy organization.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was undertaken in 205 pharmacies in the wider Brisbane, Australia, area. Two standardized patient (SP) scenarios were developed to evaluate noncompliant behavior. Data collection for scenario 1 was conducted between November 23 and December 9, 2016. Data collection for scenario 2 was conducted between September 1 and 28, 2017. A 2-sample test of proportions and a probit regression model were used to evaluate the likelihood of noncompliant treatments and overtreatments in each case scenario. Statistical analysis was performed from January 30 to June 21, 2018, and revised in May 2019.

MAIN OUTCOMES AND MEASURES

Outcomes were the observed likelihood of noncompliant treatments and overtreatments. Noncompliance is defined as treatments not complying with practice standards and guidelines set by the professional pharmacy society. Noncompliant treatments include undertreatment (patient did not receive necessary treatment) and overtreatments (patient was supplied with more than sufficient treatments) in both scenarios.

RESULTS

In scenario 1, 9 trained female SPs visited 89 pharmacies to request emergency hormonal contraception from pharmacy staff. In 45 cases, SPs reported having unprotected intercourse within the last 24 hours (case 1A), and in 44 cases, SPs reported having unprotected intercourse more than 72 hours ago (case 1B), which is past the efficacy threshold of over-the-counter emergency hormonal contraception. In scenario 2, 11 SPs (5 male and 6 female) visited 150 pharmacies (154 visits in total) to request treatment for family members or a partner with symptoms indicating bacterial conjunctivitis (case 2A; n = 73) or viral conjunctivitis (case 2B; n = 81). In scenario 1-dispensing emergency hormonal contraception when physician referral is recommended-21 of 44 pharmacists (47.7%) in case 1B violated the recommendation by selling the over-the-counter medication. With the inclusion of both no physician referral and emergency hormonal contraception sold, this rate increased to 79.5% (35 of 44 pharmacists). In scenario 2-1 case each of bacterial and viral conjunctivitis-overtreatment occurred in 55 of 154 cases (35.7%). In both scenarios, 140 of 243 pharmacies (57.6%) followed dispensing behavior compliant with the protocol, while 76 of 243 pharmacies (31.3%) involved some form of overtreatment or overselling of medication. Some evidence of an association between sex of SP and pharmacist was also found.

CONCLUSIONS AND RELEVANCE

Although the market for dispensing over-the-counter medication in Australia is regulated, relatively high rates of overtreatment and some cases of undertreatment were observed in this study. Given the unintended adverse effects, including overuse of antibiotics and corticosteroids, these observations suggest the advisability of regulatory intervention ensuring compliance with professional protocols.

PROBAST: A Tool to Assess Risk of Bias and Applicability of Prediction Model Studies: Explanation and Elaboration

Prediction models in health care use predictors to estimate for an individual the probability that a condition or disease is already present (diagnostic model) or will occur in the future (prognostic model). Publications on prediction models have become more common in recent years, and competing prediction models frequently exist for the same outcome or target population. Health care providers, guideline developers, and policymakers are often unsure which model to use or recommend, and in which persons or settings. Hence, systematic reviews of these studies are increasingly demanded, required, and performed. A key part of a systematic review of prediction models is examination of risk of bias and applicability to the intended population and setting. To help reviewers with this process, the authors developed PROBAST (Prediction model Risk Of Bias ASsessment Tool) for studies developing, validating, or updating (for example, extending) prediction models, both diagnostic and prognostic. PROBAST was developed through a consensus process involving a group of experts in the field. It includes 20 signaling questions across 4 domains (participants, predictors, outcome, and analysis). This explanation and elaboration document describes the rationale for including each domain and signaling question and guides researchers, reviewers, readers, and guideline developers in how to use them to assess risk of bias and applicability concerns. All concepts are illustrated with published examples across different topics. The latest version of the PROBAST checklist, accompanying documents, and filled-in examples can be downloaded from www.probast.org.

Resistant Infantile Bacterial Conjunctivitis in Egypt: A Microbiology Study

PURPOSE

To study the microbiological aspects of infantile bacterial conjunctivitis resistant to empirical topical antibiotic therapy in Egypt.

METHODS

Ninety-two eyes of 86 infants with bacterial conjunctivitis were included in this prospective study. They all failed to show evidence of clinical improvement after 2 weeks of empirical topical antibiotic therapy. Conjunctival swabs were obtained from all patients for bacterial culture and antibiotic sensitivity testing.

RESULTS

The age of the participants ranged from 4 to 6 months. Culture results revealed infection with a solitary organism in 48.9% of eyes. Mixed bacterial growth was reported in 47.8% of eyes, whereas 3.3% of eyes showed no bacterial growth. The most commonly isolated organisms were Staphylococcus aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa. These organisms were highly sensitive to fluoroquinolones (levofloxacin, ciprofloxacin, ofloxacin, and norfloxacin), followed by chloramphenicol, vancomycin, and amikacin, and were resistant to carbapenems (imipenem and meropenem), fusidic acid, and pipracellin.

CONCLUSIONS

Bacterial culture and antibiotic sensitivity testing provides beneficial diagnostic and therapeutic information when dealing with infantile resistant bacterial conjunctivitis. [J Pediatr Ophthalmol Strabismus. 2018;55(2):135-139.].

Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey

BACKGROUND

Acute infective conjunctivitis is common among preschool children. Public Health England (PHE) recommends that children with conjunctivitis do not need to be excluded from child care, but childcare providers are required to determine their own sickness policies and prior research suggests that children are often excluded until they are treated or have recovered. How the content of these policies impacts on prescribing decisions has not been quantified.

AIM

To assess the content of childcare providers' sickness policies and determine the impact they have on clinicians' prescribing.

DESIGN AND SETTING

An audit of childcare providers' sickness policies and a questionnaire among primary care clinicians.

METHOD

Sickness policies from childcare providers across the UK were compared with PHE guidance. Clinicians completed a questionnaire on the impact that childcare provider policies have on their decision to prescribe antibiotics to preschool children with conjunctivitis.

RESULTS

Of 164 policies examined, 86.7% excluded children with conjunctivitis and 49.4% of policies specified a requirement for antibiotics. Two-hundred clinicians completed questionnaires and 42.6% replied that they had been influenced by childcare policies when deciding whether to prescribe antibiotics in this scenario. Furthermore, 15.4% admitted that childcare policies had been the only reason they prescribed antibiotics.

CONCLUSION

Most of the childcare providers' sickness policies contain requirements that are inconsistent with PHE guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit.

Effect of "Pink Eye" Label on Parents' Intent to Use Antibiotics and Perceived Contagiousness

Parents of children who presented for a pediatrics appointment responded to a clinical vignette that described a child with symptoms consistent with acute viral conjunctivitis. In a 2 × 2 randomized survey design, the physician in the vignette either used the term "pink eye" or "eye infection" to describe the symptoms, and either told parents that antibiotics are likely ineffective at treating the symptoms or did not discuss effectiveness. When the symptoms were referred to as "pink eye," parents remained interested in antibiotics, despite being informed about their ineffectiveness. By contrast, when the symptoms were referred to as an "eye infection," information about antibiotic ineffectiveness significantly reduced interest, Mdiff = 1.63, P < .001. Parents who received the "pink eye" label also thought that the symptoms were more contagious and were less likely to believe that their child could go to child care, compared with parents who received the "eye infection" label, Mdiff = 0.37, P = .38.

Besifloxacin in the management of bacterial infections of the ocular surface

Acute bacterial conjunctivitis is a common infection of the ocular surface. Increasing rates of bacterial resistance have prompted the development of new antibiotics with improved activity against the bacterial species most often found in this disease. Besifloxacin is the first topical chlorofluoroquinolone developed solely for ophthalmic use. Studies have attested to its in vitro potency against a broad range of bacteria, as well as its efficacy in clinical studies of bacterial conjunctivitis when dosed 2 or 3 times a day. This review provides an up-to-date summary of studies on causative pathogens in acute bacterial conjunctivitis; recent geographic trends in bacterial resistance among ocular pathogens, including that of methicillin-resistant Staphylococcus aureus; the efficacy of besifloxacin in preclinical and clinical studies; its safety; and the role of besifloxacin in combating resistant strains. Further, this review provides a brief update on bacterial keratitis, causative pathogens, the development of resistance among those pathogens, and the potential role of besifloxacin in the treatment of bacterial keratitis.

Ocular Pharmacology of Tear Film, Dry Eye, and Allergic Conjunctivitis

Dry Eye Disease (DED) is "a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear-film instability with potential damage to the ocular surface." DED comprises two etiologic categories: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). Diagnostic workup of DED should include clinical history, symptom questionnaire, fluorescein TBUT, ocular surface staining grading, Schirmer I/II, lid and meibomian pathology, meibomian expression, followed by other available tests. New diagnostic tests employ the Oculus Keratograph, which performs non-invasive tear-film analysis and a bulbar redness (BR). The TearLab Osmolarity Test enables rapid clinical evaluation of tear osmolarity. Lipiview is a recently developed diagnostic tool that uses interferometry to quantitatively evaluate tear-film thickness. In DED, epithelial and inflammatory cells produce a variety of inflammatory mediators. A stagnant tear film and decreased concentration of mucin result in the accumulation of inflammatory factors that can penetrate tight junctions and cause epithelial cell death. DED treatment algorithms are based on severity of clinical signs and symptoms, and disease etiology. Therapeutic approaches include lubricating artificial tears and immunomodulatory agents.

Bedside Diagnosis of the 'Red Eye': A Systematic Review

BACKGROUND

In patients with red eye, traditional teachings suggest that photophobia, visual blurring, and eye pain indicate serious eye disease; in patients with presumed conjunctivitis, the finding of purulent drainage traditionally indicates a bacterial cause. The accuracy of these teachings is unknown.

METHODS

A MEDLINE search was performed to retrieve articles published between 1966 and April 2014 relevant to the bedside diagnosis of serious eye disease and bacterial conjunctivitis.

RESULTS

In patients with red eye, the most useful findings indicating serious eye disease are anisocoria (with the smaller pupil in the red eye and difference between pupil diameters >1 mm; likelihood ratio [LR], 6.5; 95% confidence interval [CI], 2.6-16.3) and photophobia, elicited by direct illumination (LR, 8.3; 95% CI, 2.7-25.9), indirect illumination (LR, 28.8; 95% CI, 1.8-459), or near synkinesis test ("finger-to-nose convergence test," LR, 21.4; 95% CI, 12-38.2). In patients with presumed conjunctivitis, complete redness of the conjunctival membrane obscuring tarsal vessels (LR, 4.6; 95% CI, 1.2-17.1), observed purulent discharge (LR, 3.9; 95% CI, 1.7-9.1), and matting of both eyes in the morning (LR, 3.6; 95% CI, 1.9-6.5) increase the probability of a bacterial cause; failure to observe a red eye at 20 feet (LR, 0.2; 95% CI, 0-0.8) and absence of morning gluing of either eye (LR, 0.3; 95% CI, 0.1-0.8) decrease the probability of a bacterial cause.

CONCLUSIONS

Several bedside findings accurately distinguish serious from benign eye disease in patients with red eye and, in patients with presumed conjunctivitis, distinguish bacterial from viral or allergic causes.

Acute conjunctivitis

Eye problems account for 1.5% of GP consultations in the UK, with a rate of 50 consultations per 1000 population per year. This equates to a yearly cost of 22 billion to the UK’s economy. It has been shown that 50% of sight loss could be avoided through improved eye care services and early detection of problems. To highlight this point, eye health has been chosen by the RCGP as a clinical priority between 2013 and 2016, with a particular focus on the elderly population and sight loss. Data obtained from GPs has revealed that 10–15% of the eye conditions that present to primary care involve the conjunctiva. Conjunctivitis is a particularly beneficial area about which to be knowledgeable, as it is one of the most common non-traumatic eye complaints and in many cases it is straightforward and self-limiting. This article aims to address what constitutes conjunctivitis, the different types, the clinical findings, and management including when to involve specialist services. It will also look at the differential diagnoses of the presenting symptom of the acute red eye.

Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration

The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.

Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist

Carl Moons and colleagues provide a checklist and background explanation for critically appraising and extracting data from systematic reviews of prognostic and diagnostic prediction modelling studies. Please see later in the article for the Editors' Summary.

A new diagnostic index for bacterial conjunctivitis in primary care. A re-derivation study

BACKGROUND

Eighty per cent of primary care patients with infectious conjunctivitis are treated with antibiotics, although in only 30%, there is a bacterial cause. An accurate diagnostic index to distinguish bacterial from viral conjunctivitis may help reduce unnecessary antibiotics.

OBJECTIVES

To validate and, if necessary, improve an existing diagnostic index for bacterial conjunctivitis.

METHODS

Non-experimental validation and updating study of an existing diagnostic index in Dutch General Practice. We collected 210 adult patients with incident symptoms suggestive for acute infectious conjunctivitis. GPs completed a standardized questionnaire and a physical examination of the eye(s) and took a conjunctival sample for culture. Cultures were analysed masked for the GPs' findings. On bad performance of the existing index on the new patients, we developed a new index combining the dataset on which the original model had been developed (n = 176) and the new dataset (n = 210). Bootstrapped backward variable selection and shrinkage of regression coefficients was used to protect the new index against bad performance in future patients.

RESULTS

The bacterial culture was positive in 36.3%. The items age and number of glued eyes at awakening were consistent predictors. This model classified 48% (107/386) of patients at a low (< 25%) chance of having a positive culture and 2% as at high (> 70%) chance.

CONCLUSION

Correction of a previously derived diagnostic index for bacterial conjunctivitis yielded a simple index, based on history only. The index is potentially useful to rule out bacterial conjunctivitis in patients below 50 years of age with no history of glued eyes at awakening. This study underscores the importance of external validation of diagnostic indices.

Conjunctivitis: a systematic review of diagnosis and treatment

IMPORTANCE

Conjunctivitis is a common problem.

OBJECTIVE

To examine the diagnosis, management, and treatment of conjunctivitis, including various antibiotics and alternatives to antibiotic use in infectious conjunctivitis and use of antihistamines and mast cell stabilizers in allergic conjunctivitis.

EVIDENCE REVIEW

A search of the literature published through March 2013, using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Eligible articles were selected after review of titles, abstracts, and references.

FINDINGS

Viral conjunctivitis is the most common overall cause of infectious conjunctivitis and usually does not require treatment; the signs and symptoms at presentation are variable. Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, with most uncomplicated cases resolving in 1 to 2 weeks. Mattering and adherence of the eyelids on waking, lack of itching, and absence of a history of conjunctivitis are the strongest factors associated with bacterial conjunctivitis. Topical antibiotics decrease the duration of bacterial conjunctivitis and allow earlier return to school or work. Conjunctivitis secondary to sexually transmitted diseases such as chlamydia and gonorrhea requires systemic treatment in addition to topical antibiotic therapy. Allergic conjunctivitis is encountered in up to 40% of the population, but only a small proportion of these individuals seek medical help; itching is the most consistent sign in allergic conjunctivitis, and treatment consists of topical antihistamines and mast cell inhibitors.

CONCLUSIONS AND RELEVANCE

The majority of cases in bacterial conjunctivitis are self-limiting and no treatment is necessary in uncomplicated cases. However, conjunctivitis caused by gonorrhea or chlamydia and conjunctivitis in contact lens wearers should be treated with antibiotics. Treatment for viral conjunctivitis is supportive. Treatment with antihistamines and mast cell stabilizers alleviates the symptoms of allergic conjunctivitis.

An investigation of prescription and over-the-counter supply of ophthalmic chloramphenicol in Wales in the 5 years following reclassification

Objectives

The aims of the study were to (i) quantify the sales of over-the-counter (OTC) ophthalmic chloramphenicol from all community pharmacies in Wales and investigate the impact on primary care prescriptions up to 5 years after reclassification and (ii) investigate the temporal relationship between items supplied OTC and on NHS primary care prescriptions.

Methods

Primary care prescription data (2004–2010) and OTC sales data (2005–2010) for ophthalmic chloramphenicol were obtained. The quantity sold OTC was calculated from pharmacy wholesale records and sales data from a large pharmacy multiple. Spearman’s rank correlation for prescription and OTC supplies of ophthalmic chloramphenicol was calculated for data from January 2008 to December 2010.

Key findings

OTC supply of chloramphenicol eye drops and ointment were both highest in 2007–2008 and represented 68% (57 708/84 304) and 48% (22 875/47 192) of the corresponding prescription volume, respectively. There was a steady year-on-year increase in the combined supply of OTC ophthalmic chloramphenicol and that dispensed on prescription from 144 367 items in 2004–2005 to 210 589 in 2007–2008 before stabilising in 2008–2009 and 2009–2010. A significant positive correlation was observed between prescription items and OTC sales of chloramphenicol eye drops and ointment combined (r = 0.7, P &lt; 0.001).

Conclusion

OTC availability increased the total quantity of ophthalmic chloramphenicol supplied in primary care compared to that seen prior to reclassification. Although growth in the sales of ophthalmic chloramphenicol OTC has stabilised and the supply pattern mirrors primary care prescribers, further work is required to investigate whether use is appropriate and whether the publication of updated practice guidance has changed this.

Ocular surface temperature gradient is increased in eyes with bacterial corneal ulcers

AIMS

To investigate the ocular surface temperature gradient in eyes with bacterial corneal ulcers.

METHODS

Prospective examination of 12 eyes with bacterial corneal ulcers (group 1) and 12 control eyes (group 2). Infrared thermal imaging (Tomey TG 1000) was used to study the temperature of the ocular surface. The mean, minimum and maximum temperature of the ocular surface and temperature course over a time period of 10 s of sustained eye opening were evaluated. Furthermore, a correlation between the overall corneal temperature and the temperature at the base of the corneal ulcers was determined.

RESULTS

A significant difference between both groups was present. Mean corneal temperature was 35.6°C ± 0.9 in group 1 and 34.8°C ± 0.8 in group 2 (p = 0.033). The temperature course over 10 s of sustained eye opening was -0.6°C ± 0.4 in group 1 and -0.3°C ± 0.2 in group 2 (p = 0.045). There was a close correlation between the mean temperature at the base of the corneal ulcer and the overall corneal temperature (r = 0.92, p < 0.001).

CONCLUSION

Infrared thermal imaging can be used to objectively determine the increased ocular surface temperature in patients with bacterial corneal ulcers. The use of dynamic thermography may offer new options to monitor ocular surface alterations.

Pasteurella canis and Granulicatella adiacens conjunctivitis outbreak resistant to empirical treatment in a child welfare agency

PURPOSE

To investigate pathogens associated with bacterial conjunctivitis resistant to the empirical treatment and their antibiotic resistance in a child welfare agency.

METHODS

Twenty-eight eyes in 14 children with a median age of 3 months with conjunctivitis resistant to the empirical treatment were included in this study. Samples were taken three times from the inferior fornix in both eyes using cotton swabs, cultured onto chocolate and blood agar, and prepared for Gram staining. Antibiograms were evaluated according to the Clinical and Laboratory Standards Institute criteria by disc diffusion method.

RESULTS

The conjunctival culture positivity rate was 35.7% in eyes with conjunctivitis resistant to the empirical treatment. The most common isolated bacteria were Pasteurella canis (25%), penicillin-nonsusceptible Streptococcus pneumoniae (7.1%), and Granulicatella adiacens (3.6%). According to culture results, ophthalmic solutions of vancomycin (50 mg/mL) or gentamicin (30 mg/mL) were applied in eyes with positive conjunctival culture. Previously applied multiple treatments were stopped in eyes with negative conjunctival culture. All eyes improved clinically during follow-up.

CONCLUSION

Because unusual pathogens may cause a conjunctivitis outbreak, physicians should not insist on empirical treatment. Taking conjunctival culture and antibiotic switching according to antibiogram may be helpful.

Differentiation of etiologic agents of bacterial keratitis from presentation characteristics

Presenting characteristics of bacterial corneal ulcers may suggest particular causative organisms, helping to guide treatment decisions before cultures become available. In this study, we analyze the association between presentation demographic and clinical characteristics, using data collected as part of a randomized, controlled clinical trial. Data for this study were collected as part of the Steroids for Corneal Ulcers Trial, a randomized, placebo-controlled, double-masked trial. All patients had a culture-proven bacterial corneal ulcer. Patient history, clinical examination, and photography were performed in a standardized fashion at enrollment. Analysis of variance or Fisher's exact test was used to compare characteristics by organism. Univariate logistic regression was used to analyze predictors of the most common organisms. Five hundred patients were enrolled in the trial, of whom 488 were included in this analysis. The most common organism was Streptococcus pneumoniae (N = 248, 51 %) followed by Pseudomonas aeruginosa (N = 110, 23 %). Compared to other organisms, P. aeruginosa was significantly associated with a larger baseline infiltrate/scar size [odds ratio (OR) 1.6, 95 % confidence interval (CI) 1.4-1.8] and deeper infiltrate (OR 2.4, 95 % CI 1.5-3.8). S. pneumoniae was significantly associated with a smaller baseline infiltrate/scar size (OR 0.8, 95 % CI 0.7-0.9) and dacryocystitis (OR 7.3, 95 % CI 4.1-13.3). Nocardia spp. were significantly associated with longer duration of symptoms prior to presentation (OR 1.4, 95 % CI 1.2-1.6), more shallow infiltrate (OR 0.3, 95 % CI 0.2-0.5), and better baseline visual acuity (OR 0.4, 95 % CI 0.2-0.65). Staphylococcus spp. were less likely to be central in location (OR 0.16, 95 % CI 0.08-0.3). Baseline characteristics of bacterial ulcers may suggest the likely etiology and guide early management.

Allergic conjunctivitis and dry eye syndrome

BACKGROUND

Allergic conjunctivitis (AC) and dry eye syndrome (DES) are 2 of the most common anterior inflammatory disorders of the ocular surface and one does not preclude the coexistence of the other.

OBJECTIVES

To examine the potential overlap between AC and DES as comorbidities.

METHODS

Using the validated questionnaire known as Subjective Evaluation of Symptom of Dryness, we studied self-reported itchiness, dryness, and redness. In an outpatient optometric setting, 689 patients treated from January 1, 2007, to January 1, 2011, were surveyed for their ocular history and categorized according to their reported level of discomfort of itchiness, dryness, and redness.

RESULTS

Patients ranged in age from 5 to 90 years (median age, 25 years; 39.5% male; 60.5% female). In the studied 689 patients, clinically significant itchiness was found in 194 (28.2%), dry eyes in 247 (35.8%), and redness in 194 (28.2%). Symptom overlap was demonstrated in many of the patients. Of the 194 patients with itchiness, 112 (57.7%) had clinically significant dryness. In the 247 patients with dry eyes, 112 (45.3%) had clinically significant itch. Redness was apparent in 120 of the 194 patients with itch (61.9%) and 122 of the 247 patients with dryness (49.4%). Statistical analysis demonstrated that self-reported itchiness, dryness, and redness were not independent of each other (P<.001; Pearson χ(2) test). The odds of patients with "itchy eyes" also experiencing dry eyes were 2.11 times and the odds of these patients also experiencing redness were 7.34 times that of patients with nonitchy eyes.

CONCLUSIONS

Most patients with "itchy eyes" consistent with AC also have dry eyes and redness. These results suggest that some symptomatic patients concomitantly have features of AC and DES.

Bacterial conjunctivitis

INTRODUCTION

Most cases of conjunctivitis in adults are probably due to viral infection, but children are more likely to develop bacterial conjunctivitis than they are viral forms. The main bacterial pathogens are Haemophilus influenzae and Streptococcus pneumoniae in adults and children, and Moraxella catarrhalis in children. Contact lens wearers may be more likely to develop gram-negative infections. Bacterial keratitis occurs in up to 30 per 100,000 contact lens wearers.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical treatment in adults and children with suspected bacterial conjunctivitis? What are the effects of treatment in adults and children with bacteriologically confirmed bacterial conjunctivitis? What are the effects of treatment in adults and children with clinically confirmed gonococcal conjunctivitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: ocular decongestants, oral antibiotics, parenteral antibiotics, saline, topical antibiotics, and warm compresses.

A European perspective on topical ophthalmic antibiotics: current and evolving options

BACKGROUND

Eye infections can be vision-threatening and must be treated effectively by appropriate and safe use of topical ophthalmic anti-infectives. This review will essentially consider the current and evolving treatment options for the various types of bacterial eye infections. Ocular surface bacterial infections affect subjects of all ages with a high frequency in newborns and children.

METHODS

This article presents a review of the peer-reviewed published scientific literature in order to define the well-established uses of anti-infective eye drops in the field of ocular infections. A comprehensive search of the recent published literature including topical ophthalmic anti-infectives effective in bacterial ocular infections was performed. Clinical studies provide relevant data concerning the characteristics and clinical efficacy of antibacterial eye drops in ocular anterior segment infections or for perioperative prophylaxis. Publications were included to cover the current options of antibacterial eye drops available in Europe.

RESULTS

Several recent publications identified effective topical ocular antibacterials requiring a reduced dose regimen and a short treatment course. Additional literature reviewed included data on novel perioperative prophylaxis, indications for topical fortified antibiotics and innovative research including the risk of resistance.

CONCLUSIONS

Safe and effective topical antibiotic eye drops for the treatment and prevention of ocular infections must be adapted to the type of bacteria suspected. Usual topical antimicrobials should be replaced by more recent and more effective treatments. The use of highly effective fluoroquinolones should be reserved for the most severe cases to avoid resistance. Short treatment courses, such as azithromycin, can be easily used in children, thereby improving quality of life.

Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis

BACKGROUND

Acute infective conjunctivitis is a common problem in primary care, traditionally managed with topical antibiotics. A number of clinical trials have questioned the benefit of topical antibiotics for patients with acute infective conjunctivitis.

AIM

To determine the benefit of antibiotics for the treatment of acute infective conjunctivitis in primary care and which subgroups benefit most.

DESIGN

An individual patient data meta-analysis.

METHOD

Relevant trials were identified and individual patient data gathered for meta-analysis and subgroup analysis.

RESULTS

Three eligible trials were identified. Individual patient data were available from all primary care trials and data were available for analysis in 622 patients. Eighty per cent (246/308) of patients who received antibiotics and 74% (233/314) of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at seven days in all cases combined (risk difference 0.08, 95% confidence interval (CI) = 0.01 to 0.14). Subgroups that showed a significant benefit from antibiotics were patients with purulent discharge (risk difference 0.09, 95% CI = 0.01 to 0.17) and patients with mild severity of red eye (risk difference 0.10, 95% CI = 0.02 to 0.18), while the type of control used (placebo drops versus nothing) showed a statistically significant interaction (P=0.03).

CONCLUSION

Acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics. Prescribing practices need to be updated, taking into account these results.

Bacterial conjunctivitis

INTRODUCTION

Most cases of conjunctivitis in adults are probably due to viral infection, but children are more likely to develop bacterial conjunctivitis than they are viral forms. The main bacterial pathogens are Haemophilus influenzae and Streptococcus pneumoniae in adults and children, and Moraxella catarrhalis in children. Contact lens wearers may be more likely to develop gram-negative infections. Bacterial keratitis occurs in up to 30 per 100,000 contact lens wearers.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical treatment in adults and children with suspected bacterial conjunctivitis? What are the effects of treatment in adults and children with bacteriologically confirmed bacterial conjunctivitis? What are the effects of treatment in adults and children with clinically confirmed gonococcal conjunctivitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 40 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: ocular decongestants; oral antibiotics; parenteral antibiotics; saline; topical antibiotics; and warm compresses.

Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States

BACKGROUND

The aim of this study was to estimate both the direct and indirect annual costs of treating bacterial conjunctivitis (BC) in the United States. This was a cost of illness study performed from a U.S. healthcare payer perspective.

METHODS

A comprehensive review of the medical literature was supplemented by data on the annual incidence of BC which was obtained from an analysis of the National Ambulatory Medical Care Survey (NAMCS) database for the year 2005. Cost estimates for medical visits and laboratory or diagnostic tests were derived from published Medicare CPT fee codes. The cost of prescription drugs was obtained from standard reference sources. Indirect costs were calculated as those due to lost productivity. Due to the acute nature of BC, no cost discounting was performed. All costs are expressed in 2007 U.S. dollars.

RESULTS

The number of BC cases in the U.S. for 2005 was estimated at approximately 4 million yielding an estimated annual incidence rate of 135 per 10,000. Base-case analysis estimated the total direct and indirect cost of treating patients with BC in the United States at $ 589 million. One- way sensitivity analysis, assuming either a 20% variation in the annual incidence of BC or treatment costs, generated a cost range of $ 469 million to $ 705 million. Two-way sensitivity analysis, assuming a 20% variation in both the annual incidence of BC and treatment costs occurring simultaneously, resulted in an estimated cost range of $ 377 million to $ 857 million.

CONCLUSION

The economic burden posed by BC is significant. The findings may prove useful to decision makers regarding the allocation of healthcare resources necessary to address the economic burden of BC in the United States.

Evidence-based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing

OBJECTIVE

To discover the best treatments for acute infective conjunctivitis and to discern whether antibiotics are necessary for the resolution of bacterial conjunctivitis in particular.

QUALITY OF EVIDENCE

MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews were searched. Findings were limited to full-text articles from core clinical journals in the English language, and are based on level I or level II evidence. Clinical Evidence was also searched, from which moderate-quality results have been cited.

MAIN MESSAGE

Infective conjunctivitis should be managed conservatively, with antibiotics prescribed either after a delayed period if symptoms do not improve within 3 days of onset, or not at all. This approach helps to prevent the medicalization of the condition (reducing consultations for future occurrences) and discourages the unnecessary use of antibiotics, which might delay diagnosis of other serious red eye conditions. Physicians and patients should be educated on the self-limiting nature of the condition to increase compliance with conservative treatment and change the management expectations of parents and schools.

CONCLUSION

Acute infective conjunctivitis is the most common ocular complaint dealt with in family practice; its viral and bacterial etiologies are difficult to distinguish on clinical grounds alone. Evidence suggests that properly educating patients with written information materials is the most effective way to manage this simple ailment and increase patient satisfaction.

Acute conjunctivitis: truth and misconceptions

OBJECTIVE

Acute conjunctivitis is an extremely common condition and can be associated with significant morbidity and economic burden. Despite this, considerable controversy exists pertaining to the prevalence, diagnosis, management, and treatment of the condition. A panel of ophthalmology experts was assembled to review and discuss the current evidence based literature as it pertains to each of these persistent controversies.

METHODS AND SCOPE

An acute conjunctivitis round table symposium was convened at the American Academy of Ophthalmology meeting in Atlanta, November 2008. The expert panelists consisted of four academic ophthalmologists in the field of cornea and external disease, whose discussion was informed by an English language literature survey carried out on the PubMed database for the period of January 1972 to October 2008. A narrative summary was generated from the literature review and direct transcription of this event, from which this Review article was developed.

FINDINGS AND CONCLUSIONS

Considerable light has been shed on acute microbial conjunctivitis and especially those cases caused by adenovirus. Many of the myths that have perpetuated for years have been debunked by emerging evidence. The advent and the implementation of better diagnostic tools and anti-viral medications will help clinicians to improve their diagnostic accuracy, improve management and treatment decisions, and ultimately benefit patients while saving overall healthcare costs.