Delayed antibiotics may be best for conjunctivitis (BMJ 2006)

I am always interested to read the results of Randomised Controlled Trials which include an arm with delayed antibiotics, and in 2006 Paul Little’s group in Southampton published results of three different approaches to acute infectious conjunctivitis. (A randomised controlled trial of management strategies for acute conjunctivitis in general practice. Hazel A Everitt, Paul S Little, and Peter W F Smith. BMJ 2006 333: 321)

Just over 300 children and adults with acute conjunctivitis were randomised to immediate antibiotics, no antibiotics or delayed antibiotics. In addition the patients were also randomised to receive a patient information leaflet or not, and to have an eye swab or not (in a factorial design). Information was collected on severity and duration of symptoms, and the patients’ belief in the effectiveness of antibiotics. “Participants completed diaries on concerns about their eye problem, how well their doctor dealt with their concerns, how satisfied they were with the consultation, the importance of seeing the doctor or nurse so that they could continue work or schooling, and satisfaction with the information they were given.”

Immediate antibiotics did not make a significant difference to symptom severity, but reduced the mean duration of symptoms from 4.9 days to 3.3 days and delayed antibiotics to 3.9 days, both reductions were statistically significant. Interestingly the percentage using antibiotics was 99% in the immediate group, 53% used in the delayed antibiotic group and 30% in those who were not given antibiotics at the initial consultation (presumably because the patients returned for review and were given antibiotics later).

Those who had no antibiotics or delayed antibiotics were less likely to report that they were “extremely or very likely to re-attend for future eye infections” in comparison to those given immediate antibiotics. Satisfaction with the consultation was not altered by the use of antibiotics, but satisfaction with the information given was higher with a patient leaflet and taking an eye swab increased patient concerns and worries about conjunctivitis.

The authors conclude “The delayed prescribing approach may be the best approach. Compared with no initial offer of antibiotics delayed prescribing had the advantage of reduced antibiotic use (almost 50%), no evidence of medicalisation, similar symptom control to immediate prescribing, and reduced re-attendance for eye infections.”