August 1997
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Oral antibiotics should be used in a toddler who does not
tolerate topical therapy.
SAN DIEGO — Treatments for conjunctivitis in children vary as much as the clinical presentations and the agents used.
"When you look at the list of organisms that have been reported to cause conjunctivitis, it's incredible; it's almost everything," said Gregory F. Hayden, MD, professor of pediatrics at the University of Virginia in Charlottesville, here during a recent meeting of the American Academy of Pediatrics (AAP).
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In a controlled study performed by Gigliotti and colleagues, the three most common organisms responsible for conjunctivitis in children were Haemophilus influenzae nontypable), Streptococcus pneumoniae and adenovirus.
"If you ask whether or not you can distinguish the cases caused by these organisms clinically, the answer is not exactly," Hayden said. "The adenovirus children tend to be a little older, and bilateral disease is more common with the bacterial causes," Hayden said.
"Concurrent otitis media [OM] is more common with H. influenzae and concurrent pharyngitis is more common with adenovirus," Hayden continued, "but unfortunately there is a lot of overlap."
Another study done a few years ago by Weiss and colleagues reported a similar trend, according to Hayden. "The virus was seen more often in older children and bilateral disease a little more common in bacterial infections, although in this study a lot of the virals were bilateral and a purulent discharge was more common with the bacterial infection."
Other typical presentations, such as pre-auricular adenopathy and concurrent pharyngitis, were seen more often with the viral infections. Concurrent OM was seen more often in the bacterial infections. "Again, there's a lot of overlap so your clinical diagnosis of bacterial vs. viral is not perfectly reliable," Hayden said.
Hayden discussed several principles about topical vs. systemic therapy. "Topical therapy achieves very high concentrations on the ocular surface for a very short period and the disk activity might not predict actual clinical responsiveness," Hayden said. "Some of the topical antibiotics such as polymyxin B and bacitracin can be used and are relatively safe. Just watch out for the preparations containing corticosteroids unless you are very sure you know what you are doing," he warned.
Pointing to another study done by Gigliotti, Hayden described the efficacy of a topical antibiotic vs. placebo in children with conjunctivitis caused by either S. pneumoniae or H. influenzae "The antibiotic group was given polysporin ointment [Glaxo Wellcome] and the results showed the antibiotic group did better in three to five days. But the placebo group was catching up within eight to 10 days, so clearly conjunctivitis is a self-limiting disease," he said.
In another study done by Lohr et. al., three different antibiotics delivered topically as drops, trimethoprim sulfate-polymyxin B (Polytrim, Allergan), gentamicin sulfate (Garamycin, Schering) and sulfacetamide sodium (Bleph-10, Allergan) were used to treat S. pneumoniae and H. influenzae "All three agents did well for children with S. pneumoniae but there was a trend for the Polytrim to do better in the children with H. influenzae" Hayden said.
"You can use ointments less often; they leave a film over the eyes that people don't seem to like and with certain ages it's obviously difficult [to use the ointment]," Hayden said.
"Sulfacetamide is a good drug but it does have a little sting to it," Hayden explained. He said that oral antibiotics should be used in a combative toddler in whom compliance with topical therapy seems unlikely and when there is concurrent OM or a strong risk of otitis developing based on several previous episodes.
The Committee on Infectious Diseases of the AAP, which compiles the Red Book, has recommended child care center exclusion for children with purulent conjunctivitis until examined by a physician and approved for readmission with treatment. The committee has not recommended exclusion for children with nonpurulent conjunctivitis, but other authorities have suggested exclusion of children with viral conjunctivitis until symptoms resolve.
"I do not routinely culture children with conjunctivitis," said Hayden. "I often treat with a topical or systemic antibiotic, knowing that those with bacterial causes will benefit, and advise return to child care the following day."
For more information:
- Barson WJ, Hayden GF. Red throat and pink eye: new approaches. Presented at the American Academy of Pediatrics. May 10-13. San Diego.
- Gigliotti F, et al. Etiology of acute conjunctivitis in children. J Pediatr1981;98:531-36.
- Lohr JA, et al. Comparison of three topical antimicrobials for acute bacterial conjunctivitis. Pediatr Infect Dis J 1988;7:626-29.
- American Academy of Pediatrics. Children in out-of-home child care: recommendations for inclusion or exclusion. Red Book. 1997;83.
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