Letters to the Editor

Treatment of Viral Conjunctivitis in Children

TO THE EDITOR: I am a new practicing physician in northern Wisconsin and would like some guidance on the correct treatment of conjunctivitis. During my training in family medicine, both visiting with ophthalmologists and pediatricians, it became apparent that all cases of conjunctivitis were treated with topical antibiotics regardless of whether the suspected cause was viral or bacterial. I have seen many children in my office who present with the classic symptoms for viral "pink eye"; the parents of these patients have been told by the day care providers that their child needs an antibiotic in order to return to the day care setting. I am not sure if this is a local or a national problem with the day care providers. Physicians also receive pressure from parents because their children have previously been placed on eye drops for pink eye. When did day care providers begin requiring a child to be on a topical antibiotic for what appears to be viral pink eye before allowing the child to return?

A recent Cochrane review in American Family Physician¹ suggests that we should prescribe topical antibiotics for all affected patients because of the low risk from treatment. However, what should be done about the more common viral pink eye? It is frustrating as a physician to convince parents and day care staff that an antibiotic is not helpful in these cases and should not be used. I would welcome your advice and direction.

CRAIG BENNETT, M.D.
Midelfort Clinic, Cameron
Cameron, WI 54822

REFERENCE

1. David SP. Should we prescribe antibiotics for acute conjunctivitis? (Cochrane) Am Fam Physician 2002; 66:1649-50.

IN REPLY: I would like to thank Dr. Bennett for his letter regarding the conflict between the pressure to treat all cases of conjunctivitis (viral and bacterial) with topical antibiotics. As a family physician who has treated many cases of conjunctivitis in infants and toddlers, I can understand your dilemma. You are not alone in your approach to the treatment of viral conjunctivitis. The extant evidence does not warrant the use of topical antibiotics for cases of low-risk viral conjunctivitis, such as cases that are not caused by herpes simplex virus or herpes zoster; however, a recent survey¹ of British general practitioners found that 95 percent of them prescribed topical antibiotics despite their belief that at least one half of the cases they saw were of a viral origin.

Unfortunately, evidence-based guidelines on the treatment of viral conjunctivitis either provide no recommendation or recommend supportive treatment for viral conjunctivitis. The American Optometric Society recommends the use of cold compresses, lubricants, and ocular decongestants.² However, the guidelines of the American Academy of Ophthalmology³ and the British Public Health Laboratory Service⁴ do not offer specific recommendations for treatment of presumptive nonherpetic viral conjunctivitis. Considering the practical realities of parent expectations of antibiotic treatment for all cases of conjunctivitis among children in day care, the low risk of treatment with topical antibiotics, and unclear policy guidelines, it would seem reasonable to pursue one of the following options. One option would be to provide parents with information about the self-limited nature of most cases of conjunctivitis without treatment and the lack of evidence for benefit from topical antibiotics in cases of viral conjunctivitis, and then allow the parents to choose. This is a reasonable option for practical reasons and because a large proportion of primary care physicians are uncertain about whether low-risk cases are viral or bacterial in origin.¹

A second option would be to offer a delayed prescription approach by prescribing antibiotics only for those cases that have not resolved by day 5.⁵ In one qualitative study⁶ of adult patients with conjunctivitis, most patients preferred to wait a few days for treatment once they were made aware of the self-limiting nature of conjunctivitis. However, it is unclear whether parents would take the same attitude toward their children in day care who could not return to day care without having begun antibiotics.

A third approach would be to combine clinical judgment with your knowledge of the parents' expectations and make individual recommendations given your level of certainty of the diagnosis and implications on the physician-patient relationship of your treatment decisions.

SEAN P. DAVID, M.D., S.M.
Brown University Center for Primary Care and Prevention
111 Brewster St.
Pawtucket, RI 02860

REFERENCES

1. Everitt H, Little P. How do GPs diagnose and manage acute infective conjunctivitis? A GP survey. Fam Pract 2002;19:658-60.
2. American Optometric Association. Consensus Panel on Care of the Patient with Conjunctivitis, Quinn CJ. Care of the patient with conjunctivitis: reference guide for clinicians. St. Louis, Mo.: American Optometric Association; 1996.
3. American Academy of Ophthalmology. Conjunctivitis. San Francisco, Calif.: American Academy of Ophthalmology; 1998.
4. Public Health Laboratory Service. Guidelines on the management of communicable diseases in schools and nurseries. Conjunctivitis. Retrieved April 16, 2003, from the World Wide Web: www.phls.co. uk/topics_az/conjunctivitis/guidelines_schools.htm.
5. Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: a systematic review. Br J Gen Pract 2001;51:473-7.
6. Everitt H, Kumar S, Little P. A qualitative study of patients' perceptions of acute infective conjunctivitis. Br J Gen Pract 2003;53:36-41.

Is Tacrolimus the Best Therapy for Atopic Dermatitis?

TO THE EDITOR: I read with interest the article, "Topical Tacrolimus: A New Therapy for Atopic Dermatitis,"¹ because I recently saw a patient who experienced therapeutic failure with a $100 tube of tacrolimus for atopic dermatitis.

Because the response rate with tacrolimus is 27 to 36 percent compared with a 6 percent response rate for the vehicle alone, there is little doubt that tacrolimus works better than its vehicle alone. However, practicing physicians need to know whether tacrolimus works better than other available therapies, such as oral antihistamines, topical emollients, topical doxepin, and topical corticosteroids. This information would help physicians decide whether to order such an expensive new treatment or stay with the available remedies.

EDWARD P. MCAULIFFE, M.D.
Kaiser Permanente
899 Hwy 287
Broomfield, CO 80020

REFERENCE

1. Russell JJ. Topical tacrolimus: a new therapy for atopic dermatitis. Am Fam Physician 2002;66: 1899-902.

Correction

The article "Antidepressants: Update on New Agents and Indications" (February 1, 2003, page 547) contained an error in the description of venlafaxine. On page 551, the second sentence under the subheading "Venlafaxine" should have read: It is a bicyclic antidepressant that produces strong inhibition of norepinephrine and serotonin reuptake.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.