The management of acute infective conjunctivitis in general practice

Abstract

Acute infective conjunctivitis (AlC) is a common self-limiting condition presenting to general practice. However, evidence is limited on GPs current management of AlC, patients' understanding of conjunctivitis or the most appropriate management strategy for AlC in general practice.

The aims of this thesis where to: 1) To determine GPs' current management strategies for AlC 2) To gain an understanding of patients concerns and beliefs about AlC and develop a patient information leaflet (PIL). 3) To assess the effect of common management strategies for AlC on symptom resolution and patients belief in antibiotics.

Three complementary studies were used: 1) A postal survey of 300 GPs regarding their diagnosis and management of AlC. 2) A qualitative study involving interviews with 25 patients to explore conjunctivitis from the patients' perspective. 3) An open randomised controlled tria~ with 307 recruits, to assess the effect of different management strategies (immediate, delayed or no offer of antibiotics; a patient information leaflet and an eye swab) for AlC in general practice.

The results were: 1) Survey: 95% of responding GPs usually prescribe topical antibiotics for AlC despite 58% stating that they thought at least half of the cases they see are viral in origin. Only 36% of GPs believed they could discriminate between viral and bacterial infection
2) Qualitative study: patients regarded conjunctivitis as a minor illness although some considered it might become more serious if not treated. They stated a preference not to take medication but believed that conjunctivitis would not clear without treatment. However, they were open to alternative management approaches (e.g. delayed prescription approach) because they trusted their GPs judgement. Once aware of the self-limiting nature of conjunctivitis, patients felt they would prefer to wait a few days to see if it improved before seeking medical advice even if this resulted in a few more days of symptoms.
3) Randomised trial: different prescribing strategies did not affect symptom severity in the ftrst 3 days, but duration of moderately bad symptoms was less with antibiotics (control 4.83 days, immediate 3.26 days (p=0.001), delayed 3.86 days (p=0.002)). Compared with no initial offer of antibiotics, antibiotic use was higher in the immediate group (control 30%, immediate 99% (p=0.001), delayed 53% (p=0.004)) as was belief in the effectiveness of antibiotics (control 47%, immediate 67% (p=0.03); delayed 55% (p=0.35)) and intention to re-consult (control 40%, immediate 68% (p=0.001), delayed 41 % (p=0.98)). A patient information leaflet or an eye swab had no affect on the main outcomes, but an eye swab seemed to increase patient worry about AlC and a PIL seemed to increase satisfaction with the consultation and the amount of information received. Re-attendance in the next two weeks was less in the delayed group (delayed OR 0.33 (0.11;0.98); immediate OR 0.65 (0.26; 1.63)).

In conclusion: Most general practitioners prescribe topical antibiotics for most cases of acute infective conjunctivitis -a self-limiting condition. Most patients are unaware of the self-limiting nature of AlC. A delayed prescribing approach is probably the most appropriate strategy to use for the management of acute conjunctivitis in primary care - it reduces antibiotic use by nearly 50%, shows no evidence of 'medicalisation', provides similar symptom duration and severity to immediate prescribing and reduces re-attendance in the short term compared with no offer of antibiotics.

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ORCID for Hazel A. Everitt: orcid.org/0000-0001-7362-8403

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