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Chloramphenicol for Conjunctivitis?

Chloramphenicol for Conjunctivitis?. Tim Robson and Liz Morris GPVTS ST2. Why?. 2-5% of all GP consultations are for eye problems infective conjunctivitis ~35% (NICE CKS) Recent media and GMC focus on responsible antibiotic prescribing

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Chloramphenicol for Conjunctivitis?

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  1. Chloramphenicol for Conjunctivitis? Tim Robson and Liz Morris GPVTS ST2

  2. Why? • 2-5% of all GP consultations are for eye problems • infective conjunctivitis ~35% (NICE CKS) • Recent media and GMC focus on responsible antibiotic prescribing • But more widespread availability of OTC chloramphenicol.. • What should we be advocating?

  3. Question: [P] In adults with acute, infective conjunctivitis, [I] Is use of chloramphenicol treatment better than [C] No treatment/placebo [O] At reducing severity or duration of symptoms?

  4. Search strategy: • PubMed • [conjunctivitis] AND [(infect* OR bacter*) NOT allergic] AND [chloramphenicol] • Filters: Human; English; • Cochrane Library • Antibiotic AND conjunctivitis

  5. Results • 132 total results • Exclusions • Allergic, chronic • Neonatal/Paediatric • Multi-resistance or Rare organisms • Relevance (eg wound infections..) • Paper text unavailable • No placebo control

  6. Results • 2 primary literature papers: • Br J Gen Pract. 2011 Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Jefferis J et al. • BMJ. 2006 A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. Everitt H et al. • Data included in above meta-analysis • 1 x Review • Cochrane Database Syst Rev. 2012 Antibiotics versus placebo for acute bacterial conjunctivitis. Sheikh A et al • 1 x chloramphenicol prescribing/OTC use study • Br J Gen Pract. 2009 Relative impact of clinical evidence and over-the-counter prescribing on topical antibiotic use for acute infective conjunctivitis. Davis Het al

  7. Critical appraisal

  8. Discussion • NICE CKS quotes the Cochrane RV – statistical benefit in symptoms and duration -but advises prescribe only in severe cases • GP Update course: Pragmatic approach of statistical significance vs clinical significance : “Antibiotics in adults & children may confer some small benefit early on, although the clinical relevance of this is doubtful – being symptom-free 6 hours sooner, 5 days into the illness! And by day 7 there is no advantage in having antibiotics.” • Changes in prescribing since OTC available (BJGP paper): 2005-7 prescribing of chloramphenicol decreased, but overall usage increased due to increasing levels of OTC uptake

  9. The bottom line… • Statistically: • There is a small benefit in cure rate with antibiotics versus placebo; this is more pronounced for early cure vs late cure • Clinically: • Absolute & relative difference in cure rate between treatment & placebo groups was small (6-11% absolute; 8-36% relative) • There is no good data to support one antibiotic versus another, or recommend treatment duration • Mildly red eyes with purulent discharge may benefit more than other subgroups

  10. The bottom line… • Or… • In poor quality data, there is a small statistical benefit (of uncertain clinical significance) of antibiotics versus placebo in acute infective conjunctivitis • So… • Watch & wait is probably reasonable

  11. References • National Institute for Health and Clinical Care Excellence, Clinical Knowledge Summaries, August 2015 , Conjunctivitis – Infective: Acute infective conjunctivitis. • British National Formulary – Chloramphenicol • Cochrane Database Systematic Review, September 2012 ,Antibiotics versus placebo for acute infective conjunctivitis, • BMJ. 2006 Aug 12;333(7563):321. Epub 2006 Jul 17. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. Everitt H et al • Br J Gen Pract. 2011 Sep;61(590):e542-8. doi: 10.3399/bjgp11X593811. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Jefferis J et al. • Br J Gen Pract. 2009 Dec;59(569):897-900. doi: 10.3399/bjgp09X473132. Relative impact of clinical evidence and over-the-counter prescribing on topical antibiotic use for acute infective conjunctivitis. Davis Het al

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