DR. ROSINA THOMAS (T14385)
Abstract:
Context:
A wide range of potent topical antibiotics are now at the disposal of each Ophthalmologist and they are being prescribed indiscriminately.
Aims:
To assess the trends in prescribing topical antibiotics for ocular surface infections and pre and post operative prophylaxis among Ophthalmologists in Kerala and to analyse whether they are in line with evidence based recommendations
Settings and Design:
Prescription pattern of topical antibiotics among Ophthalmologists in Kerala were surveyed by mail or by interviews using a questionnaire. The responses were statistically analysed and compared with current recommendations.
Results:
The 112 Ophthalmologists who participated in the survey dispensed a mean of 14.8 (range 1-60) topical antibiotic prescriptions in a day. The commonest indication for a topical antibiotic was infective conjunctivitis (67%) followed by pre and post operative prophylaxis (23.3%). The most popular topical antibiotics prescribed were Moxifloxacin (30.4%), Ofloxacin (25.6%) and Ciprofloxacin (18.8 %). 81.2 % of participants believed that majority of cases of infective conjunctivitis were mild and self limiting. 82.2% among them would prescribe a topical antibiotic for them. 92% of surgeons prescribed a topical antibiotic preoperatively and it was Moxifloxacin in 47.35% cases.
Conclusions
Though 81.2 % of participants believed that majority of cases of infective conjunctivitis were mild and self limiting, 82.2% of them would still prescribe a topical antibiotic. Pre-operative antibiotics are used by 92% of surgeons, though no conclusive evidence supports the same.
Key-words: antibiotics, conjunctivitis, fluoroquinolones
Key Messages:
Rampant and injudicious use of topical antibiotics, especially fourth generation fluoroquinolones like Moxifloxacin raises the possibility of emergence of drug resistance. New rational and evidence based guidelines need to be formulated on the prescribing pattern of topical antibiotics in the community which are practical and cost effective
Introduction:
In developing countries like ours, acute infectious conjunctivitis is a common presentation to general practitioners in the primary care setting1. It is also the commonest condition managed by Ophthalmologists. A wide spectrum of topical antibiotics is now available to each practitioner. But the current practice of prescribing broad spectrum topical antibiotics by Ophthalmologists raises serious concerns. The aim of the study was to assess the trends in prescribing topical antibiotics for ocular surface infections and pre and post operative prophylaxis among Ophthalmologists in Kerala and to analyse whether they are in line with evidence based recommendations.
Subjects and Methods:
Prescription pattern of topical antibiotics among Ophthalmologists in Kerala were surveyed by an internet based survey tool (Sogo Survey). Invitations to take part in survey were sent via email. Interviews using a printed questionnaire were conducted for Ophthalmologists who were not accustomed to online methods of survey.
The responses were recorded and statistically analysed. Statistical analyses were performed using SPSS Version 16.0. Results of categorical variables were reported as count and percentages. The differences between categorical variables were analyzed using the nonparametric test- Fisher’s exact Test. P-value <0.05 was considered as significant for all comparisons. The results were compared with current recommendations.
Results:
A total of 112 Ophthalmologists participated in the survey. 42 (37.5%) among them practised in Government Institutions, whereas the rest 70 (62.5%) worked in private hospitals or clinics.
Thirteen (11.6%) of participants worked in Primary care institutions, 34 (30.4%) in Secondary care and 65 (58.0%) in Tertiary care centres.
Among the 112 participants in the study, 51 (45.5%) were General ophthalmologists, 22 (19.6 %) were trainee Ophthalmologists and 39(34.8%) were super-specialists.
On an average, they dispensed 14.8 (range 1-60) topical antibiotic prescriptions in a day. No statistical co-relation could be found with the number of antibiotic prescriptions in a day and the number of years of clinical experience of the Ophthalmologist or with the number of patients seen in the OPD in a day.
The commonest indication for prescribing a topical antibiotic was infective conjunctivitis (75, 67%) followed by pre and post operative prophylaxis (26, 23.2%) and cases of non-specific red eyes (11, 9.8%).
Among all categories of Ophthalmologists, the most commonly prescribed topical antibiotic was Moxifloxacin (30.4%), followed by Ofloxacin (25.6%), Ciprofloxacin (18.8%), Tobramycin (12.5 %), Chloramphenicol (10.7%) and Gatifloxacin (1.8%). Those in Government hospitals prescribed more of Ciprofloxacin and Tobramycin whereas Ofloxacin and Moxifloxacin were more used in private institutions. Primary care physicians used Ciprofloxacin, Tobramycin and Chloramphenicol more frequently than those in secondary and tertiary care. [Table-1]
Among the 112 participants, 68 (60.7 %) agreed that most cases of acute infective conjunctivitis in the adult population were viral and self-limiting. (Contradiction in the percentage mentioned in the Abstract on page 6 ). Ninety one (81.2 %) believed that majority of cases of bacterial conjunctivitis were mild and self limiting, whereas 21 (18.8%) thought they progressed to complications if untreated.
In cases of uncomplicated viral conjunctivitis, 92 (82.2%) would prescribe an antibiotic. Forty four (39.3%) participants would always prescribe a topical antibiotic, 48 (42.9%) would do so occasionally, but 20 (17.9%) would never. [Table 2], [Table 3]
One hundred and two (91.1%) Ophthalmologists would advise an antibiotic for a case of bacterial conjunctivitis, 10 (8.9%) would not. A topical antibiotic was used by 96 (85.7%) participants in non specific red eye and by 45(40.2 %) in non– infective conditions like allergic conjunctivitis, subconjunctival haemorrhages, dry eyes and corneal degenerative conditions.
In cases of infective conjunctivitis, 101(90.2%) participants would prescribe a topical antibiotic at the first visit, rather than wait and watch for the emergence of complications. The advantages of initiating topical antibiotic therapy according to the participants were symptomatic relief (21.4%), shortened course of infection (66%) and reduced chances of recurrence and transmission (1.8%). 10.7% of participants thought that a topical antibiotic would worsen symptoms by causing surface toxicity.
Topical antibiotics were usually prescribed less than four times a day by four (3.6%), four times a day by 59(52.7%) and more than four times a day by 49 (43.7%). [Table 4]
Sixty four (57.1%) of the participant Ophthalmologists took time for patient education, whereas 48 (42.9%) did not.
Fifty six (50%) of respondents believed that the use of a topical antibiotic pre-operatively can prevent a post-operative intraocular infection, 11 (9.8%) did not think so and 45(40.2%) were unsure. 92 % of surgeons routinely prescribed a pre-operative topical antibiotic whereas 8 % did not. The first choice of pre-operative antibiotic was Moxifloxacin (47.3%), followed by Ofloxacin (42%) and Gatifloxacin (9.8 %).
Discussion:
According to the present survey, infective conjunctivitis (67%) was the most common indication for the prescription of a topical antibiotic among Ophthalmologists in Kerala, practising in both Government and private institutions and at all levels of medical care. It was managed by all participants from trainee Ophthalmologists to super-specialists and with varying years of clinical experience.
70% of cases of acute infectious conjunctivitis in the adult population are viral in aetiology. It is usually caused by adenovirus infection. It is a self-limiting condition that usually resolves within two weeks of onset of symptoms. There is no evidence supporting the use of anti-viral medication and their efficacy has not been proven1. Though 60.7 % of the Ophthalmologists were aware of these etiological factors and the natural course of the condition, 82.2 % of them would still prescribe a topical antibiotic for a patient with viral conjunctivitis.
Bacterial conjunctivitis is commonly due to infection with Haemophilus influenzae, Streptococcus pneumoniae or Staphylococcus aureus2. A Cochrane systematic review found that acute bacterial conjunctivitis is often a self-limiting condition, 65 % patients treated with placebo showed significant improvement. Patients treated with a broad-spectrum topical antibiotic had improved microbiological and clinical outcome, especially when treated early (days 2 to 5). The use of antibiotics speed recovery, reduce relapse and transmission and may prevent important sight-threatening complications. But the risk of adverse events in those treated with placebo was also found to be low1. 91.1% of participants would prescribe a topical antibiotic for bacterial conjunctivitis, whereas 8.9% would not.
A diagnosis of conjunctivitis is usually made on the basis of a clinical history and examination. Since at times it is difficult to differentiate between infective and non- infectious conjunctivitis. So, for a presumed case of infective conjunctivitis, most practitioners prescribe a broad-spectrum topical antibiotic on an empirical basis without culture3,4. Patients are instructed to seek follow-up care if the expected improvement does not occur or if vision becomes affected. According to the present survey, 85.7 % of participating consultants would prescribe a topical antibiotic for a case of non specific red eyes. Antibiotic eye drops were also injudiciously used for non infectious conditions like allergic conjunctivitis, subconjunctival haemorrhages and non-infective corneal pathologies by 40.2% of Ophthalmologists.
Fluoroquinolones are currently the most popular broad-spectrum antibiotics for treatment and prophylaxis of eye infections because of their safety, excellent penetration into the aqueous and vitreous, long duration of tear concentration, and broad spectrum of antimicrobial activity. An increasing number of guidelines recommend avoiding the use of fluoroquinolones and combinations except for the most severe infections or following treatment failure7. But in Kerala, fourth generation fluoroquinolones like Moxifloxacin are rampantly prescribed for uncomplicated infective conjunctivitis and non- infective conditions, more so in private institutions.
Participating Ophthalmologists prescribed a topical antibiotic for a patient with infective conjunctivitis in the belief that it would lessen the patient’s symptoms, reduce duration of infection and chances of recurrence. Though these advantages have been proven by numerous studies, they come at the cost of worsening surface toxicity and increased risk of developing drug resistance6.
A large proportion of Ophthalmologists (90.2%) prescribed a topical antibiotic empirically at the time of diagnosis for an acute simple infective conjunctivitis, rather than wait and watch (9.8%) for the emergence of complications. A better option that has been recommended is to delay treatment for 5 days and prescribe antibiotics if no improvement5.
The usual factors that influenced the choice of topical antibiotic in most of practicing Ophthalmologists in Kerala were local availability of drugs, cost of drug and affordability of the patient, rather than knowledge of etiological factors and drug sensitivity of the infecting organisms. Promotion by pharmaceutical companies rarely influenced the participants.
The American Academy of Ophthalmology suggests a 5-to-7-day course of a broad-spectrum topical antibiotic, which is the most convenient or least expensive one usually available, since there is no clinical evidence suggesting the superiority of any particular antibiotic in simple bacterial conjunctivitis7.
The practice of prescribing topical antibiotic for infections at frequencies more than or less than the recommendation of four times a day by 47.3% of consultants and tapering of antibiotics should be avoided to prevent generation of drug resistance. Compliance with the length of time (7-10 days) the antibiotics are prescribed for is also particularly important.
The economic impact of infective conjunctivitis is also substantial. Preventive infection-control measures by good personal hygiene and patient education can be extremely cost-effective. But in routine busy clinical practice, 42.9 % of participating Ophthalmologists do not bother to take time for patient education, which is the only proven method of disease control.
A qualitative study of patients’ perceptions of acute conjunctivitis performed in the UK8 revealed that most patients when informed about the self limiting nature of the disease were satisfied without antibiotic prescription. So whenever an infection of viral aetiology is suspected, the emphasis should be on patient education regarding its self-limiting nature, thus avoiding thousands of unnecessary antibiotic prescriptions every year.
Moreover, treatment of all red eyes with topical antibiotics can result in a delay and confusions in the diagnosis of other more severe and urgent non infective conditions.
Though extensive research has been done, the only two prophylactic methods proven to be effective in post-operative endophthalmitis prevention are antisepsis and intracameral injection of 1 mg cefuroxime at the end of the surgical procedure9. Though 50% surgeons were aware of the futility of a pre-operative antibiotic, in their endeavour to avoid the worst catastrophe, 92% of them would prescribe a pre-operative topical antibiotic, which is usually a fourth generation fluoroquinolone (57.1%). Resistance to the fluoroquinolone with Staphylococcus isolated from endophthalmitis has been shown to be due to topical surgical prophylaxis, especially for prolonged periods.
The other possible causes of emerging resistance to topical antibiotics as suggested by the participants were indiscriminate prescription of highly potent antibiotics, irrational use of combinations of antibiotics with steroids and NSAIDs, prescription of topical antibiotics by general practitioners and other specialists and over the counter sale of topical antibiotics.
Recent reports of fluoroquinolone resistance with Staphylococcus10 and Pseudomonas which is more common with the second (ciprofloxacin and ofloxacin) and third generation (levofloxacin and purified ofloxacin) than by a fourth-generation fluoroquinolone (moxifloxacin and gatifloxacin) could emerge as a major therapeutic challenge. As of yet, the problem is not a public health issue, since drug resistance may be due to antibiotic over use rather than patient-to-patient spread.
The current practice of prescribing broad spectrum topical antibiotics by Ophthalmologists in Kerala raises concerns of antibiotic resistance, cost-effectiveness, and potential increase in complications due to antibiotic use. Rampant and irrational treatment of infective conjunctivitis and other non-infective conditions with antibiotics, inappropriate dosing regimen and prolonged duration of therapy should be checked. Use of highly effective fourth generation fluoroquinolones like Moxifloxacin should be judicious and reserved for most severe cases. New rational and evidence based guidelines need to be formulated on the prescribing pattern of topical antibiotics in the community which are practical and cost effective, with more emphasis on preventive aspects and patient education.
References:
- Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: Cochrane systematic review and meta-analysis update. British Journal of General Practice. 2005; 55: 962-964.
- Everitt HA, Little PS, Smith PW. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. BMJ. 2006; 333: 321.
- Visscher KL, Hutnik ML C, Thomas M. Evidence-based treatment of acute infective conjunctivitis. Breaking the cycle of antibiotic prescribing. Can Fam Physician 2009;55(11):1071 – 5.
- Vichyanond P, Brown Q, Jackson D. Acute bacterial conjunctivitis. Bacteriology and clinical implications. Clin Pediatr 1986;25(10):506-9.
- Ramesh S, Ramakrishnan R, Bharathi MJ, Amuthan M, Viswanathan S. Prevalence of bacterial pathogens causing ocular infections in South India. Indian J Pathol Microbiol 2010;53: 281-6.
- Rietveld R P, Van Weert H C, Ter Riet G. Diagnostic impact of signs and symptoms in acute infectious conjunctivitis: systematic literature search. BMJ 2003; 327(7418):789.
- American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Conjuctivitis. San Francisco, CA: American Academy of Ophthalmology; 2013.
- Rose P. Management strategies for acute infective conjunctivitis in primary care: a systematic review. Expert Opin Pharmacother 2007; 8(12):1903-21.
- Barry P, Behrens-Baumann W, Pleyer U, Seal D. ESCRS guidelines on prevention, investigation and management of post-operative endophtalmitis. Version 2. Santen. The European Society for Cataract & Refractive Surgeons. 2007:1–37.
- Marangon FB, Miller D, Muallem MS, et al. Ciprofloxacin and levofloxacin resistance among methicillin-sensitive Staphylococcus aureus isolates from keratitis and conjunctivitis. Am J Ophthalmol 2004: 137: 453-8.
Tables:
Table-1: Commonest antibiotic prescribed and type of health care institute
| Topical antibiotic Prescribed | Health care institute | P value | |
| Govt. Hospital | Private Hospital | ||
| Ciprofloxacin | 20 | 1 | <0.001 |
| Ofloxacin | 0 | 29 | |
| Moxifloxacin | 0 | 34 | |
| Tobramycin | 12 | 2 | |
| Gatifloxacin | 1 | 1 | |
| Chloramphenicol | 9 | 3 | |
Table 2. Frequency distribution of Usage of topical antibiotic for uncomplicated viral conjunctivitis
| Frequency | Percent | |
| Yes | 92 | 82.14 |
| No | 20 | 17.85 |
| Total | 112 | 100 |
Table3. Knowledge action mismatch
| Most of acute infective conjunctivitis cases are mild and self limiting | Usage of Topical Antibiotic for Uncomplicated Conjunctivitis | P value | |
| Yes | No | ||
| Agree | 63 | 5 | 0.001 |
| Disagree | 29 | 15 | |
Table 4: Frequency of topical antibiotic administration in infective conjunctivitis
| Prescription of an antibiotic | Frequency | Percent |
| <4 times/ day | 4 | 3.6 |
| 4 times/ day | 59 | 52.7 |
| >4 times/ day | 49 | 43.7 |
| Total | 112 | 100 |
Leave a Comment