Recommend the best treatment
Alan G. Kabat, OD, FAAO: Even with pharmaceuticals, you get what you pay
for. Newer drugs are typically better and, hence, carry a higher price tag.
While some practitioners prefer to use generic medications because they are
less costly, older therapies have significant limitations. Patients and
practitioners alike need to beware of such “bargains.”
Alan G. Kabat |
In bacterial conjunctivitis, I opt for the latest generation
fluoroquinolones. My personal preference is moxifloxacin, but I would not fault
someone for selecting besifloxacin, which appears to have an equivalent
spectrum of activity and similar dosing.
Each of these drugs offers excellent coverage for both gram-positive and
gram-negative organisms, as well as minimal ocular toxicity and convenient
dosing at three times daily. Compared with older generation fluoroquinolones
(e.g., ciprofloxacin) or aminoglycosides (e.g., gentamicin), these newer drugs
have far less potential for bacterial resistance and adverse events. If we
consider that less than 10% of eye care practitioners routinely culture for
bacterial conjunctivitis, it makes sense to select an antibiotic regimen with
the greatest potential for success out of the gate.
Of course, we need to be sensitive to our patients’ financial
concerns, and we can always elect to prescribe a less costly option if someone
simply cannot afford our preferred therapy. But, clearly, cheaper is rarely
better.
Our goal should be to recommend the best treatment option for a given
disorder, be it pharmaceutical, optical or otherwise. When selecting a
medication, we should first consider the global efficacy of that drug within
the specific class, then we should evaluate the safety of our choice for a
given patient. Cost should be our third consideration.
- Alan G. Kabat, OD, FAAO, is an associate professor at Nova
Southeastern University. He can be reached at (954) 262-1440;
kabat@nova.edu.
Consider risk, comorbidity, finances
Julie A. Tyler, OD, FAAO: Before making an antibiotic selection, I will
consider a few key areas. Specifically, I will look at associated risk factors,
comorbidities and the patient’s financial options. Depending on the
severity of the conjunctivitis, these factors will vary in degree of
importance.
Julie A. Tyler |
For example, if the patient with bacterial conjunctivitis is also a
contact lens wearer, I generally will prescribe the newest fluoroquinolone due
to the broad-spectrum coverage and decreased risk of resistance. Prescribing a
fluoroquinolone is especially important if there are any signs of secondary
corneal infiltration.
In contrast, if the patient has a comorbidity of significant lid or
ocular surface disease, I would consider using azithromycin 1%, which has the
benefits of a broad-spectrum topical antibiotic with anti-inflammatory
properties, in addition to a limited dosing regimen for conjunctivitis. All of
those qualities have proven beneficial for patients with accompanying lid
disease. Moreover, when the patient also has severe lid disease, I will
recommend azithromycin for longer than the 5-day conjunctivitis regimen.
Unfortunately, many of my patients are uninsured or have limited
financial resources. In such cases I will use the “tried and true”
antibiotics such as Polytrim (polymyxin B-trimethoprim, Allergan) or
medications available in generic form such as tobramycin.
Finally, individuals with an intact immune system can likely fight off
most bacterial conjunctivitis without medication in a week to 10 days. In cases
where the conjunctivitis is not severe and finances are a concern, I sometimes
give the patient the option to use only supportive therapy but to call if the
symptoms or vision worsens.
- Julie A. Tyler, OD, FAAO, is an associate professor and Primary Care
Module chief at Nova Southeastern University College of Optometry. She can be
reached at jtyler@nova.edu.
Use broad-spectrum treatment
Jill Autry, OD, RPh: I must preface my answer by saying I believe many
conjunctivitis cases are misdiagnosed as bacterial when they are actually
viral. This leads to overuse of antibiotics by all practitioners. Epidemiologic
studies have demonstrated this fact, and even “culture positive”
cases are probably normal ocular flora contaminants. I also see this clinically
when, practicing in a referral center, I examine patients being treated for
bacterial conjunctivitis that is actually viral and in desperate need of
anti-inflammatory treatment, not antibacterial.
Jill Autry |
However, in true bacterial conjunctivitis, studies show that, although
most cases will resolve without therapy, treating the condition will lessen the
severity and length of symptomatology. Depending on the study cited,
gram-positive organisms such as Staphylococcus aureus or
Streptococcus pneumoniae are more common (60% to 70% of cases) than
gram-negative organisms such as Haemophilus influenza (30% to 40% of
cases). This illustrates our need for broad-spectrum coverage.
I would treat most patients with a newer-generation fluoroquinolone.
These agents are well known for their tolerability, lack of allergic reactions,
broad-spectrum coverage, ability to cover resistant organisms and
compliance-friendly (twice to four times daily) dosing.
Although some of the latest class additions may offer theoretic
advantages due to increased concentration (Zymaxid, gatifloxacin 0.5%,
Allergan) and lack of oral equivalency (Besivance, besifloxacin 0.6%, Bausch +
Lomb), all newer-generation products will work well.
I would use tobramycin, an aminoglycoside, if the patient lacked
insurance coverage and did not need extended treatment due to concerns of
corneal and conjunctival toxicity. I would use polysporin if an ointment was
necessary in a child younger than 1 year of age or in any case where drops
could not be used. After 24 to 48 hours, I would add a topical steroid
providing there was a decrease in the purulent nature of the discharge. After
all, the word conjunctivitis still means inflammation of the conjunctiva.
- Jill Autry, OD, RPh, a Primary Care Optometry News Editorial
Board member, is a partner at Eye Center of Texas in Houston. She can be
reached at (713) 797-1010; jill_autry@hotmail.com.
Newer drugs work more quickly
Walter L. Choate Jr., OD, FAAO: Bacterial conjunctivitis is not
frequently encountered in most optometry practices, largely because primary
care physicians and pediatricians typically treat it. However when we see these
patients, it is usually for a second opinion.
Walter L. Choate Jr. |
Regarding whether to start a patient on a latest-generation drop for
acute bacterial conjunctivitis, it is important to note that the disease itself
is self-limited and will improve in a week or two with no treatment. It is also
important that most patients never make it into the chair of an eye physician
for treatment. As such, in almost all of those cases, this disease is treated
successfully with first- and second-generation topical antibiotics.
Most optometric physicians will probably reach for a combination of
tobramycin and dexamethasone or tobramycin and loteprednol, both of which
contain a second-generation antibiotic. With the addition of a steroid,
inflammation will be improved substantially. Most, if not all, patients with
bacterial conjunctivitis improve dramatically with these drugs.
The literature indicates that very little bacterial resistance results
from the use of topical antibiotics. Therefore, one would conclude that the use
of the latest-generation antibiotic should be appropriate, especially in severe
cases.
However in real-world practice, we see price as the defining barrier.
Indeed, if all of the newest-generation antibiotics were the same cost as
earlier-generation products, perhaps all new prescriptions would be issued with
the latest products. After 30 years of patient experience with a wide spectrum
of antibiotics, I can say that most work very well – even the old ones,
but we as clinicians will always be charged with making the patient better
quickly. The newest antibiotics offer many benefits in efficacy and comfort.
- Walter L. Choate Jr., OD, FAAO, is a member of the Primary Care
Optometry News Editorial Board. He can be reached at (615) 851-7575;
walterchoate@aol.com.