Family Practice Vol. 19, No. 6, 658-660
© Oxford University Press 2002
How do GPs diagnose and manage acute infective conjunctivitis? A GP survey
a Community Clinical Sciences (CCS) Division, Faculty of Medicine, Health and Biological Sciences, Southampton University and
b Primary Medical Care, Aldermoor Health Centre, Southampton, UK.
Dr Everitt, Primary Medical Care, Aldermoor Health Centre, Aldermoor Close, Southampton SO15 6ST, UK; E-mail: hae1{at}soton.ac.uk
Everitt H and Little P. How do GPs diagnose and manage acute infective conjunctivitis? A GP survey. Family Practice 2002; 19: 658–660.
Received 4 December 2001; Revised 2 April 2002; Accepted 6 July 2002.
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Abstract |
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Objective. To determine GPs’ diagnosis and management of acute infective conjunctivitis (AIC)—one of the commonest but least researched acute infections seen in primary care.
Methods. A postal questionnaire survey of 300 GPs from two Health Authorities in Southern England.
Results. 236 (78%) GPs returned the questionnaire. 92% of those responding felt confident or very confident in the diagnosis of AIC. 95% usually prescribe topical antibiotics for AIC despite 58% stating that they thought at least half of the cases they see are viral in origin and only 36% believing that they could discriminate between bacterial and viral infection. There was considerable variability in GPs’ use of individual signs to make the diagnosis of AIC (from 99% using eye discharge to 31% using conjunctival oedema) and in the features used to discriminate viral from bacterial infection (from 87% using type of discharge to 47% using amount of discharge). GPs rarely perform eye swabs or give patient information leaflets to patients with AIC.
Conclusion. Most GPs still prescribe topical antibiotics for most cases of AIC—a condition where only half of the cases are likely to be due to a bacterial infection, and even bacterial infections are self-limiting. Further research is needed to explore the potential benefits and disadvantages of topical antibiotics, and to develop clinical or microbiological methods to help GPs to target antibiotic prescription.
Keywords. Acute infective conjunctivitis, management, diagnosis.
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Introduction |
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Acute infective conjunctivitis (AIC) is common (2% of GP consultations).1–4 In England, 3.4 million community prescriptions for topical ocular antibiotics are issued each year, costing the NHS £4.7 million.5 However, little information is available on how GPs currently manage this condition or about the effectiveness of treatment.
The limited evidence suggests that bacterial conjunctivitis is self-limiting, with 64% of cases resolving in two to five days without treatment.5 Traditionally, topical antibiotics are prescribed in an attempt to shorten the illness, reduce complications and re-infection. However, evidence for their effectiveness is limited.5 Topical antibiotics may improve the clinical remission rate at days two to five by 30%.5,6 Significant complications following bacterial conjunctivitis are rare.5 Clinically, it is difficult to distinguish bacterial from viral conjunctivitis—only 50% of clinically diagnosed cases have a bacterial aetiology.7
Increasing bacterial resistance has focused attention on reducing antibiotic prescribing and evidence has emerged that prescribing for minor self-limiting infections can lead to ‘medicalization’ and an increased reconsultation for similar complaints in the future.8 Yet little attention has been paid to the use of topical antibiotics for AIC.
We report a survey of how GPs currently diagnose and manage AIC to clarify the current position and enable future research to focus on clinically important issues.
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Methods |
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In January 2001 a questionnaire was posted to 303 GPs in Southampton and South-West Hampshire and Portsmouth and South-East Hampshire Health Authorities. All the GPs were principals on the Health Authority list. Non-responders received two follow-up mailings. The questionnaire was short to maximize the response rate.
Questions asked included: signs and symptoms used in the diagnosis of AIC; examination and investigations undertaken; confidence with diagnosis; discrimination of bacterial from viral conjunctivitis; the proportion of AIC considered to have a bacterial aetiology; and usual management strategies including prescription, use of a delayed prescription strategy and patient information leaflets.
The GPs also provided information on gender, number of years as principal, practice list size, number of sessions, attainment of the MRCGP and any specialist ophthalmology experience so as to define the study group.
Re-sending of the questionnaire to 50 GPs showed moderately good test–retest reliability.9
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Results |
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Of the 303 GPs approached, three had either left the practice or were on long-term sick leave, giving a study group of 300 GPs. Seventy-eight per cent (234) questionnaires were returned. The study group were similar in gender, number of GP sessions worked and experience to all registered GP principals in the UK.10
Diagnosis of AIC
The main features the GPs used to diagnose AIC were eye discharge (99% of respondents) and conjunctival injection (94%) (see Table 1
). However there was considerable variability in other features used, for example, 32% of GPs indicated they used presence of a swollen eyelid in diagnosis and 31% used conjunctival oedema.
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All GPs said they performed a visual inspection of the eye in presumed cases of AIC, 26% said they usually perform ophthalmoscopy and 17% that they usually stain the cornea.
Ninety-two per cent (215/233) were confident or very confident in their ability to diagnose conjunctivitis. The other 8% gave a neutral response, with no GPs indicating that they were not confident. However, despite this high level of confidence with diagnosis, only 36% felt they could discriminate bacterial from viral infection. Of those who felt they could discriminate, again there was variability in the features used: 85% used history of a cold, 87% the nature of the discharge and 47% the amount of discharge.
There was also considerable variability in the proportion of cases of AIC that the GPs believed were caused by bacterial infection (range <10% to >90% of cases). Most GPs (58%) thought that less than half of cases of AIC that they see have a bacterial aetiology.
Management of AIC
Most GPs (95%) prescribed topical antibiotics for AIC. Most did not use a delayed prescription strategy, a patient information leaflet (PIL) or take an eye swab.
Twenty-one per cent said that they prescribed for every case of AIC. The remaining 79% felt happy not to prescribe in certain cases (e.g. mild infection or babies with sticky eyes) but they still prescribed for most patients.
Neither GP experience (years as a GP) or having had specialist ophthalmology training were related to prescribing for AIC or using a delayed prescribing approach.
Amongst the 67% of GPs that ever took eye swabs for AIC, most (84%) did so in a small minority of cases (<10%).
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Discussion |
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To our knowledge this is the first study to explore GPs’ diagnosis and management of AIC in detail. The good response rate (78%), similar characteristics of the responders to national data sets10 and the reliability of the questionnaire,9 mean these results should be reasonably reliable and generalizable.
Inevitably, results from a survey are susceptible to reporting bias. However, there is little evidence of this in these results—for example, the vast majority of GPs reported prescribing antibiotics contrary to recent campaign pressure to reduce antibiotic prescribing.
Main Results
Previous GP surveys on eye related conditions indicated a lack of confidence in Ophthalmology.1 In contrast, this survey shows GPs to have a high level of confidence in diagnosing AIC. An encouraging finding, as AIC is probably the most commonly seen eye condition in general practice.1–4
However, there was considerable variability in the features used to diagnose AIC. Additionally, most GPs (64%) did not feel able to discriminate between bacterial and viral conjunctivitis. This diagnostic uncertainty may explain why GPs are prescribing antibiotics for most cases of AIC, despite believing that a significant proportion of cases are not bacterial.
Further research is needed to determine whether a clinical scoring system could be developed to enable GPs to better target antibiotic prescriptions for AIC.
Management
Our results show that GPs prescribe for most cases of AIC—consistent with previous research.1 Should prescribing be the norm? Most cases (64%) of bacterial conjunctivitis are cured by day two to five without treatment. Currently, GPs prescribe for many patients who in fact have viral conjunctivitis. Topical antibiotics may improve the early cure rate by 30%5,6 but what is the clinical significance of this? Prescribing increases the risk of antibiotic resistance and allergic reactions and could lead to medicalization of AIC and an increased likelihood of reconsultation.8
A delayed prescription strategy (providing a prescription to use if required after a few days) may be appropriate for AIC, as a significant number of patients will improve within a few days. However, only a minority of surveyed GPs ever used this strategy. Enabling patients to selfcare for AIC could increase patient empowerment and reduce pressure for same-day appointments.
More research is needed to clarify the advantages and disadvantages of prescribing topical antibiotics for AIC.
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Conclusion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
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Most GPs prescribe topical antibiotics for most cases of AIC—a minor self-limiting condition in which only half of cases are likely to have a bacterial aetiology. Further research is needed to explore the potential benefits and disadvantages of prescribing. Few GPs believe they can discriminate between bacterial and viral conjunctivitis. This diagnostic uncertainty may contribute to the high rate of antibiotic prescribing. The development of robust clinical or microbiological methods to help GPs make this distinction would enable them to better target antibiotic prescription.
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Acknowledgments |
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We are grateful to the GPs in Southampton and South-West Hampshire and Portsmouth and South-Eeast Hampshire Health Authorities who participated in the survey. We would also like to thank Dr Michael Moore, Dr Santinder Kumar and Dr Ian Williamson for their comments on the manuscript. This work was funded by the MRC. HE and PL are funded by the MRC.
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References |
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1 Sheldrick JH, Wilson AD, Vernon SA, Sheldrick CM. Management of ophthalmic disease in general practice. Br J Gen Pract 1993; 43: 459–462.[Medline]
2 McDonnell PJ. How do general practitioners manage eye disease in the community? Br J Ophthalmol 1988; 72: 733–776.
3 Wilson A. The Red Eye: a general practice survey. J R Coll Gen Pract 1987; 37: 62–64.[Medline]
4 Dart JKG. Eye disease at a community health centre. Br Med J 1986; 293: 1477–1480.[ISI][Medline]
5 Sheikh A, Hurwitz B. Topical antibiotics for acute bacterial conjunctivitis: a systematic review. Br J Gen Pract 2001; 51: 473–477.[Medline]
6 Gigliotti F. Efficacy of topical antibiotic therapy in acute conjunctivitis in children. J Paediatrics 1984; 104: 623–626.[ISI][Medline]
7 Mahajan VM. Acute bacterial infections of the eye: their aetiology and treatment. Br J Ophthalmol 1983; 67: 191–194.
8 Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmouth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. Br Med J 1997; 315: 350–352.
9 Brennan P. Statistical methods for assessing observer variability in clinical measures. Br Med J 1992; 304: 1491–1494.[ISI][Medline]
10 Profile of general practitioners. RCGP information sheet, 2000.
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