Antibiotic Treatment and Health Care Use in Children and Adolescents With Conjunctivitis

Acute infectious conjunctivitis affects 1 in 8 children and adolescents annually in the US.¹ Although the American Academy of Ophthalmology suggests that foregoing immediate topical antibiotic treatment is safe and effective in most circumstances,² antibiotics are frequently prescribed.³ Since most cases are mild and self-limited regardless of treatment, the national burden of conjunctivitis is largely attributable to costs of medical visits and missed work or school rather than to serious clinical sequelae.^2,4 In this study, we evaluated the frequency of topical antibiotic treatment and the association of antibiotic treatment with subsequent health care use among commercially insured children and adolescents (hereafter, children) with acute infectious conjunctivitis in the US.

This cohort study included data from the 2021 MarketScan Commercial Claims and Encounters Database.⁵ We included individuals (aged 1-17 years) with ambulatory care encounters who had a conjunctivitis diagnosis (eTable and eFigure in Supplement 1). The Harvard Pilgrim Healthcare Institute’s Institutional Review Board deemed this study exempt from review and informed consent because it was not human participant research. We followed the STROBE reporting guideline.

The primary exposure was a topical antibiotic prescription dispensed within 1 day of the index encounter. Outcomes were assessed 2 to 14 days after the index encounter. The primary outcomes were ambulatory care revisits (1) for conjunctivitis and (2) with same-day dispensation of a new topical antibiotic. Ambulatory care revisits with same-day dispensations were studied to capture instances of possible treatment failure. Secondary outcomes included emergency department (ED) revisits and hospitalizations with any infectious conjunctivitis diagnosis. We used logistic regression to evaluate the association between antibiotic treatment and primary outcomes, adjusting for characteristics of children, visits, and clinicians. Analyses were conducted between October 2023 and April 2024 using R version 4.3.2 (R Core Team).

After exclusions, 44 793 ambulatory care encounters were included. Children had a median (IQR) age of 5 (2-10) years and included 21 210 females (47%) and 23 583 males (53%) (Table 1).⁶

Topical antibiotics were dispensed within 1 day after 31 087 encounters (69%). Topical antibiotics were less frequently dispensed after visits to eye clinics (34%), in children aged 6 to 11 years (66%), and in children with viral conjunctivitis (28%).

Ambulatory care revisits for conjunctivitis within 14 days occurred after 3.2% (95% CI, 3.1%-3.4%) of index encounters. All-cause revisits with a same-day antibiotic dispensation occurred after 1.4% (95% CI, 1.3%-1.5%) of index encounters. In multivariable analysis, topical antibiotic treatment was not associated with ambulatory care revisits for conjunctivitis (adjusted OR [AOR], 1.11; 95% CI, 0.99-1.25) or revisits with same-day topical antibiotic dispensation (AOR, 1.10; 95% CI, 0.92-1.33) (Table 2). Hospitalizations for conjunctivitis occurred for 0.03% and ED revisits for 0.12% of children, with no differences across exposure groups. Among children who were initially evaluated in eye clinics, ambulatory care revisits occurred for 9.5%, and antibiotic treatment was associated with increased odds of ambulatory care revisits (AOR, 1.84; 95% CI, 1.36-2.48).

More than two-thirds of commercially insured children with conjunctivitis filled a prescription for topical antibiotics within 1 day of an ambulatory care visit. Revisits and new antibiotic dispensations were rare, regardless of initial topical antibiotic treatment, suggesting that not receiving antibiotics may not be associated with additional health care use. Children who were initially evaluated in eye clinics were infrequently treated with topical antibiotics but had more frequent ambulatory care revisits when antibiotics were dispensed, suggesting a higher threshold for treatment and closer follow-up care for presumed bacterial conjunctivitis.

Study limitations include an inability to distinguish scheduled from unscheduled revisits, incomplete clinical data (including rare complications of conjunctivitis), and inability to confirm the accuracy of the coded diagnosis of infectious conjunctivitis (eg, in children who did not receive a thorough eye examination). Given that antibiotics may not be associated with improved outcomes or change in subsequent health care use and are associated with adverse effects and antibiotic resistance, efforts to reduce overtreatment of acute infectious conjunctivitis are warranted.

Accepted for Publication: April 30, 2024.

Published Online: June 27, 2024. doi:10.1001/jamaophthalmol.2024.2211

Corresponding Author: Daniel Shapiro, MD, MPH, UCSF Pediatric Emergency Medicine, 550 16th St, PO Box 0649, San Francisco, CA 94158 (daniel.shapiro@ucsf.edu).

Author Contributions: Drs Shapiro and Oke had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Shapiro, Geanacopoulos, Subramanian, Oke.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Shapiro.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Shapiro, Geanacopoulos, Oke.

Administrative, technical, or material support: Shapiro, Wu.

Supervision: Shapiro, Subramanian, Wu, Bardach.

Conflict of Interest Disclosures: Dr Oke reported receiving grants from Agency for Healthcare Research and Quality, National Center for Advancing Translational Sciences, Research to Prevent Blindness, and Knights Templar Eye Foundation outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2.