Pediatrics – PICO #1

Brief description of patient problem/setting (summarize the case very briefly)

8 y/o F, accompanied by father, comes in to the pediatrics emergency room c/o red itchy eyes with discharge x 2 days. Pt’s father reports daughters’ eyes were crusting every morning and needed to be cleaned out. This is their second time in the pediatric ER within the last two days.

Search Question: Clearly state the question (including outcomes or criteria to be tracked)

In pediatric patients with viral conjunctivitis, are ophthalmic antibiotics more effective than symptomatic treatment, in reducing duration of illness and clinical course?

Question Type: What kind of question is this? (boxes now checkable in Word)

☐Prevalence                             ☐Screening                  ☐Diagnosis

☐Prognosis                              ☒Treatment                 ☒Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices.

– If meta-analysis or systematic review are not available, randomized controlled clinical trials will also offer great supporting evidence as they are carefully planned experiments, reduce the potential for bias, and allow for comparison between intervention and control groups.

– Cohort studies could also be used since they allow to follow the patients who have already received a particular treatment forward over time. This is not as reliable as randomized controlled clinical trials since patients might differ in ways other than in the variable that is being observed.

PICO search terms:

ChildrenAntibioticsSymptomatic treatmentReducing Illness
Pediatric patientsOphthalmic Antibiotics Efficacy
Viral Conjunctivitis  Symptom relief

Search tools and strategy used:

Please indicate what data bases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters.
Explain how you narrow your choices to the few selected articles.

Results found:


  • Pediatric + Viral conjunctivitis – 97
  • Pediatric + Viral conjunctivitis + Treatment – 49
  • Pediatric + Viral conjunctivitis + Antibiotics treatment – 11

York College Library

  • Pediatric + Viral conjunctivitis – 322
  • Pediatric + Viral conjunctivitis + Treatment – 177
  • Pediatric + Viral conjunctivitis + Treatment + Last 10 Years + Peer Reviewed – 34

Identify at least 3 articles (or other appropriate reputable sources) that answer your specific question with the highest available level of evidence (you will probably need to look at more than 3 articles to get the 3 most focused and highest-level articles to address your question). Please make sure that they are Medline indexed.

Please post the citation and abstract for each article (to include the journal and authors’ names and date) and say why you chose it.
Please also note what kind of article it is (e.g. meta-analysis, cohort study, or independent blind comparison with gold standard of diagnosis, etc.).

At the bottom of each abstract, please comment on what your key points are from this article (including any points or concepts included in the article, but not present in the abstract – i.e. make the concepts understandable to the reader)

Please note that if the evidence is not in the abstract, you must clearly summarize the evidence in your posting.

Citation: Frost HM, Sebastian T, Durfee J, Jenkins TC. Ophthalmic antibiotic use for acute infectious conjunctivitis in children. Journal of American Association for Pediatric Ophthalmology and Strabismus. 2021;25(6):350.e1-350.e7. doi:  
Type of article: Meta-analysis  
Abstract Background: Infectious conjunctivitis is among the most common pediatric infections worldwide; antibiotics are often not indicated. We aimed to determine factors associated with ophthalmic antibiotic prescribing and changes in prescribing prior to and during the COVID-19 pandemic at a single center.   Methods: Encounters for children with infectious conjunctivitis from 2017 to 2020 at Denver Health and Hospital Authority clinics were analyzed retrospectively. Factors associated with prescribing were evaluated using multivariable logistic regression modeling. Encounter numbers and prescribing patterns for telephone versus in-person visits before and during the pandemic were compared and stratified.   Results: Of 5,283 patients encounters for conjunctivitis, 3,841 (72.7%) resulted in an ophthalmic antibiotic prescription. Concurrent diagnosis with acute otitis media (adjusted odds ratio [aOR] 0.20 (95% CI, 0.16-0.25) and later study year (2018-aOR = 0.76 [95% CI, 0.65-0.89]; 2019- aOR = 0.57 [95% CI, 0.48-0.67]) were associated with reduced odds of prescribing. Compared with those evaluated in pediatric clinics, patients evaluated in family medicine (aOR = 0.69 [95% CI, 0.58-0.83]) or optometry/ophthalmology clinics (aOR = 0.06 [95% CI, 0.02-0.14]) were less likely to have antibiotics prescribed, whereas, patients evaluated via telephone had a 5.43 (95% CI, 3.97-7.42) greater odds of being prescribed ophthalmic antibiotics. Antibiotic prescribing increased from 67.8% prior to the COVID-19 pandemic to 81.9% during the pandemic (P < 0.0001).   Conclusions: Discordant with national guideline recommendations, ophthalmic antibiotic use for conjunctivitis was high. Telephone visits were associated with higher rates of prescribing. Rates of prescribing increased significantly during the COVID-19 pandemic.  
Why I chose it: I chose this article because it shows us that although providers may offer topical antibiotics for bacterial conjunctivitis, both bacterial and viral conjunctivitis are both self-limiting and using ophthalmic antibiotics show minimal benefit when being used. More adverse drug reactions occur with use of ophthalmic antibiotics like ocular surface toxicity and children may grow up with more antibiotic resistance strains of bacteria in the future. Additionally, the effectiveness of antibiotics was gradually declining with acute conjunctivitis cases, as well as disrupting the normal flora in the eye.  
Citation: Mahoney MJ, Ruegba Bekibele, Notermann SL, Reuter TG, Borman-Shoap EC. Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management. 2023;10(5):808-808. doi:  
Type of article: Systematic Review and Meta-Analysis  
Abstract: Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.  
Why I chose it: I chose this article because it went through all the pathologies that came with conjunctivitis including bacterial, viral, herpetic, and allergic. The article showed that even with bacterial conjunctivitis in a pediatric patient, no treatment, delayed treatment, or immediate treatment were all appropriate responses for treatment and all routes led to a resolution of the disease without any adverse effects related to sight. The article also touched on, as mentioned previously, that antibiotic use did have adverse drug reactions when used. Ultimately, viral and bacterial conjunctivitis are both self-limiting and usage of antibiotics should be used seldomly for bacterial cases.
Citation: Pinto, R. D. P., Lira, R. P. C., Abe, R. Y., Zacchia, R. S., Felix, J. P. F., Pereira, A. V. F., Arieta, C. E. L., de Castro, R. S., & Bonon, S. H. A. (2015). Dexamethasone/Povidone Eye Drops versus Artificial Tears for Treatment of Presumed Viral Conjunctivitis: A Randomized Clinical Trial. Current Eye Research, 40(9), 870–877.  
Type of article: Randomized Control Study  
Abstract: Purpose: To determine whether topical dexamethasone 0.1%/povidone-iodine 0.4% reduces the duration of presumed viral conjunctivitis better than artificial tears and whether the treatment relieves the symptoms of this disease. Methods: Randomized, masked and controlled trial. One-hundred twenty-two patients with a clinical diagnosis of presumed viral conjunctivitis were randomized to either the treatment group or the control group. Physicians and patients were masked to the treatment. Swabs were taken from the conjunctival fornix for adenovirus PCR analyses. Patients in the treatment group received topical dexamethasone 0.1%/povidone-iodine 0.4% eyedrops four times daily, and patients in the placebo group received artificial tears four times daily, both for seven days. Symptoms were recorded on the day of recruitment and at the time of a follow-up examination 5, 10 and 30 d later. The main outcome was duration of the disease. The others outcomes were overall discomfort, itching, foreign body sensation, tearing, redness, eyelid swelling, side effects of the eye drops, intraocular pressure and the incidence of subepithelial corneal infiltrates. Results: There was no statistically significant difference between the treatment group and the control group in terms of the patients’ symptoms, intraocular pressure and incidence of subepithelial cornea infiltrates during the entire follow-up period. Patients of the treatment group reported more stinging (p50.001) and a shorter conjunctivitis duration (9.4 ± 4.6 d in the dexamethasone 0.1%/povidone-iodine 0.4% group versus 11.8 ± 4.9 d in the artificial tears group, p = 0.009). Conclusions: The use of topical dexamethasone 0.1%/povidone-iodine 0.4% eye drops four times daily appears to reduce the duration of conjunctivitis, although it causes more stinging than artificial tears.  
Why I chose it: I chose this article because it was a randomized control trial between using conservative management (artificial tears) to treat viral conjunctivitis and trying to actively treat the disease with steroids. The outcome was that using steroids did reduce the duration of the conjunctivitis but it only reduced the timeframe by 2 days and the participants complained of stinging in their eyes as well as having 4 times more corneal infiltration versus the participants who had the artificial tears. For some, being symptom free for two days is worth the adverse effects that might come through.  

What is the clinical “bottom line” derived from these articles in answer to your question?

According to the American Academy of Ophthalmology, conjunctivitis is the most common cause of red eye in pediatric patients with most of the cases (up to 80%) being viral. Conjunctivitis is a self-limiting disease where only a minority of patients actively benefit from using antibiotics. Even when used for the appropriate pathologies (i.e. bacterial), there is only a modest benefit from the antibiotics. Unfortunately, usage of antibiotics brings upon more resistance with future bacterial infections. It also introduces other pathologies (i.e. corneal infiltration that needs a separate treatment application). Symptomatic treatment with warm compresses, pain control, and artificial tears are more than enough to get through the disease process.

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