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Pediatric Acute Bacterial Conjunctivitis: 2010 Update Before we get started Comment cards (90 day follow-up survey) Please hold questions until end of program

Educational Objectives Educational Objectives Appropriately assess individuals presenting with symptoms consistent with bacterial conjunctivitis and construct a comprehensive differential diagnosis Describe and apply strategies to prevent the spread of bacterial conjunctivitis Evaluate treatment options Demographic & Pre-Test Questions

Which degree best describes you? 1. MD or DO 2. Physician Assistant 3. Nurse Practitioner 4. Medical Student 5. Other Pre-test: Acute bacterial conjunctivitis will resolve without antibiotics over how many days? 1. 1. One to three 2. Three to five 3. Six to eight 4. >Eight

Pre-Test: Of the following, the most effective topical antibiotic for acute bacterial conjunctivitis is likely to be: 1. Tobramycin or Gentamicin 2. Erythromycin or Azithromycin 3. Besifloxacin or Moxifloxacin 4. Ciprofloxacin or Ofloxacin 5. Sulfa combination Sulfa combination Pink eye?? How do you decide?

ARS Question ARS Question In pediatric acute conjunctivitis, which is the most reliable sign suggesting a bacterial source: 1. Redness of bulbar conjunctiva 2. Green or mucoid discharge from the conjunctiva 3. Exposure to another person w/ conjunctivitis 4. Bilateral involvement 0% 0% 0% 0% 1 2 3 4

Pediatric Acute Bacterial Conjunctivitis Microbial infection involving bulbar/palpebral conjunctiva of the eye Self-limited illness, typically lasting 8 10 days w/o antibiotics Most frequently observed among infants, toddlers, pre-school children a Which one has pink eye? 1 in 8 children has an episode every year 5 million cases in the US annually a Rose P, et al. The Lancet. 2005; 366:37-43. Kowalski RP, Dhaliwal DK. Expert Rev Anti Infect Ther. 2005;3:131-139. Hovding G. Acta Ophthalmol. 2008;86:5-17. Pink eye: Other Questions?? v Epidemiology and Age? v Bacterial vs viral? v Natural history observation vs. Antibiotic treatment v Strengths and problems with topical Antibiotics

Pediatric Acute Conjunctivitis: Bacterial vs. Viral vs. Allergic Clinical finding Bacterial Viral Allergic Bilateral eyes 50-74% 35% Mostly Conjunctival discharge Conjunctival redness Mucopurulent in younger child; Mild, Watery, or sleepers only Rare Common in older child, uncommon in infants and toddlers Usually Usually Conjunctival w/aom 20-73% 10% NO Pruritic No (but many rub eyes) No Major Pediatric Acute Conjunctivitis: diagnosis Diagnosed on clinical basis-- mostly Treatment is empiric-- mostly Bacterial Cultures-- --rarely performed Costly Obtained in refractory cases, neonates, Obtained in refractory cases, neonates, periorbital cellulitis Viral cultures/pcr for suspected Herpes, Viral cultures/pcr for suspected Herpes, Adenovirus Woods lamp (R/O Foreign Body, Herpes or abrasion?) Zebras: Kawasaki s, s, measles, herpes

Blepharitis (Staphylococcal) Infection on eyelid Secondary conjunctivitis S. aureus School age & Adolescents Ocular itching & irritation Associated with recurrent chalazion Pediatric Acute Conjunctivitis: Bacterial versus Viral Year Bacterial % of Conj with AOM Viral Locale/author 1981 65%? 20% Gigliotti (J Pediatr 1981) 1993 78%? 13% Weiss (J Pediatr 1993) 1997-98 68% 39%? Block/rural KY (Antimcrob Ag Chemother 2000) 2005 55% 32%? 2002 80%?? 2007 78%?? Buznach/Israel (PIDJ 2005) Jackson/Ottawa (Can J Ophthalmol 2002) Patel/Delaware (Acad Emerg Med 2007)

Neonates Common Pathogens of Bacterial Conjunctivitis <1 week Neisseria gonorrhoea 1-2 2 weeks Chlamydia trachomatis Haemophilus influenzae Streptococcus pneumoniae Older infants and toddlers (1-3 years) without Otitis School-aged children/adolescents S aureus H influenzae S pneumoniae H influenzae S pneumoniae Moraxella catarrhalis Staphylacoccus aureus With Otitis H influenzae Pichichero ME. Bacterial Conjunctivitis in Children: Antibacterial Treatment Options in an Era of Increasing Drug Resistance: S pneumoniae 2010 Aug 19, Clin Pediatr (Phila). Management of pediatric acute conjunctivitis Any difference for newborn, toddler, young child, adolescent? Do you culture? Which topical anti Which topical anti-infective? infective? Cost/formulary issues? AOM + ABC: do you treat with oral antibiotics, topical antibiotics, or both?

Neonate with Conjunctivitis Algorithm for evaluating conjunctivitis Pichichero ME. 2010 Aug 19, Clin Pediatr (Phila). Older Infant/Toddler with Conjunctivitis Pichichero ME. 2010 Aug 19, Clin Pediatr (Phila).

School-aged Child/Adolescent with Conjunctivitis Pichichero ME. 2010 Aug 19, Clin Pediatr (Phila). CASE: 8 week old female with bilateral purulent conjunctivitis failed neosporin, polytrim, ocuflox ophth drops (October 2010). Dacryostenosis? Eye culture? Chlamydia PCR? Received oral Keflex and TMP-SMX to cover for MRSA. PNSP grows 2 days later from eye culture.

Topical antibiotics are effective in ABC: older study only I young child 3-5 5 days clinical cure rate (n=116): Polymyxin-bacitracin oint 62% Placebo 28% 3-5 5 days bacterial cure rate: Polymyxin-bacitracin oint 71% Placebo Placebo 19% Difference still present at 8-10 8 days. Gigliotti, J Pediatr 1984; 104:623 Natural history of untreated true true Acute Bacterial Conjunctivitis No topical antibiotic equals watchful waiting at 10-14 14 days.* Self-limited limited disease eventually! eventually! Why treat with antibiotics Improved in 2-5 2 5 days Miserable infection with d/c pouring out of eye Unable to attend daycare; lost work days Highly contagious An office visit ensures it is just pink eye *Sheikh A, Cochrane Review 2006

Co-infections of Pediatric Acute Conjunctivitis: Bacteria versus Virus Bacterial associations (age dependent) Preseptal cellulitis (usually with ethmoid sinusitis or trauma) fever, leukocytosis,, tenderness of the orbital tissues AOM: common under age 3 y.o.. (about 35-40%) MRSA: uncommon; associated with skin infection elsewhere; blepharitis Viral associations Keratitis (painful, photophobia, tearing, decreased vision) Suspicion of herpes requires referral to ophthalmologist Adenovirus: pharyngitis and fever (neg. strep test) 6 y.o. female with periorbital herpetic lesions, without conjunctival involvement. This child should be referred to the ophthalmologist for evaluation. 4 y.o. female with runny nose, itchy red eyes. Note palpebral edema and nodular conjunctival hyperplasia Allergic conjunctivitis

5 y.o. male with AOM AND traumatic preseptal cellulitis (hit with a softball in the eye area), usually caused by S. aureus. Contrast this with URI/sinusitis associated preseptal cellulitis, where S pneumo predominates. Which antibiotic(s)? Conjunctivitis - AOM Healthy 8 mo infant with purulent conjunctivitis & symptomatic bilateral AOM: Pathogens of conjunctivitis? Pathogens of AOM? Oral and/or topical antibiotic coverage? Eye culture positive for B-lactamase + H. influenzae

Ideal Topical Antibiotic for ABC Ideal Topical Antibiotic for ABC Broad spectrum Potent activity against prevalent pathogens Convenient dosing Local treatment for a local disease (if NO AOM!) Low incidence of adverse events (AEs ( AEs) Bactericidal Low propensity for resistance development Long dwell time at site of infection (ocular surface) Topical Options for ABC: most approved for >12 m.o. Macrolides: Azithromycin (Azasite Azasite) Erythromycin Quinolones: Besifloxacin (Besivance Besivance) Ciprofloxacin (Ciloxan Ciloxan) Ocuflox Moxifloxacin Ocuflox (Ofloxacin Ofloxacin) (Vigamox Vigamox) Gatifloxacin Gatifloxacin (Zymar Zymar) Miscellaneous: Polytrim Polytrim (PolymyxinB /Trimethoprim Trimethoprim) Sulfacetamide (Bleph-10) Bacitracin Ointment Aminoglycoosides: Tobramycin (Tobrex Tobrex) Gentamicin (Garamycin Garamycin) Neomycin (neosporin ( combo)

Summary of Older Topical Antibiotics Sulfamethoxazole (Gantrisin Gantrisin) cheap This stuff burns minimal coverage of any eye pathogen May cause severe hypersensitivity Aminoglycosides (Tobra Tobra, Genta,, Neomycin) Cheap Resistance to S. pneumo and Group A Strep May cause chemical conjunctivitis, allergy. Am J Ophth 2008; 145:951 Summary of QuinoloneTopical Antibiotics (Each of these is well-tolerated; occasional local irritation) Older quinolones (ciprofloxacin, ofloxacin) Good H. inf 2008, 115:51-6] inf and fair SP coverage [Cavuoto K Ophthalm Reasonable cost (generics) Newer quinolones (moxifloxicin moxifloxicin, gatifloxacin, besifloxacin) Expensive Excellent coverage of all eye pathogens Besifloxacin - better in vitro for MRSA and has novel eye-film drop to retain drug longer in conjunctival sac Am J Ophth 2008; 145:951

Moxifloxacin vs Poly-trim N=56 <18 y.o. Poly Poly-trim qid 7d vs moxi tid 7d. 48 hr. clinical cure rates: Moxi 81% vs Poly-trim 44% (p=0.001) Caveats: Many older children Very small sample size Minimal difference at end of therapy visit Granet, J Ped Ophth Strabismus 2008; 45:330 Azithro/Quinolones In Vitro (MIC 90 ) Activity vs typical ABC pathogens

Clinical Resolution in Pediatric Patients: Besi vs Moxi Conclusions: Pediatric conjunctivitis in young children Acute bacterial conjunctivitis warrants topical therapy Newer topical Quinolones are more potent and rapidly clearing than other classes of topicals; however,cost and formulary issues may force clinicians to use polytrim or neosporin first line. Sulfa, Erythromycin and Aminoglycosides should not be used any more.

Pink Eye Something to Ponder Post Test & Evaluation

Post-test: Acute bacterial conjunctivitis will resolve without antibiotics over how many days? 1. 1. One to three 2. Three to five 3. Six to eight 4. >Eight Pre Test Post Test

Post-test: Of the following, the most effective topical antibiotic for acute bacterial conjunctivitis is likely to be: 1. Tobramycin or Gentamicin 2. Erythromycin or Azithromycin 3. Besifloxacin or Moxifloxacin 4. Ciprofloxacin or Ofloxacin 5. Sulfa combination Pre Test Post Test

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Conclusion Thank you for attending!