Comment on “Clinical Features of Bacterial Conjunctivitis in Children”

Abstract

The authors conclude that pediatric conjunctivitis is mostly bacterial in etiology and suggest that the empiric use of topical antibiotics in children presenting with conjunctivitis may be useful.The utility of topical antibiotic therapy relies on the assumption that the conjunctivitis being treated is indeed caused by bacteria. Conjunctivitis in both children and adults can be caused by multiple etiologies, including allergy, viral infection, bacterial infection, and other less common causes. There is a large body of literature that supports a viral etiology in most cases of conjunctivitis. For example, in a study of 388 patients with conjunctivitis, adenovirus was deemed responsible in up to 75% of the patients, whereas bacteria were determined to be causative in 18%.2 In another study of 459 children with conjunctivitis, in 60%, the illness was viral in etiology. 3The methodology used in the Patel et al.1 study did not test for a viral cause of conjunctivitis, thereby incorrectly citing bacteria as the causative agent in all culturepositive cases (78%). Common isolates in their study included Haemophilus influenza, Streptococcus pneumoniae, and Staphylococcus aureus. Brook, 4 in a study of acute conjunctivitis in children, found that control eyes were culture-positive 90.9% of the time. Perkins et al.,5 in a similar study, recovered bacterial isolates in 90.6% of control eyes. Moreover, all three of the abovementioned bacteria were found to be colonizing control eyes.In the study conducted by Patel et al., 1 the authors described clinical variables correlating with positive bacterial cultures as a history of so-called sticky lids and the presence of mucoid and/or purulent discharge on examination. It is well known in the ophthalmologic community that sticky lids and mucoid discharge are frequently associated with both viral and allergic conjunctivitis in addition to dry eye, lacrimal dysfunction, and chemical irritation. We believe that the authors' conclusion regarding the etiology of conjunctivitis in pediatric ED patients may be flawed. It is possible that some of the eyes cultured were infected with a virus and that the positive bacterial cultures are only representative of the normal pediatric conjunctival flora or contaminants. Methods of improving the study to better support the conclusion could have included the use of controls and testing for virus by cell culture with confirmatory immunofluorescense staining, polymerase chain reaction, or Rapid Pathogen Screening Adeno Detector. 6 The use of clinical history is important, but performance of a slit lamp examination is also vital in diagnosing etiologies of different conjunctivitis. The methodology used in the study did not include the use of a slit lamp in identifying etiologic causes of conjunctivitis. Findings indicative of adenovirus infestation of conjunctiva, such as petechial hemorrhages, follicular reaction, and subepithelial infiltrates, can be seen by using this method. The examination of everted eyelids with a slit lamp is the mainstay p...