Conjunctivitis outbreak in Delhi: Lessons learnt to combat breach in antimicrobial stewardship

Sir,

Conjunctivitis is the most common eye inflammation in adults and children, is usually self-limiting in nature and is easily manageable by a general practitioner. ¹ Recently, a conjunctivitis outbreak was seen following torrential rains in north India. An adenoviral aetiology was proven in 8.3% of cases, and no other bacterial or viral aetiology was documented.

However, during this outbreak drugs prescribed were antibacterial eye drops alone or in combination with steroids or other drugs. In an ideal world, it would be expected that health systems are driven to prevent such abuse of drugs. However, this recent conjunctivitis outbreak, highlights how we have again failed to learn the lesson.

It has been nearly 3 years since the first Covid pandemic hit India. One of the grave mistakes noted during this time was an inappropriate use of antibiotics and steroids. Failure to regulate pharmaceutical supplies in India, have contributed to overuse and ease of access to various medications owing to a lack of standard treatment guidelines and poor or non-existent regulations.

It has been estimated that at least 50% of an average family spending on medicines in the country is incurred on irrational or unnecessary drugs and diagnostic tests. This combined with poor community knowledge of medication safety and usage compounds a grave problem, by which antibiotic resistance is fostered and further impoverishes community. In fact, India, with one-sixth of the world's population, was the largest consumer of antibiotics for human medicine in 2010.

Viral aetiology is responsible for ∼80% of cases of acute conjunctivitis, often misdiagnosed as bacterial in origin. In most cases, topical antihistamines and cold compresses ameliorate the symptoms. Available antivirals and topical antimicrobials are not useful, and antibiotic eye drops may spread infection to a contralateral eye. ² The problem is not confined to India; an American study found that ∼60% of patients were prescribed antibiotic eye drops in conjunctivitis, even though antibiotics are rarely necessary, and ∼20% received an antibiotic-steroid combination eye drop. These are inappropriate for most patients as they prolong or exacerbate certain types of viral infection. Steroids may also increase the risk of glaucoma and cataracts.

Several reasons exist for over-prescription of antibiotics; ³ it is a challenge to differentiate bacterial conjunctivitis from other types, and many physicians have the habit of prescribing antibiotics ‘just in case’, ‘erring on the side of caution’. Patients also often falsely believe that antibiotics are absolutely necessary to resolve their red eye problem and may urge their physicians to comply. ⁴ Clinic posters may go some way to inform both parties!