HELPDESK ANSWERS
drops were applied twice daily for 3 days, and 0.3%
In patients with acute bacterial
conjunctivitis, what is the preferred
antibiotic?
EVIDENCE-BASED ANSWER
In patients one month or older with acute bacterial
conjunctivitis, topical antibiotics are found to benefit
early clinical remission over a placebo (SOR: A, meta-
analysis of randomized controlled trials [RCTs]).
However, no adequate evidence exists to definitively
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recommend one specific antibiotic. In children 18
years old or younger, topical azithromycin is more
effective by day 3 than topical tobramycin, with azi-
thromycin having somewhat more convenient dosing
(SOR: B, RCT). Topical polymyxin B-trimethoprim is
noninferior to topical moxifloxacin (SOR: B, RCT).
Copyright © 2018 by Family Physicians Inquiries Network, Inc.
DOI 10.1097/01.EBP.0000545094.91529.b0
2012 meta-analysis of 11 randomized controlled
A trials (RCTs) (N53,673) evaluated the use of topical
antibiotics versus placebo in acute bacterial conjunctivi-
tis.1 Patients were aged 1 month or older (including
adults) and had clinical and/or microbiologic diagnosis of
acute bacterial conjunctivitis. Topical antibiotics
included azithromycin, polymyxin/bacitracin, moxi-
floxacin, ciprofloxacin, norfloxacin, besifloxacin, and
chloramphenicol, with placebo comparison. Topical
antibiotics led to increased relief in symptoms at 2 to 5
days after diagnosis (six studies; N52,116; relative risk
[RR], 1.4; 95% CI, 1.2–1.6) and in early (2–5 day) micro-
biologic cure (seven studies; N51,850; RR, 1.6; 95% CI,
1.4–1.8) compared with the placebo. Also, a modest
benefit in clinical cure was observed at 6 to 10 days after
diagnosis with antibiotics versus placebo (eight studies;
N52,365; RR, 1.2; 95% CI, 1.1–1.3) and microbiological
cure at 6 to 10 days (nine studies; N52,649; RR, 1.4;
95% CI, 1.2–1.5). One limitation of this analysis was that
the duration of antibiotic treatment was not clearly stated.
Additionally, the type of analysis did not support com-
parison between active agents.
A 2015 international, multicenter RCT (N5286) of
patients aged 1 day to 18 years compared the efficacy
of topical azithromycin and tobramycin drops in children
with purulent conjunctivitis.2 Azithromycin 1.5% topical
46 Volume 21 • Number 8 • September 2018
Copyright © 2018 by Family Physicians Inquiries Network, Inc. Unauthorized reproduction of this article is prohibited.
tobramycin drops were applied once every 2 hours for
2 days, then four times daily for 5 additional days.
Patients were assessed for complete resolution of con-
junctival discharge at 3 days and 7 days after diagnosis.
At the 3-day follow-up, the azithromycin group had sig-
nificantly more patients with complete resolution of con-
junctival discharge than the tobramycin group (68% with
azithromycin vs 49% with tobramycin; P5.005). At 7
days, resolution rates were similar tobramycin (89% for
azithromycin vs 78% for tobramycin). Additionally,
patients/parents rated azithromycin as easier to use
(rated “very easy” in 65% of patients vs 13% of tobra-
mycin group; P,.01) and were more satisfied with the
treatment duration (“very satisfactory” or “satisfactory”
in 95% of patients on azithromycin vs 77% of patients on
tobramycin; P,.01). A potential limitation of this study
was failure to blind by frequency of administration.
A 2013 single-blinded randomized control trial (N5124)
compared the efficacy of polymyxin B-trimethoprim (Poly-
trim®) versus moxifloxacin in children with acute conjunc-
tivitis.3 Children were 1 to 18 years old and diagnosed
clinically with acute conjunctivitis (lid edema, conjunctival
erythema, eye discharge, and/or subconjunctival hemor-
rhage). Polytrim was given four times a day, and moxiflox-
acin was given three times a day, both for 7 days.
Outcomes were measured as clinical improvement after
4 to 6 days and clinical cure or complete resolution of
symptoms at 7 to 10 days. Polytrim was found to be non-
inferior to moxifloxacin in clinical cure at 4 to 6 days (72%
and 77%, respectively; difference, –5%; 90% CI, –20% to
11%). At the 7 to 10-day follow-up, 95% of the moxiflox-
acin group and 96% of the Polytrim group had achieved
clinical cure. A limitation of this study was that the partic-
ipants were only in New York and could be nonrepresen-
tative of other populations and failure to blind by frequency
of administration.
Beth Brinkman, MD
Keith Stelter, MD, MMM
University of Minnesota Mankato
Family Medicine Residency Program
Mankato, MN
The authors declare no conflicts of interest.
References
1. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov
U. Antibiotics versus placebo for acute bacterial
Evidence-Based Practice
 HELPDESK ANSWERS
conjunctivitis. Cochrane Database Syst Rev. 2012; (9):
CD001211. [STEP 1]
2. Bremond-Gignac D, Messaoud R, Lazreg S, Speeg-
Schatz C, Renault D, Chiambaretta F. A 3-day regimen with
azithromycin 1.5% eyedrops for the treatment of purulent
bacterial conjunctivitis in children: efficacy on clinical signs and
impact on the burden of illness. Clin Ophthalmol. 2015; 9:
725–732. [STEP 2]
3. Williams L, Yogangi M, Murante B, et al. A single-
blinded randomized clinical trial comparing polymyxin
B-trimethoprim and moxifloxacin for treatment of acute
conjunctivitis in children. J Pediatr. 2013; 162:857–861.
[STEP 2]
Is poor periodontal oral health in
pregnancy a risk factor for spontaneous
abortion or stillbirth?
EVIDENCE-BASED ANSWER
Periodontal disease marked by increased probing
depth or increased loss of attachment is associ-
ated with an increased risk of late miscarriage or
stillbirth. Self-report of urgency-based dental
treatment is associated with a history of mis-
carriage (SOR: B, prospective and retrospective
cohort studies).
Copyright © 2018 by Family Physicians Inquiries Network, Inc.
DOI 10.1097/01.EBP.0000544856.89158.6d
A 2006 prospective cohort study investigated the re-
lationship between periodontal disease and adverse
pregnancy outcomes in 1,793 nonsmoking women of
various ethnicities and socioeconomic backgrounds.1
Patients entered the study and had dental examinations
at 12 weeks of gestation. The mean probing depth was
calculated for each patient, with deeper probing in-
dicating more significant periodontal disease. Only
17 women experienced miscarriage between 12 and
24 weeks. The median value of the mean probing depths
was higher in the miscarriage group than in the group that
gave birth at term (2.7 vs 2.4 mm; P5.006). Each milli-
meter increase in probing depth increased the odds of
miscarriage by 3.8 (95% CI, 1.7–8.8). Study limitations
included enrollment bias and the small number of
miscarriages.
Evidence-Based Practice
Copyright © 2018 by Family Physicians Inquiries Network, Inc. Unauthorized reproduction of this article is prohibited.
A 2004 prospective cohort study evaluated 3,738
women of various ethnicities and socioeconomic back-
grounds to assess the relationship between periodontal
disease and adverse pregnancy outcomes including
a composite outcome of late miscarriage (12–24 weeks
of gestation), intrauterine demise on or after 24 weeks,
and stillbirth.2 Dental researchers examined patients at
the 12-week visit for periodontitis by pocket probing
depth, loss of attachment, and counting sites of plaque
and bleeding. Only 49 women experienced the compos-
ite outcome. Patients with miscarriage or stillbirth had
a mean probing depth of 2.6 mm compared with 2.4
mm in patients with term delivery (P5.003). Similarly,
patients with miscarriage or stillbirth had 0.31 mm loss
of attachment compared with 0.20 mm in patients with
term delivery (P5.038). Sites with bleeding or plaque did
not differ between the groups.
A 2008 cross-sectional retrospective cohort study
investigated whether oral healthcare patterns (self-
rated oral health, preventive dental treatment, and
urgency-based dental care) were associated with a his-
tory of miscarriage.3 The study included 328 postpar-
tum white women with a singleton delivery, 74 of whom
reported having had a previous miscarriage. Patient
self-reporting of urgency-based dental treatment was
associated with an increased odds of having a history
of miscarriage compared with not reporting this care
(odds ratio, 2.5; 95% CI, 1.2–5.4). Not receiving
preventive dental treatments and poor self-rated
oral health were not significantly associated with
miscarriage.
Brenna Harris, DO
Alexinna Johns, MD
East Pierce Family Medicine Residency
Puyallup, WA
The authors declare no conflicts of interest.
References
1. Farrell S, Ide M, Wilson RF. The relationship between
maternal periodontitis, adverse pregnancy outcome and
miscarriage in never smokers. J Clin Periodontol. 2006;
33(2):115–120. [STEP 3]
2. Moore S, Ide M, Coward PY, et al. A prospective study to
investigate the relationship between periodontal disease and
adverse pregnancy outcomes. Br Dent J. 2004; 197(5):
251–258. [STEP 3]
3. Heimonem A. Oral health care patterns and the history of
miscarriage. Oral Dis. 2008; 14(8):734–740. [STEP 3]
Volume 21 • Number 8 • September 2018 47