Abstract
This cross-sectional study examines the patterns of topical antibiotics dispensation to commercially insured school-aged children with acute infectious conjunctivitis.
Acute infectious conjunctivitis affects 1 in 8 children annually and is associated with at least 3 million missed school days per year in the US.1 Medical evaluation and/or treatment with topical antibiotics is often a requirement for children to return to school.2 However, conjunctivitis is usually a self-limited illness, and guidelines do not recommend universal treatment.3 Policies for managing conjunctivitis in school-aged children vary across states,4 and it is not known whether state policies affect antibiotic prescription patterns. This study describes state-level variation in topical antibiotic use for pediatric conjunctivitis and evaluates the association of state-level policies with antibiotic use.
Methods
The Harvard Pilgrim Health Care Institute Institutional Review Board approved this cross-sectional study and waived informed consent because deidentified data were used. We followed the STROBE reporting guideline. We included children (aged 3 to 17 years) with acute infectious conjunctivitis diagnosis in the 2021 MarketScan Commercial Claims and Encounters Database, which includes more than 30 million US employees and their dependents. We excluded children who had noninfectious (eg, allergic) conjunctivitis, filled a prescription for antibiotics in the prior 14 days, or had missing data for state of residence (eTable in Supplement 1).
The primary exposure was the 2021 state-level return-to-school policy for children with conjunctivitis, as defined in a published survey.4 Policies were categorized as requiring evaluation, treatment, or symptom resolution; specifying no restrictions on return to school; or no policy. The primary outcome was the dispensation of a topical antibiotic within 1 day of the index visit for conjunctivitis. We used mixed-effects logistic regression to evaluate the association between state policy and antibiotic prescription, adjusting for characteristics of patients, visits, and clinicians as fixed effects and including the state as a random effect (Table). Analyses were performed between January and November 2024 using R, 4.3.2 (R Core Team). Statistical significance was defined as 2-sided P < .05.
Table. Factors Associated With Topical Antibiotic Treatment of US Children With Acute Infectious Conjunctivitis.
| Factor | Topical antibiotics prescribed, No. (%) | Mixed-effects logistic regressiona | ||
|---|---|---|---|---|
| No (n = 8413) | Yes (n = 18 488) | OR (95% CI) | P value | |
| State-level policy | ||||
| No policy | 2554 (31) | 5727 (69) | 1 [Reference] | NA |
| Policy requiring evaluation, treatment, or symptom resolution | 4979 (32) | 10 684 (68) | 1.02 (0.87-1.20) | .79 |
| Policy specifying no restrictions on return to school | 880 (30) | 2077 (70) | 1.02 (0.83-1.25) | .84 |
| Age groupb | ||||
| Preschool | 2566 (27) | 6963 (73) | 1.28 (1.20-1.36) | <.001 |
| Elementary school | 3313 (34) | 6380 (66) | 1 [Reference] | NA |
| Middle and high school | 2534 (33) | 5145 (67) | 1.11 (1.04-1.18) | .002 |
| Sex | ||||
| Male | 4531 (32) | 9557 (68) | 1 [Reference] | NA |
| Female | 3882 (30) | 8931 (70) | 1.10 (1.04-1.16) | <.001 |
| Complex chronic conditionc | ||||
| No | 8061 (31) | 17 716 (69) | 1 [Reference] | NA |
| Yes | 352 (31) | 772 (69) | 1.11 (0.97-1.26) | .15 |
| Index encounter on a school nightd | ||||
| No | 6611 (32) | 14 299 (68) | 1 [Reference] | NA |
| Yes | 1802 (30) | 4189 (70) | 1.06 (1.00-1.14) | .056 |
| Index encounter seasone | ||||
| Spring | 1685 (34) | 3222 (66) | 1 [Reference] | NA |
| Summer | 2117 (33) | 4213 (67) | 1.05 (0.97-1.14) | .25 |
| Fall | 2897 (29) | 7047 (71) | 1.19 (1.11-1.29) | <.001 |
| Winter | 1714 (30) | 4006 (70) | 1.18 (1.08-1.28) | <.001 |
| Index encounter setting | ||||
| Ambulatory clinic | 6864 (28) | 17 491 (72) | 1 [Reference] | NA |
| Eye clinicf | 1219 (68) | 579 (32) | 0.19 (0.18-0.22) | <.001 |
| ED | 330 (44) | 418 (56) | 0.49 (0.43-0.57) | <.001 |
Abbreviations: ED, emergency department; NA, not applicable; OR, odds ratio.
Mixed-effects logistic regression model includes all covariates as fixed effects and the state as a random effect.
Preschool: age 3 to 5 years or younger, elementary school: age 6 to 11 years or younger, and middle and high school: age 12 to 17 years or younger.
Children with an insurance claim in the prior 6 months for a condition expected to last at least 1 year and likely to result in hospitalization at a tertiary care hospital.
School night is defined as Sunday, Monday, Tuesday, Wednesday, or Thursday.
Spring: March to May, Summer: June to August, Fall: September to November, and Winter: December to February.
An ambulatory clinic in which the treating clinician’s specialty is listed as ophthalmology or optometry.
Results
This study included 26 901 children with acute infectious conjunctivitis (median [IQR] age, 7 [4-12] years; 12 813 females [48%]). Topical antibiotics were dispensed to 69% (95% CI, 68%-69%) of children. Antibiotics were more frequently dispensed to children who were preschool-aged, female, evaluated in the fall and winter seasons, and evaluated by non–eye specialists (Table).
The state-level proportion of children treated with topical antibiotics ranged from 38% (95% CI, 10%-74%) in Vermont to 83% (95% CI, 74%-90%) in South Dakota (Figure). In the multivariable analysis, compared with no policy, neither the policy requiring evaluation, treatment, or symptom resolution (OR, 1.02; 95% CI, 0.87-1.20) nor the policy specifying no restrictions on return to school (OR, 1.02; 95% CI, 0.83-1.25) was associated with topical antibiotic treatment (Table).
Figure. Proportion of Children With Acute Infectious Conjunctivitis Prescribed Topical Antibiotics.
Discussion
We identified state-level variation in the dispensation of topical antibiotics to children with acute infectious conjunctivitis, but state-level policies were not associated with topical antibiotic use. These findings suggest that local policies, parental preferences, health care facility–level characteristics, or other unmeasured covariates may explain the observed variation in antibiotic treatment.
Excluding children with conjunctivitis from school is controversial.5 Although acute infectious conjunctivitis is generally self-limited,3 isolation may protect others from infection. However, missed school is costly for children and caregivers,6 other similarly contagious conditions (eg, respiratory tract infections) are not equally scrutinized,5 and requiring health care visits or antibiotic treatment prior to school return is not cost-effective.1 While topical antibiotics may accelerate symptom resolution in some cases,3 guidelines do not support universal treatment, and antibiotic overuse remains a public health concern.
Study limitations include its focus on commercially insured children, which limits the generalizability of the findings to publicly insured and uninsured children. Additionally, we do not rule out the potential implications of certain local policies for antibiotic prescribing patterns, as we are unable to account for local guidelines or the interaction between state-level and local policies. Further research is needed to identify factors underlying variation in antibiotic use and to promote uniform guidelines for practitioners and families.
eTable. Administrative Codes
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eTable. Administrative Codes
Data Sharing Statement
