Pros and Cons of Steroids for Viral Conjunctivitis

Approximately 1% of all emergency room visits and 2% of all primary care visits are due to conjunctivitis. In the overwhelming majority of these cases, adenovirus is the culprit.1 Because of the frequency of viral conjunctivitis and its associated patient discomfort and lost days at work or school, a cure is constantly being searched for. Unfortunately, the mainstay of therapy today is limited to ameliorating the symptoms until the natural course resolves.

Traditional therapies include application of artificial tears and ocular lubricants along with cool compresses. Patient counseling regarding how to decrease viral spread by fre- quent hand washing and staying out of school or work is also helpful. For many patients, however, the symptoms of conjunctivitis are simply too disabling for supportive therapy alone. This has led some practitioners to suggest the use of topical steroid drops.
PROS AND CONS

Many physicians have found topical steroids to be helpful for patients with debilitating conjunctivitis. By reducing inflammation, steroids can bring dramatic improvement in patient comfort. However, others caution that steroids may delay resolution of the disease, prolonging the contagious course of the virus. In fact, studies in rabbit models have shown that topical steroids may prolong ocular shedding of adenovirus by several weeks.2

Until recently, no well-designed human study has assessed the risks and benefits of topical steroids in the treatment of viral conjunctivitis. In a study by Wilkins and colleagues,3 111 patients with presumed viral conjunctivitis were randomly assigned to receive either preservative-free dexamethasone 0.1% or hydroxypropyl methylcellulose (the vehicle used by the Moorfields pharmacy for compounding topical dexam- ethasone) four times daily for 1 week. Statistically significantly more patients in the dexamethasone group (39 of 45) felt the drops to be helpful than in the vehicle group (30 of 43). No adverse events were seen in either group.

The decision to use steroids for the treatment of viral conjunctivitis is a personal one. Research has shown that, when used appropriately (ie, in cases where bacterial or herpetic infection has been ruled out and when used in short pulses), topical steroids can be beneficial to patients by ameliorating the symptoms for which they initially presented. Steroid use may somewhat prolong the length of the contagious period; however, many patients will gladly accept this so that they may begin to feel ocular relief.

Topical steroid drops should be used with great caution, as herpetic viral infection of the ocular surface is a common mimicker of adenoviral conjunctivitis, and unopposed steroid drops can promote viral replication and corneal scarring. Additionally, as noted above, multiple studies have demonstrated that topical steroids prolong the viral shedding period.2 The key to managing adenoviral conjunctivitis is to limit its spread. Patients with viral conjunctivitis who are treated with topical steroid drops may return to work or school while they are still in the contagious phase of the infection, and therefore have the potential to further increase the disease burden on the health care system.

Because the symptoms of adenoviral conjunctivitis may be severe, investigators have explored other treatment options for patients with symptomatic disease including a topical combination of dexamethasone 0.1% and povidoneiodine 0.4%.4 This novel formulation was compared with cidofovir 0.5%, a combination tobramycin-dexamethasone ophthalmic suspension (Tobradex; Alcon Laboratories, Inc., Fort Worth, Texas), and balanced salt solution in rabbit eyes. The combination topical dexamethasone 0.1% and povidoneiodine 0.4% was equally effective as cidofovir 0.5% in reducing viral titers and was the most efficacious in reducing clinical symptoms of adenovirus infection in rabbit eyes.

A dexamethasone/povidone-iodine combination drop is not yet commercially available, but other options are. Gordon et al demonstrated that topical ketorolac or diclofenac did not increase the viral shedding period and may be a safer alternative t topical steroids.5 More recently, during an epidemic of viral conjunctivitis in a military garrison in Karachi, Pakistan, 200 patients were randomly assigned to topical decongestant/antihistamine combination drops or to eye washing and cool compresses.6 Acute illness symptoms of eye watering, itching, burning, pain, and photophobia lasted a mean 4.91 days in the decongestant/ antihistamine drop and 7.86 days in the cool compresses group.
CONCLUSION

If a combination drop of dexamethasone 0.1% and povidoneiodine 0.4% becomes available, this may be a suitable alternative for treatment of viral conjunctivitis, as it not only provided symptomatic relief but also decreased the viral load in an animal model. For the present and in selected cases of viral conjunctivitis, such as in eyes with subepithelial infiltrates or in post-LASIK patients in whom there is a risk of diffuse lamellar keratitis and corneal edema, topical steroids may be indicated. In others, however, given the currently available pharmacologic therapies, it may be prudent to try alternative topical regimens before initiation of steroidtherapy.

Meningitis in Сhildren

Meningitis is the medical term for inflammation of the tissues (meninges) that surround the brain and spinal cord. The inflammation is most commonly caused by a virus or a bacterium, which travels from an infection in another part of the body through the bloodstream to the meninges. The treatment and long-term outlook of meningitis differ considerably based upon the cause.

There are two main types of meningitis: viral and bacterial.

Bacterial meningitis — There are many types of bacteria that can cause bacterial meningitis. The most likely type depends upon the child's age, history of vaccinations, and current or past medical problems. The two most common causes of bacterial meningitis in older infants and children in the United States are bacteria called Streptococcus pneumoniae or pneumococcus and Neisseria meningitidis or meningococcus.

Certain factors can increase a child's risk of developing bacterial meningitis, including recent exposure to someone with bacterial meningitis, recent infection (eg, ear or sinus infection), travel to areas where bacterial meningitis is common (eg, sub-Saharan Africa), serious head injury, problems with the immune system, cochlear implants, and certain anatomic abnormalities.

Bacterial meningitis is a medical emergency that must be treated quickly to minimize the risk of serious illness or even death. Even when treated appropriately, children who recover from bacterial meningitis sometimes have long-term complications.

Viral meningitis — The most common cause of viral meningitis is a family of viruses called enterovirus. In the United States, enteroviral meningitis is seen more frequently from June to October. Enteroviruses are spread by direct contact with feces during activities such as diaper changing or indirectly through contaminated water, food, and surfaces.

Other viruses that cause meningitis can be spread by airborne droplets, direct contact, during birth, or through the bite of an animal (eg, rabies) or bug (eg, mosquito, tick).

In developed countries, viral meningitis is more common than bacterial meningitis and is generally less severe. Children with viral meningitis usually recover completely with supportive treatment.


MENINGITIS TREATMENT

The treatment for meningitis depends upon whether the meningitis is caused by a virus or a bacterium. However, this distinction may not be clear until the culture results are available (usually 48 to 72 hours after they are obtained). In many cases, children are treated as if they have bacterial meningitis until bacterial meningitis is definitively excluded. The reason for this is that there is a significant risk of serious illness or even death if the child has bacterial meningitis and treatment is delayed for a prolonged period of time.

Bacterial meningitis — Bacterial meningitis is a life-threatening illness that requires hospitalization and treatment with intravenous antibiotics. The child will be monitored closely for signs of complications. Depending upon the severity of the illness, the child may also need supportive treatments to aid breathing, maintain blood pressure, prevent excessive bleeding, and keep the child hydrated.

Antibiotics — Treatment with antibiotics is usually started immediately after the blood tests and lumbar puncture are performed. Treatment is administered intravenously. Oral antibiotics are not recommended. The concentration of antibiotics necessary to treat bacterial meningitis cannot be achieved with oral administration.

Length of treatment — The length of antibiotic treatment depends upon the results of the bacterial cultures.

    If the cultures are negative and the child has improved, antibiotics may be discontinued after 48 to 72 hours.
    If the cultures are positive, the length of treatment depends upon the bacteria that is identified and whether there are complications. The treatment course may range from several days to several weeks.

Viral meningitis — In most cases, there is no medication that can eliminate the virus causing viral meningitis. Instead, treatment is supportive, meaning that it is given to support the child while he or she recovers. This generally includes rest, encouraging the child to drink an adequate amount of fluid (when alert enough to do so), providing intravenous fluids (if unable to drink enough fluid), and medications to treat fever and/or headache (eg, acetaminophen or ibuprofen). These medications should be dosed according to weight, not age.

Pros and Cons of Steroids for Viral Conjunctivitis

Approximately 1% of all emergency room visits and 2% of all primary care visits are due to conjunctivitis. In the overwhelming majority of these cases, adenovirus is the culprit. Because of the frequency of viral conjunctivitis and its associated patient discomfort and lost days at work or school, a cure is constantly being searched for. Unfortunately, the mainstay of therapy today is limited to ameliorating the symptoms until the natural course resolves.

Traditional therapies include application of artificial tears and ocular lubricants along with cool compresses. Patient counseling regarding how to decrease viral spread by frequent hand washing and staying out of school or work is also helpful. For many patients, however, the symptoms of conjunctivitis are simply too disabling for supportive therapy alone. This has led some practitioners to suggest the use of topical steroid drops.

PROS AND CONS
Many physicians have found topical steroids to be helpful for patients with debilitating conjunctivitis. By reducing inflammation, steroids can bring dramatic improvement in patient comfort. However, others caution that steroids may delay resolution of the disease, prolonging the contagious course of the virus. In fact, studies in rabbit models have shown that topical steroids may prolong ocular shedding of adenovirus by several weeks.

Until recently, no well-designed human study has assessed the risks and benefits of topical steroids in the treatment of viral conjunctivitis. In a study by Wilkins and colleagues,3 111 patients with presumed viral conjunctivitis were randomly assigned to receive either preservative-free dexamethasone 0.1% or hydroxypropyl methylcellulose (the vehicle used by the Moorfields pharmacy for compounding topical dexamethasone) four times daily for 1 week. Statistically significantly more patients in the dexamethasone group (39 of 45) felt the drops to be helpful than in the vehicle group (30 of 43). No adverse events were seen in either group.

The decision to use steroids for the treatment of viral conjunctivitis is a personal one. Research has shown that, when used appropriately (ie, in cases where bacterial or herpetic infection has been ruled out and when used in short pulses), topical steroids can be beneficial to patients by ameliorating the symptoms for which they initially presented. Steroid use may somewhat prolong the length of the contagious period; however, many patients will gladly accept this so that they may begin to feel ocular relief.

Topical steroid drops should be used with great caution, as herpetic viral infection of the ocular surface is a common mimicker of adenoviral conjunctivitis, and unopposed steroid drops can promote viral replication and corneal scarring. Additionally, as noted above, multiple studies have demonstrated that topical steroids prolong the viral shedding period.2 The key to managing adenoviral conjunctivitis is to limit its spread. Patients with viral conjunctivitis who are treated with topical steroid drops may return to work or school while they are still in the contagious phase of the infection, and therefore have the potential to further increase the disease burden on the health care system.

Because the symptoms of adenoviral conjunctivitis may be severe, investigators have explored other treatment options for patients with symptomatic disease including a topical combination of dexamethasone 0.1% and povidoneiodine 0.4%.4 This novel formulation was compared with cidofovir 0.5%, a combination tobramycin-dexamethasone ophthalmic suspension (Tobradex; Alcon Laboratories, Inc., Fort Worth, Texas), and balanced salt solution in rabbit eyes. The combination topical dexamethasone 0.1% and povidoneiodine 0.4% was equally effective as cidofovir 0.5% in reducing viral titers and was the most efficacious in reducing clinical symptoms of adenovirus infection in rabbit eyes.

A dexamethasone/povidone-iodine combination drop is not yet commercially available, but other options are. Gordon et al demonstrated that topical ketorolac or diclofenac did not increase the viral shedding period and may be a safer alternative t topical steroids.5 More recently, during an epidemic of viral conjunctivitis in a military garrison in Karachi, Pakistan, 200 patients were randomly assigned to topical decongestant/antihistamine combination drops or to eye washing and cool compresses.6 Acute illness symptoms of eye watering, itching, burning, pain, and photophobia lasted a mean 4.91 days in the decongestant/ antihistamine drop and 7.86 days in the cool compresses group.