Objective: to assess different management strategies for acute infective conjunctivitis.<br/><br/>Design: open, factorial, randomised controlled trial.<br/><br/>Setting: 30 general practices in southern England.<br/><br/>Participants: 307 adults and children with acute infective conjunctivitis.<br/><br/>Intervention: one of three antibiotic prescribing strategies--immediate antibiotics (chloramphenicol eye drops; n=104), no antibiotics (controls; n=94), or delayed antibiotics (n=109); a patient information leaflet or not; and an eye swab or not.<br/><br/>Main outcome measures: severity of symptoms on days 1-3 after consultation, duration of symptoms, and belief in the effectiveness of antibiotics for eye infections.<br/><br/>Results: prescribing strategies did not affect the severity of symptoms but duration of moderate symptoms was less with antibiotics: no antibiotics (controls) 4.8 days, immediate antibiotics 3.3 days (risk ratio 0.7, 95% confidence interval 0.6 to 0.8), delayed antibiotics 3.9 days (0.8, 0.7 to 0.9). Compared with no initial offer of antibiotics, antibiotic use was higher in the immediate antibiotic group: controls 30%, immediate antibiotics 99% (odds ratio 185.4, 23.9 to 1439.2), delayed antibiotics 53% (2.9, 1.4 to 5.7), as was belief in the effectiveness of antibiotics: controls 47%, immediate antibiotics 67% (odds ratio 2.4, 1.1 to 5.0), delayed antibiotics 55% (1.4, 0.7 to 3.0), and intention to reattend for eye infections: controls 40%, immediate antibiotics 68% (3.2, 1.6 to 6.4), delayed antibiotics 41% (1.0, 0.5 to 2.0). A patient information leaflet or eye swab had no effect on the main outcomes. Reattendance within two weeks was less in the delayed compared with immediate antibiotic group: 0.3 (0.1 to 1.0) v 0.7 (0.3 to 1.6).<br/><br/>Conclusions: delayed prescribing of antibiotics is probably the most appropriate strategy for managing acute conjunctivitis in primary care. It reduces antibiotic use, shows no evidence of medicalisation, provides similar duration and severity of symptoms to immediate prescribing, and reduces reattendance for eye infections.<br/><br/>Trial registration: current controlled trials ISRCTN32956955
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