What are the prevalence of and reasons for misrepresentation and nonadherence regarding public health measures against COVID-19?In this national survey study of 1733 US adults, nearly half of participants reported misrepresentation and/or nonadherence regarding COVID-19 public health measures. The most common reasons included wanting life to feel normal and wanting to exercise personal freedom.These findings suggest that misrepresentation and nonadherence regarding COVID-19 public health measures constitute a serious public health challenge. This survey study explores the prevalence of, reasons for, and characteristics associated with misrepresentation and nonadherence regarding COVID-19 public health measures among survey respondents in the US. The effectiveness of public health measures implemented to mitigate the spread and impact of SARS-CoV-2 relies heavily on honesty and adherence from the general public.To examine the frequency of, reasons for, and factors associated with misrepresentation and nonadherence regarding COVID-19 public health measures.This survey study recruited a national, nonprobability sample of US adults to participate in an online survey using Qualtrics online panels  from December 8 to 23, 2021. The survey contained screening questions to allow for a targeted sample of one-third who had had COVID-19, one-third who had not had COVID-19 and were vaccinated, and one-third who had not had COVID-19 and were unvaccinated.The survey assessed 9 different types of misrepresentation and nonadherence related to COVID-19 public health measures and the reasons underlying such behaviors. Additional questions measured COVID-19–related beliefs and behaviors and demographic characteristics.The final sample included 1733 participants. The mean (SD) participant age was 41 (15) years and the sample predominantly identified as female (1143 of 1732 [66.0%]) and non-Hispanic White (1151 of 1733 [66.4%]). Seven hundred twenty-one participants (41.6%) reported misrepresentation and/or nonadherence in at least 1 of the 9 items; telling someone they were with or about to be with in person that they were taking more COVID-19 preventive measures than they actually were (420 of 1726 [24.3%]) and breaking quarantine rules (190 of 845 [22.5%]) were the most common manifestations. The most commonly endorsed reasons included wanting life to feel normal and wanting to exercise personal freedom. All age groups younger than 60 years  and those who had greater distrust in science  had significantly higher odds of misrepresentation and/or nonadherence for at least 1 of the 9 items.In this survey study of US adults, nearly half of participants reported misrepresentation and/or nonadherence regarding public health measures against COVID-19. Future work is needed to examine strategies for communicating the consequences of misrepresentation and nonadherence and to address contributing factors. However, these measures can involve significant psychological,6 social ,8 financial ,9 and physical 12 burdens that make adherence difficult.Public health measures have the potential to dramatically reduce the spread and impact of the disease,Given the difficulty and costs associated with many public health measures, members of the public may exercise dishonesty and nonadherence regarding these measures. For example, people may withhold information about having COVID-19 during a health screening to allow them to attend their health care appointment or continue going to work. Reporting being vaccinated when one is not would allow a person to participate in an event restricted to those who are vaccinated or to avoid judgment from vaccinated friends.14 and specifically regarding their medical information and behaviors, particularly when it is embarrassing or potentially self-serving.17 For instance, previous research17 found that a substantial percentage of US adults withhold important information from their clinicians and that the reasons for doing so include concerns about being judged or lectured and not wanting to have to make a difficult change in behavior. In addition, in a national probability sample of adults receiving medical care for HIV,15 a substantial minority had sex without disclosing their positive HIV status.Such scenarios are quite plausible given that it is well-established that people often misrepresent or do not disclose information in general,18 found that 55% of respondents reported some concealment of COVID-19 symptoms, and among those instructed to quarantine, 53% reported denying the need to do so when asked. Another study19 found that approximately 10% of full-time in-person employees reported going to work despite having a confirmed case of COVID-19 or a close contact with a confirmed case, and in a study of 69 people who were told to quarantine due to COVID-19 exposure or possible symptoms,20 nearly half (46%) broke quarantine rules.Misrepresentation of COVID-19–related health information and nonadherence to public health measures may undermine the effectiveness of these measures. One of the few studies that examined this question early in the pandemicThese few studies were conducted very early in the pandemic, only examined a few types of misrepresentation or nonadherence, and/or did not explore the reasons for these behaviors. Therefore, our understanding of the prevalence of and reasons for these behaviors during the COVID-19 pandemic remains limited. To address these limits, the present study explored the prevalence of, reasons for, and characteristics associated with misrepresentation and nonadherence regarding COVID-19 public health measures.AAPOR) reporting guideline.From December 8 to 23, 2021, we conducted an online survey of US adults that focused on their experiences and challenges throughout the COVID-19 pandemic. Qualtrics online panels were used to send targeted invitations to potential participants, and those interested began the survey. Qualtrics was used in part because of its access to a diversified cohort of US residents. Using an online platform also allowed for additional screening to ensure adequate representation. Specifically, screener questions at the beginning of the survey were used to select a sample in which one-third had had COVID-19, one-third had not had COVID-19 and were at least partially vaccinated , and one-third had not had COVID-19 and had not received any COVID-19 vaccinations. Multiple mechanisms were in place to ensure that the survey could not be completed by “bots” or cheaters . The survey also assessed whether, throughout the pandemic, participants did not mention that they thought they might have or knew they had COVID-19 when being screened to enter a clinician’s office or a public place (among those who thought they might have or knew they had COVID-19), told someone they were with or were about to be with that they were taking more COVID-19 prevention measures than they actually were, told someone they were vaccinated for COVID-19 when they were not (among those who were not vaccinated), told someone they were not vaccinated when they were (among those who were vaccinated), and told someone that they did not have to quarantine when they were supposed to (among those who were told to quarantine).Participants were also asked whether, during the pandemic, they had ever avoided getting tested (among those who thought they might have COVID-19) and if they ever broke quarantine rules (among those who were told to quarantine).If participants answered affirmatively to any of the misrepresentation or nonadherence items, they were asked to indicate yes or no to a list of reasons for the corresponding behavior. These reasons were consistent across similar items but differed where appropriate. They included items such as: “It’s no one else’s business,” “I didn’t want someone to judge or think badly of me,” “I wanted to exercise my freedom to do what I want,” and “I didn’t think COVID-19 was real.” Participants could say yes to all reasons that applied to them and type additional reasons for each item if desired.religiosity), political party affiliation, political social beliefs, vaccine attitudes, where they obtained COVID-19 information, how often they wore a mask in a retail or grocery store, whether they have taken more or fewer COVID-19 prevention measures compared with those with whom they interact, belief in science,21 and conspiracy beliefs about COVID-19.22 Participants self-reported their age, gender identity, race and ethnicity, and location of residence (state and size of town or city). Race and ethnicity were included to allow us to describe the sample and because COVID-19 and its public health measures disproportionately impacted individuals from underserved populations. Finally, participants could provide feedback on the survey in an open text box.Participants also reported their religious beliefs  with the use of multiple packages.26 We report demographic statistics, the percentage of participants who engaged in the 9 misrepresentation and nonadherence behaviors, and the reasons for these behaviors.Analyses were conducted in R Studio,P values were adjusted using Holm-Bonferroni correction.27We used multiple logistic regression to conduct an exploratory analysis of the characteristics that were associated with whether or not participants reported misrepresentation or nonadherence in any of the 9 items . Separate models for each of the 9 items did not differ substantially from the overall model and are provided in the eTable in the Of the 2260 people who received the email invitation and accessed the survey, 1811 completed it . We excluded 59 participants who provided indecipherable responses in the open text boxes and 19 participants who completed the survey in less than one-third of the median completion time (2 minutes and 58 seconds), leaving a final analytic sample of 1733 participants. Participants had a mean (SD) age of 41 (15) years ; of 1732 with responses available, 1143 identified as female (66.0%), 548 identified as male (31.6%), and 41 provided other gender identity responses (2.4%). Most participants identified as non-Hispanic White (1151 [66.4%]) and most had completed a bachelor’s degree or more (470 [27.1%]). Consistent with sampling quotas, 477 (27.5%) reported having had COVID-19, 499 (28.8%) reported not having had COVID-19 and being at least partially vaccinated, and 509 (29.4%) reported not having had COVID-19 and being unvaccinated. An additional 160 participants (9.2%) were unsure whether they had COVID-19 and were at least partially vaccinated, and 81 (4.7%) were unsure whether they had COVID-19 and were not vaccinated. An additional 7 participants (0.4%) did not respond regarding either their COVID-19 status or their vaccination status. Participant characteristics and additional survey measures are provided in Overall, 721 participants (41.6%) reported misrepresentation or nonadherence for at least 1 of the 9 behaviors . Among t28  indicated that younger participants  compared with those 60 years or older and those with greater disbelief in science  had significantly higher odds of reporting misrepresentation or nonadherence in any of the 9 items  to clincians.17 Our findings regarding participants’ reasons for misrepresentation and nonadherence  are aligned with prior research demonstrating the desire to maintain personal autonomy in response to past governmental health requirements30 and denials of reputable medical  and scientific information.36These results are consistent with the little research conducted to date demonstrating misrepresentation and nonadherence regarding COVID-19 public health measures17 and lower likelihood of medical adherence in general38 and regarding COVID-19 preventive measures specifically.40 Similarly, greater disbelief in science has been an important factor associated with nonadherence to health behaviors during the pandemic 42 and beyond.43 These groups may represent an important focus for efforts to address misrepresentation and nonadherence.The results also suggest that younger participants and those with greater disbelief in science may be more likely to engage in misrepresentation or nonadherence. Younger patients have been found to have a higher likelihood of dishonesty regarding disclosure of medical information12 such misrepresentation and nonadherence may have placed others at risk of COVID-19. For example, not disclosing thinking or knowing one has COVID-19 when entering a clinician’s office endangers clinicians, office staff, and other patients who may be at increased risk of severe outcomes from COVID-19.Overall, the results of this study suggest that some participants misrepresented their COVID-19 status and/or vaccination status and did not adhere to public health measures. Although these public health measures can involve tremendous psychological, social, financial, and physical burdens,44 , thereby likely making our results an underestimate of how commonly people misrepresent or are nonadherent in this setting. Third, although the study captured the percentage of individuals who misrepresented or were nonadherent, it cannot speak to the frequency or the degree of these behaviors. In addition, indicated reasons for misrepresentation and nonadherence may have been post hoc explanations, rather than the original determinants. Finally, there may have been other reasons why people misrepresented or were nonadherent that we did not measure . For instance, participants may have avoided getting a COVID-19 test because they did not want to risk infecting others at the testing site. In addition, participants may not have mentioned a COVID-19 diagnosis or symptoms in a screening because they thought they were no longer contagious and therefore believed it to be irrelevant. This could have led us to overestimate the cases of misrepresentation and nonadherence that are of concern . However, screening questions typically include a time frame that preempts this possibility . Furthermore, the general public is often uninformed about viral transmission45; therefore, full disclosure is necessary for the medical screener to assess actual risk level.The present research has limitations. First, the online sample is not fully representative of the US population, although it allowed for a larger and more diverse sample size than data collected using other means and ensured the inclusion of sufficient participants differing in COVID-19 history and vaccination status. We also acknowledge that with an online nonprobability sample, the findings from our model do not offer unbiased population level insights and should be interpreted with caution. These findings provide important preliminary insights for hypothesis testing about factors that may be associated with misrepresentation or nonadherence regarding COVID-19 public health guidelines. Second, in a study examining the extent to which people are misrepresenting the truth, participants may have been dishonest in their survey responses. However, if this occurred, participants likely provided answers that were more socially desirableThe results of this survey study reveal a serious public health challenge for the COVID-19 pandemic and any future infectious disease outbreaks. With misrepresentation and nonadherence regarding public health measures being fairly common, the effectiveness of these measures in preventing disease spread may be undermined. This possibility highlights the need for further research examining strategies for educating the public on the importance of honesty and adherence in these situations as well as for addressing the factors  that drive misrepresentation and nonadherence. It also underscores the importance of public health officials, policy makers, and media personalities fostering trust and engagement in these public health measures to reduce the occurrence and therefore the impact of misrepresentation and nonadherence.


Intrauterine devices (IUDs) are one of the most common forms of long-term contraception used by patients around the world. Many studies have been performed over the past few decades demonstrating the safety of many common hormonal and metallic intrauterine devices in Magnetic Resonance (MR) imaging; however, the stainless steel ring IUD (often termed the “Chinese” IUD) is still considered MR Unsafe. This device was used in the 1980s and 1990s in China, where as many as 60 million women in China were using an IUD by 1988, and approximately 90% of those were stainless steel ring IUDs. In a major metropolitan area hospital such as ours with a large immigrant population, we encounter females with this ring IUD several times a year. As this population ages, the need for medical care  is projected to increase. The purpose of this case review is to examine the imaging and clinical course of patients with stainless-steel ring intrauterine devices who safely received 1.5T Brain MR scans at our institution for clinically necessary diagnostic imaging. The long-acting effect and reversibility of intrauterine devices make them a good option for females of reproductive age wishing to temporarily delay pregnancy. Because of their widespread use, IUDs are commonly encountered in the MR environment, where the predominant clinical MR safety concern is regarding heating of the implant and theoretical displacement from the uterus (rendering the contraceptive effect nil).2Intrauterine devices (IUDs) are one of the most common forms of long-term contraception used by patients around the world. Usage is estimated at approximately 8% in Europe and North America and in Eastern and South-Eastern Asia, usage is 18.6% and IUDs are the most common contraceptive used.3 Despite these guidance documents, situations arise outside of those defined by Instructions For Use (IFUs), whereby patient care needs necessitate re-evaluation of prior MR safety concerns.3 These exceptional situations arise in cases where a medical device is used differently to how the manufacturer has instructed  and Medicines and Healthcare products Regulatory Agency (MHRA)). These “off-label” cases occur in instances where the MR Safety Officer/radiologist/physicist in conjunction with the referring physician use scientific rationale and sound medical evidence and appropriate consent to tailor care to the individual patient.There are four major international organizations that evaluate standards for MR performance and safety including the National Electrical Manufacturer’s Association (NEMA), the International Electrotechnical Commission (IEC), The International Commission on Non-Ionizing Radiation Protection (ICNIRP) and the American Society for Testing and Materials . Of these, the ASTM International standardizes medical device testing, labeling and terminology . Guidelines for MR safety practices have been issued by several radiologic societies, including the American College of Radiology (ACR), Canadian Association of Radiologists and European Union.3 However, some have discrete metallic components  that help induce the contraceptive effect. Even a slightly ferromagnetic implantable device can move or heat when introduced to a magnetic field, which can both interfere with the proper functioning of the device and theoretically pose a safety hazard for the patient.4–6 However, studies have been performed over the past few decades demonstrating the safety of many common hormonal and metallic intrauterine devices in MR imaging.2,3,7,8 The conditional safety of many other commonly encountered metallic implants  has been shown in vivo when scanned under controlled situations .3 Theoretically, these commonly encountered metallic implants were thought to be unsafe in laboratory ex vivo tests (due to the mild heating or displacement observed when scanned out of the body) but this theoretical lack of safety was subsequently disproved in observational in vivo studies.3The majority of intrauterine devices are made entirely of plastic and release hormones to prevent pregnancy. These hormone-based plastic IUDs are considered MR Safe.3,9 This device, sometimes referred to as the “Chinese ring IUD,” is a stainless-steel ring used in China during the 1980s and 1990s. In part prompted by the country’s former one-child policy, as many as 60 million women in China were using an intrauterine device by 1988, and approximately 90% of those were stainless-steel rings.10 While these devices are no longer used in new patients, many females still have them, likely because they were designed without a removal string, making them difficult to extract.11 The classification of the stainless-steel ring device as MR unsafe is based on a recent study performed by Bussman et al.9 The ex vivo study found that both displacement force and torque were significantly higher for the stainless-steel devices when introduced to a magnetic field. The stainless-steel devices exhibited a displacement force of 7.6N and a high degree of torque, while all other metallic IUDs tested exhibited a displacement force of 0.5 mN and no torque effect.9 The study also found the stainless-steel ring produced an artefact many times larger than other metallic IUDs, with the artefact on gradient echo up to 200 mm in diameter and on spin echo up to 150 mm in diameter.9 These findings  are concerning in theory, because it has been shown that a conventional (non-ring) IUD can perforate the uterus at forces from 20 to 54N, and it is unclear how that extrapolates to a ring IUD.12 For reference, typical insertion forces for a conventional (non-ring) IUD range from 1.5 to 6.5N, and removal forces range from 1 to 5.8N.12 In clinical practice, however, it is shown extensively that the shape and design of these ring IUDs require significantly greater removal force, such that even in experienced hands, one-third of these devices need to removed in the operating room, as opposed to in the office setting.13 Therefore, it is unlikely that these ring IUDs will be displaced from the uterus during an MRI procedure.One intrauterine device in particular has been deemed MR unsafe according to current imaging consensus statements.ex vivo MR imaging of stainless-steel ring intrauterine devices move in the magnetic field and generate an artefact greater than other IUD types, it is unclear that these differences are clinically significant. As an important corollary, Maralani et al 2019 describe the evolution of MR Safety as regards pacemakers and defibrillators ). These CIEDs were previously classified “MR Unsafe” and now are often able to be scanned under specific circumstances .3 Similarly, for the Chinese ring IUD, refusal to perform an MRI exam for a theoretical concern of displacement or heating of the ring IUD based only on ex vivo data can have important adverse clinical consequences. In a major metropolitan area hospital such as ours with a large immigrant population, we encounter females with this ring IUD several times a year. As this population ages, the need for medical care  is projected to increase. The purpose of this case review is to examine the imaging and clinical course of patients with stainless-steel ring intrauterine devices who safely received 1.5T Brain MR studies at our institution for clinically necessary diagnostic imaging.While the Bussmann study demonstrates that This study was IRB approved as a Quality Improvement study, with waiver of informed consent. Our hospital database was retrospectively searched from 1 January 2014 to 1 April 2021 for radiology MRI reports that included either “circular IUD” “ring IUD” or “Chinese IUD” in the body or impression. Clinical indication for each scan, the type of MR performed, the scan time, and the radiologist’s impression were all recorded. Complications during and after the scans, as well as device movement, were assessed via technology notes and follow-up medical records, including imaging and clinical notes.Of the 56 patients, all Chinese female immigrants, who underwent various radiographic imaging studies noting the presence of a ring intrauterine device, eight patients  underwent 1.5T MRI . The MRIs were obtained after informed consent and risk-benefit discussion between the MR Safety Officer with the referring physician, noting the urgent need for an MRI and the inability to answer the clinical question with other modalities (such as a CT or ultrasound). All eight MRIs occurred without adverse event. The typical appearance of the ring (Chinese) IUD is shown in The findings of this case review suggest that stainless-steel ring intrauterine devices may be safer for MR imaging than previous theoretical physics research has posited. All eight patients with stainless-steel intrauterine devices who underwent 1.5T Brain MRIs did so without incident, and all follow-up evaluations demonstrated that the devices were not displaced from the uterus during the scans. The scans provided critical, clinically relevant information for these patients, influencing both diagnosis and treatment course. 2/8 patients had important positive findings seen on MRI that were not appreciated on CT, including evidence for acute infarction and metastatic disease. The other 6/8 patients had important negative findings, such as the absence of a subdural hemorrhage or absence of a subarachnoid hemorrhage . Other papers have suggested removing the ring IUD as a preemptive way to obtain the MR study; however, this is not a realistically feasible option in a critically ill patient, particularly as these circular IUDs are difficult to remove.9 the cases evaluated here suggest that an MR Unsafe classification is unwarranted when imaging the brain with 1.5T MRI. The displacement force and torque on the stainless-steel devices were insufficient to move the devices out of the uterus or to cause the patients any discomfort during or after the scans. The most likely explanation for this discrepancy is that the displacement force and torque placed on a stainless-steel device in a patient is not substantial enough to dislodge the device from its place embedded in the endometrium of the uterus when imaging the brain at 1.5T. It is important to note, however, that the force and torque experienced by the device is highly dependent on both the system used and location of the device in the system. For example, in the Bussmann study at the location of ex vivo measurement on the 3T system used, the B0 field  was 1.8T and the field gradient was 4.5 T/m, such that the product of field strength and field gradient  was 8.1 T2/m, while in our study we can expect that at the device location (approximately 0.6m from isocenter) B0 should be approximately 1T and field gradient should be approximately 2 T/m for a field-gradient product of approximately 2 T2/m.While the study by Bussman et al has served as an underlying justification for declaring these devices MR Unsafe,Stainless-steel intrauterine devices are becoming increasingly uncommon, as they are no longer used in new patients. However, there are patients who still have these devices from the 1980s and 1990s when they were commonplace in some countries, and many of these patients may have clinical indications for MR imaging at some point in the future. Many of these females are now in their late 40s and early 70s, which indicates that radiology practices will continue to see patients with stainless-steel ring IUD for years to come that require MR imaging. Our experience with these patients suggests that the determination of these devices as MR unsafe should be revisited, and that practices that see such patients should consider performing 1.5T MR scans if the scans are clinically necessary and no imaging alternative will suffice.in vivo could further elucidate the types of MR scans these patients can receive, and further investigation of pelvic MR imaging with these devices could clarify the extent to which the additional artefact impacts the clinical utility of such studies.While more systematic study of the safety of stainless-steel ring intrauterine devices is difficult due to the relative paucity of patients with such devices, further study of the clinical safety and utility of MR imaging in patients with these devices is warranted. In particular, clinical evaluation of stainless-steel device safety in MR imaging at 3T Many studies have shown that common hormonal and metallic intrauterine devices are safe to scan with MR imaging; however, the stainless-steel ring IUD (often termed the “Chinese” IUD) is still considered MR unsafe.These stainless-steel ring IUDs were placed in the 1980s and 1990s, and the females who received these ring IUDs are now in their late 40s to 80s, and their need for medical care and medical (MR) imaging is increasing.Removing the ring IUD is technically difficult and often not feasible prior to obtaining a clinically necessary MR study.In this retrospective study, eight patients with ring IUDs safely underwent clinically necessary Brain MR imaging studies at 1.5T without adverse event.The information from these clinically important MR imaging studies allowed pre-operative planning for Gamma-knife brain surgery in one patient and avoided an unnecessary risky interventional neuroradiology study in another.These results suggest that the determination of ring IUDs as MR unsafe should be revisited and that the practices see such patients should consider performing 1.5T MR scans if the scans are clinically necessary and no imaging alternative will suffice.


Are topical antibiotics effective for the management of acute infective conjunctivitis in children?In this randomized clinical trial with 88 participants, use of topical antibiotics reduced the time to clinical cure, and in the meta-analysis with 584 participants, the use of topical antibiotics was associated with a significant reduction in the proportion of children who had symptoms of conjunctivitis on days 3 to 6 compared with those receiving a placebo.These findings suggest that topical antibiotic therapy should be considered for acute infective conjunctivitis in children because antibiotics were associated with significantly shorter recovery times. This study assesses the efficacy of topical antibiotic therapy for acute infective conjunctivitis among children. Although topical antibiotics are often prescribed for treating acute infective conjunctivitis in children, their efficacy is uncertain.To assess the efficacy of topical antibiotic therapy for acute infective conjunctivitis.A randomized clinical trial was conducted in primary health care in Oulu, Finland, from October 15, 2014, to February 7, 2020. Children aged 6 months to 7 years with acute infective conjunctivitis were eligible for enrollment. The participants were followed up for 14 days. A subsequent meta-analysis included the present trial and 3 previous randomized clinical trials enrolling pediatric patients aged 1 month to 18 years with acute infective conjunctivitis.Participants in the present randomized clinical trial were randomized to moxifloxacin eye drops, placebo eye drops, or no intervention.The primary outcome in the present randomized clinical trial was time to clinical cure (in days); in the meta-analysis, the primary outcome was the proportion of participants with conjunctival symptoms on days 3 to 6.P = .04), while in the survival analysis both moxifloxacin and placebo eye drops significantly shortened the time to clinical cure relative to no intervention. In the meta-analysis, a total of 584 children were randomized , and the use of topical antibiotics was associated with a significant reduction in the proportion of children who had symptoms of conjunctivitis on days 3 to 6 compared with placebo eye drops .The randomized clinical trial included 88 participants (46 [52%] girls), of whom 30 were randomized to moxifloxacin eye drops , 27 to placebo eye drops , and 31 to no intervention . The time to clinical cure was significantly shorter in the moxifloxacin eye drop group than in the no intervention group (3.8 vs 5.7 days; difference, −1.9 days; 95% CI, −3.7 to −0.1 days; In this randomized clinical trial and systematic review and meta-analysis, topical antibiotics were associated with significantly shorter durations of conjunctival symptoms in children with acute infective conjunctivitis.2013-005623-16ClinicalTrialsRegister.eu Identifier:  Gigliotti et al3 reported in the first randomized trial of acute conjunctivitis in children that we know of that treatment with topical antibiotics resulted in a greater cure rate than that among those receiving placebo eye drops, whereas a trial conducted by Rose et al4 found that there was no difference in the clinical recovery between children treated with chloramphenicol eye drops and those treated with a placebo.4 However, since the placebo eye drops used by Rose et al4 contained antiseptic agents as preservatives, both groups may have received anti-infective therapy. Finally, to our knowledge, all previous meta-analyses showing modest beneficial effects of topical antibiotics have combined pediatric and adult patients.5Acute conjunctivitis is a common infection in children and is usually caused by bacteria.In this randomized clinical trial (RCT), children with acute infective conjunctivitis receiving topical antibiotics were compared with control participants receiving a placebo, while an additional control group that received no intervention was included because placebo eye drops alone may be beneficial due to their washout effect. The study was then continued by performing a systematic review and meta-analysis of data extracted from the present trial and previous RCTs.CONSORT) guideline. The systematic review and meta-analysis were registered with Prospero (CRD42021255970) and were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline.6 The study protocol and statistical analysis plan are shown in The protocol was found ethically acceptable by the Finnish Medical Agency and the Ethical Committee of the North Ostrobothnia’s Hospital District, Oulu, Finland. Only children whose parents or legal representatives provided written informed consent were included in the trial. The RCT followed the Consolidated Standards of Reporting Trials , discharge, or soreness or swelling of the eyelids. The exclusion criteria were allergy to fluoroquinolones, antibiotic therapy 7 days prior to the study, severe infection, allergic conjunctivitis, a trauma, or a foreign body in the eye. All the children were from Finnish-speaking families.The eligible children were randomized to receive moxifloxacin eye drops, placebo eye drops, or no intervention in a 1:1:1 ratio. A biostatistician created a randomization list in permuted blocks of 6 in a random order, and the results were enclosed in sealed, numbered opaque envelopes containing either a code for the study group or the words no treatment. After informed consent had been obtained, the study physician opened the envelope and revealed a code (A or B) or no treatment.The participating children, their parents, and the physicians and nurses were blinded to the assignment of the moxifloxacin and placebo eye drop groups, while the study design for the no intervention group was randomized but unblinded. The pharmacy distributed the eye drops and instructions to the families in opaque cardboard boxes in which the moxifloxacin eye drops were packed in plastic bottles and the placebo eye drops in single-dose vials. Both the bottles and the vials were transparent and did not have labels.Conjunctival and nasopharyngeal specimens subjected to respiratory pathogen polymerase chain reaction (PCR) testing and bacterial culture were obtained from the participants, and detailed descriptions of these microbiological samples are available in the study protocol . The parThe primary outcome was time (days) to clinical cure, defined as resolution of all conjunctival symptoms without relapse for 2 days. The secondary outcome was a relapse of conjunctivitis within 14 days of randomization. The outcomes were identified from the daily symptom sheet diaries that the parents completed for 14 days. In addition, the physician contacted the parents after the 14-day follow-up to ensure a clinical cure.conjunctivitis, bacterial NOT trachoma for the literature search. Two investigators (M.H. and U.K.) independently screened the titles and abstracts to identify eligible studies according to the given inclusion criteria. After that, 3 investigators  reviewed the full manuscripts to determine those to be included and excluded. Data for all variables were extracted independently by 3 investigators .RCTs were considered eligible if they compared topical or systemic antibiotics for the management of acute conjunctivitis in children and adolescents aged 1 month to 18 years with a control group without antibiotic therapy. We identified the literature in ClinicalTrials.gov, Cochrane Library, Google Scholar, PubMed, ScienceDirect, and Scopus from database inception up to November 9, 2021, using the Medical Subjects Headings terms 7 and consensus was reached by discussion.The primary outcome of the meta-analysis was the proportion of participants who had conjunctival symptoms on days 3 to 6, while secondary outcomes were the proportion of participants who had conjunctival symptoms on days 7 to 10 and the proportion without a microbiological cure on days 7 to 10. The trials were assessed for the risk of bias independently by 3 investigators  using the Cochrane Collaboration tool for assessing the risk of bias in randomized trials,4 we estimated that acute infective conjunctivitis in children will resolve in a mean (SD) of 5 (2) days without treatment, so a 1.5-day difference in cure time could be considered clinically significant. With a statistical power of 80% and a 2-sided α error of .05, we calculated that the sample size needed was 29 children per group.Based on prior studies,2 test was used to test the statistical significances of the differences in relapse rates between the 3 groups. Data were analyzed with SPSS statistics software version 27.0 (IBM Corp).A 1-way analysis of variance test, followed by a Tukey post hoc test, was used to compare the mean times to clinical cure between the moxifloxacin, placebo, and no intervention groups with 95% CIs. Variations in the cure times were compared between the moxifloxacin group and both control groups separately with Kaplan-Meier log rank (Mantel-Cox) survival statistics. The χ2I statistic was used to investigate the heterogeneity between the trials. A random-effects model was chosen for this, as it was assumed that the RCTs represented a random sample of all studies evaluating the efficacy of treatment for acute infective conjunctivitis. Potential publication bias in the trials was analyzed using a funnel plot and the Egger or Harbord-Egger test. The analyses of the outcomes were performed using Comprehensive Meta Analysis software version 3.3.070 .Data from the RCTs in the meta-analysis were used to calculate odds ratios (ORs) and 95% CIs comparing the intervention with a placebo. The A total of 209 children with acute conjunctivitis were evaluated for eligibility, and 114 children were excluded: 25 because they did not meet the inclusion criteria, and 89 because their families declined to participate . After rHaemophilus influenzae in all groups.Most children had symptoms of respiratory tract infection and a positive nasopharyngeal PCR for respiratory viruses (eTables 1 and 2 in P = .04) (P = .94). Similarly, when the children receiving placebo eye drops were compared with those who did not receive any intervention, there was no significant difference in the time to clinical cure . In the Kaplan-Meier survival analysis, both moxifloxacin and placebo eye drops significantly shortened the time to clinical cure relative to no intervention   . When thctively) .P = .43 for moxifloxacin vs placebo eye drops and P = .10 for moxifloxacin eye drops vs no intervention) (Relapse of conjunctivitis occurred in 5 children (17.9%) in the moxifloxacin group, 2 children (7.4%) in the placebo group, and 1 child (3.2%) in the no intervention group (vention) . Moxiflo8 and the present results were included in the analysis.The database search revealed a total of 2938 records, 21 of which met the study criteria . Of thes3 and Rose et al,4 together with the present study, were RCTs, whereas the work published by Comstock et al8 was a post hoc subgroup analysis of 3 RCTs, and only the data on children aged 1 to 5 years were included in the present meta-analysis. The trials by Gigliotti et al,3 Rose et al,4 and Comstock et al8 compared topical antibiotics with a topical placebo, whereas the present trial compared topical antibiotics with a topical placebo and with the absence of an intervention. The risk of bias was assessed to be low in the trials by Gigliotti et al,3 Rose et al,4 and the present RCT but moderate in the trial by Comstock et al8    . The pro8 The meta-analysis showed that the use of topical antibiotics was associated with a significant reduction in the proportion of participants who had a positive bacterial culture from the conjunctivae on days 7 to 10 compared with those who had received the placebo  (eFigure 5 in Microbiological cures by days 7 to 10 were reported in 3 studies.8 found that the use of topical antibiotics was associated with a significant reduction in the proportion of children who had symptoms of conjunctivitis on days 3 to 6 compared with cases receiving a placebo. The evidence for this has previously been conflicting. Gigliotti et al3 showed in the early 1980s that treatment with polymyxin-bacitracin eye drops resulted in higher clinical cure rates on days 2 to 5 than treatment with a placebo, but when Rose and colleagues4 conducted a large trial consisting of 326 outpatient children with acute infective conjunctivitis in 2005, they found no significant difference in the cure rates at 1 week between the children treated with chloramphenicol eye drops and those treated with placebo eye drops. The present study, which was designed to address current inconsistencies, found that topical antibiotics were effective when used to treat acute infectious conjunctivitis in children.This systematic review and meta-analysis of combined data from the present trial and 3 previous studies4 has been that none of the trials have included a control group without an intervention. It has been suggested that placebo eye drops alone may be of benefit in the management of acute infective conjunctivitis because of their washout effect. Moreover, the largest trial of which we are aware found no difference in cure times between antibiotic eye drops and a placebo,4 but it included a placebo solution that contained preservatives with antiseptic properties. To avoid the bias caused by washout or anti-infective effects of a placebo, groups with no intervention at all and a placebo solution that did not contain any preservatives were included in the present RCT. As a result, the placebo eye drops significantly reduced the time to clinical cure in the present time-to-event analysis by comparison with no treatment, although the difference in the mean times to clinical cure between the groups was not statistically significant. These findings do suggest, however, that lubricating eye drops may make some contribution to the management of acute infective conjunctivitis in children.An acknowledged weakness of previous RCTs5 of the management of acute infective conjunctivitis in 2012 that led the authors to conclude that topical antibiotics can be of benefit for the treatment of conjunctivitis in that they improved the clinical cure rates both on days 2 to 5 and on days 6 to 10. That meta-analysis, however, included both adults and children, so that the results cannot be directly generalized to pediatric populations. To our knowledge, the present meta-analysis is the first to date to be based on data from pediatric patient populations alone.The Cochrane collaboration conducted a systematic review and meta-analysis9 Accordingly, more than 80% of the children in this RCT had a positive bacterial conjunctival culture. Although most of the present children with acute infective conjunctivitis presented with respiratory tract symptoms, respiratory viruses were only detected in the conjunctivae of 12%, which is in accordance with previous observations.9Previous research into the etiology of acute infective conjunctivitis in children has found that approximately 80% of cases are caused by pathogenic bacteria.The strengths of this trial include a randomized, placebo-controlled study design with the inclusion of a control group receiving no treatment, which mimics a clinical situation. We then conducted a systematic review and meta-analysis of all RCTs we could find that were carried out with pediatric patient populations, including the RCT presented here. The results are directly applicable to primary care settings.This study has limitations. We were not able to compare topical antibiotic therapy with no intervention in the meta-analysis because the present RCT was, to our knowledge, the only trial that had included a control group without an intervention. Moreover, the placebo solutions used in the 4 trials included in the meta-analysis varied, so that we could not assess possible differences between them. Furthermore, we could not compare the efficacy of topical antibiotic therapy separately in children with bacterial and viral conjunctivitis.In this RCT, use of topical antibiotics reduced the time to clinical cure, and in the meta-analysis of combined data from the present trial and previous RCTs, the use of topical antibiotics was associated with a significant reduction in the proportion of children who had symptoms of conjunctivitis on days 3 to 6 compared with those receiving a placebo. The present RCT results also suggest that lubricating eye drops may have some benefits for the management of acute infective conjunctivitis in children.