[Efficacy assessment of azithromycin 1.5% eye drops versus tobramycin 0.3% on clinical signs of purulent bacterial conjunctivitis]

Antibiotics versus placebo for acute bacterial conjunctivitis

BACKGROUND

Acute bacterial conjunctivitis is an infection of the conjunctiva and is one of the most common ocular disorders in primary care. Antibiotics are generally prescribed on the basis that they may speed recovery, reduce persistence, and prevent keratitis. However, many cases of acute bacterial conjunctivitis are self-limited, resolving without antibiotic therapy. This Cochrane Review was first published in The Cochrane Library in 1999, then updated in 2006, 2012, and 2022.

OBJECTIVES

To assess the benefits and side effects of antibiotic therapy in the management of acute bacterial conjunctivitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2022, Issue 5), MEDLINE (January 1950 to May 2022), Embase (January 1980 to May 2022), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.

CLINICALTRIALS

gov), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases in May 2022.   SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which any form of antibiotic treatment, with or without steroid, had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical and systemic antibiotic treatments.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies and determined the included RCTs, which were further assessed for risk of bias using Cochrane methodology. We performed data extraction in a standardized manner and conducted random-effects meta-analyses using RevMan Web.

MAIN RESULTS

We included 21 eligible RCTs, 10 of which were newly identified in this update. A total of 8805 participants were randomized. All treatments were topical in the form of drops or ointment. The trials were heterogeneous in terms of their eligibility criteria, the nature of the intervention (antibiotic drug class, which included fluoroquinolones [FQs] and non-FQs; dosage frequency; duration of treatment), the outcomes assessed and the time points of assessment. We judged one trial to be of high risk of bias, four as low risk of bias, and the others as raising some concerns. Based on intention-to-treat (ITT) population, antibiotics likely improved clinical cure (resolution of clinical symptoms or signs) by 26% (RR 1.26, 95% CI 1.09 to 1.46; 5 trials, 1474 participants; moderate certainty) as compared with placebo. Subgroup analysis showed no differences by antibiotic class (P = 0.67) or treatment duration (P = 0.60). In the placebo group, 55.5% (408/735) of participants had spontaneous clinical resolution by days 4 to 9 versus 68.2% (504/739) of participants treated with an antibiotic. Based on modified ITT population, in which participants were analyzed after randomization on the basis of positive microbiological culture, antibiotics likely increased microbiological cure (RR 1.53, 95% CI 1.34 to 1.74; 10 trials, 2827 participants) compared with placebo at the end of therapy; there were no subgroup differences by drug class (P = 0.60). No study evaluated the cost-effectiveness of antibiotic treatment. Patients receiving antibiotics had a lower risk of treatment incompletion than those in the placebo group (RR 0.64, 95% CI 0.52 to 0.78; 13 trials, 5573 participants; moderate certainty) and were 27% less likely to have persistent clinical infection (RR 0.73, 95% CI 0.65 to 0.81; 19 trials, 5280 participants; moderate certainty). There was no evidence of serious systemic side effects reported in either the antibiotic or placebo group (very low certainty). When compared with placebo, FQs (RR 0.70, 95% CI 0.54 to 0.90) but not non-FQs (RR 4.05, 95% CI 1.36 to 12.00) may result in fewer participants with ocular side effects. However, the estimated effects were of very low certainty.

AUTHORS' CONCLUSIONS

The findings of this update suggest that the use of topical antibiotics is associated with a modestly improved chance of resolution in comparison to the use of placebo. Since no evidence of serious side effects was reported, use of antibiotics may therefore be considered to achieve better clinical and microbiologic efficacy than placebo. Increasing the proportion of participants with clinical cure or increasing the speed of recovery or both are important for individual return to work or school, allowing people to regain quality of life. Future studies may examine antiseptic treatments with topical antibiotics for reasons of cost and growing antibiotic resistance.

Efficacy of azithromycin 1% and 1.5% ophthalmic solutions compared to tobramycin 0.3% eye drops: A systematic review and meta-analysis

Background:

Azithromycin 1% and 1.5% ophthalmic preparations are used widely in clinical practice for the treatment of signs and symptoms of eye diseases. The aim of this study was to render conclusive evidence by comparing the efficacy of azithromycin 1% and 1.5% over tobramycin 0.3% ophthalmic solutions for the treatment of eye diseases in a short duration in terms of bacterial resolution, the cure rate, and resolving clinical sign and symptoms.

Methods:

Systematic searches were performed in the electronic database (MEDLINE, Embase, Emcare, CINAHL, Scopus, PubMed, ProQuest, and Web of Science) and other sources. Multicenter randomized controlled trial studies conducted in English were identified and screened. Analysis of individual studies was conducted using the OpenMeta-analyst and Review Manager Version 5.3 software.

Results:

Eleven studies were included in the systematic review and meta-analysis. In clinical cure rate, azithromycin 1% and 1.5% eye drops were more effective than tobramycin 0.3% eye drops in short duration dosing (⩽5 days) with a twice-a-day regimen (relative risk = 1.13; 95% confidence interval: 1.008, 1.28), whereas on increased duration (>5 days), azithromycin is almost similarly as effective as tobramycin (relative risk = 1.007; 95% confidence interval: 0.96, 1.05). There was no significant difference in efficacy of bacterial resolution of azithromycin (1%, 1.5%) eye drops compared to tobramycin (0.3%) eye drops (relative risk = 0.99; 95% confidence interval: 0.96, 1.018). Azithromycin eye drops are effective in improving the signs and symptoms of eye disease.

Conclusion:

Azithromycin 1% or 1.5% is more effective in the clinical cure rate of eye disease than tobramycin 0.3% eye drops in ⩽5 days of treatment. It is also the best choice of treatment for improving the signs and symptoms of eye disease. So that we recommend clinicians to use azithromycin 1% or 1.5% eye drops.

Systematic Review Registration:

PROSPERO 2019 CRD42019139911

Antibiotics versus placebo for acute bacterial conjunctivitis

BACKGROUND

Acute bacterial conjunctivitis is an infection of the conjunctiva. Both the palpebral and the bulbar ocular conjunctival surfaces are usually affected and typically become red and inflamed. Antibiotic therapy is widely used for the treatment of acute bacterial conjunctivitis. This Cochrane Review was first published in The Cochrane Library in 1999; updated in 2006 and again in 2012.

OBJECTIVES

To assess the benefits and harms of antibiotic therapy in the management of acute bacterial conjunctivitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), MEDLINE (January 1950 to July 2012), EMBASE (January 1980 to July 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 18 July 2012.

SELECTION CRITERIA

We included double-masked randomised controlled trials (RCTs) in which any form of antibiotic treatment had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical, systemic and combination (for example, antibiotics and steroids) antibiotic treatments.

DATA COLLECTION AND ANALYSIS

Two authors (UN and SM) independently checked and reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies. We graded the included RCTs for methodological quality using Cochrane methodology. We performed data extraction in a standardised manner. We performed random-effects meta-analyses using RevMan.

MAIN RESULTS

We identified 11 eligible RCTs which randomised a total of 3673 participants. One further trial, which was published in abstract form in 1990 but has yet to be reported fully, is currently 'awaiting assessment'. Six of the 11 included studies have been included for the first time in this latest (2012) update. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. We judged two of the trials to be of high quality and graded the remainder as poor quality.Meta-analyses of data on clinical and microbiological remission rates revealed that topical antibiotics were of benefit in improving 'early' (days two to five) clinical (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.61) and microbiological (RR 1.55, 95% CI 1.37 to 1.76) remission rates. At the 'late' time point (days six to 10), antibiotics were found to still confer modest benefits in clinical remission (RR 1.21, 95% CI 1.10 to 1.33) and microbiological cure rates (RR 1.37, 95% CI 1.24 to 1.52). By days six to 10, 41% (95% CI 38 to 43) of cases had resolved in those receiving placebo. We found no data on the cost-effectiveness of antibiotics. No serious outcomes were reported in either the active or placebo arms of these trials, suggesting that important sight-threatening complications are an infrequent occurrence.

AUTHORS' CONCLUSIONS

Although acute bacterial conjunctivitis is frequently self limiting, the findings from this updated systematic review suggest that the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission in comparison to the use of placebo. Use of antibiotic eye drops should therefore be considered in order to speed the resolution of symptoms and infection.

Azithromycin 1.5% ophthalmic solution: in purulent bacterial or trachomatous conjunctivitis

The second-generation macrolide azithromycin is available as a 1.5% ophthalmic solution for use in the treatment of bacterial or trachomatous conjunctivitis. This article reviews the pharmacological properties of azithromycin 1.5% ophthalmic solution and its clinical efficacy and tolerability in patients with purulent bacterial conjunctivitis or trachomatous conjunctivitis caused by Chlamydia trachomatis. Azithromycin 1.5% ophthalmic solution had good in vitro activity against Haemophilus influenzae and C. trachomatis, and achieved good concentrations in tear samples from healthy volunteers. Azithromycin 1.5% ophthalmic solution for 3 days (1 drop twice daily) was noninferior to tobramycin 0.3% ophthalmic solution for 7 days (1 drop every 2 hours) in paediatric and adult patients with purulent bacterial conjunctivitis, with regard to clinical cure and bacteriological resolution on day 9, in a randomized, investigator-masked, multicentre study. In children with trachomatous inflammation, 3-day treatment with azithromycin 1.5% ophthalmic solution was noninferior to a single dose of azithromycin oral suspension, with regard to clinical cure rate in the worst eye at 60 days, in a randomized, double-masked, multicentre study. Azithromycin 1.5% ophthalmic solution was well tolerated in patients with bacterial or trachomatous conjunctivitis. Most events were of mild to moderate severity.

Update and critical appraisal of the use of topical azithromycin ophthalmic 1% (AzaSite) solution in the treatment of ocular infections

Azithromycin is an azalide that acts by binding to the 50S ribosomal subunit of susceptible microorganisms and interfering with microbial protein synthesis. Azithromycin is also noted by anti-inflammatory and immunomodulatory activity. AzaSite^® (Inspire Pharmaceuticals, Inc, Durham, NC) is azithromycin ophthalmic solution, 1% formulated in polycarbophil (the aqueous mucoadhesive polymer contained in DuraSite^®) that delivers high and prolonged azithromycin concentrations in a variety of ocular tissues, including the conjunctiva, cornea and particularly the eyelid. AzaSite was approved by the Food and Drug Administration (FDA) in the US in 2007, for the treatment of bacterial conjunctivitis caused by susceptible isolates. This article aims to evaluate the peer-reviewed published scientific literature and to define well-established uses of AzaSite eye drops in the field of ocular infections.

Bacterial conjunctivitis

CLINICAL QUESTION

What is the best treatment for bacterial conjunctivitis?

RESULTS

Topical antibiotics expedite recovery from bacterial conjunctivitis. The choice of antibiotic usually does not affect outcome.

IMPLEMENTATION

Recognition of key distinguishing features of bacterial conjunctivitis Pitfalls that can be recognized in the history and physical examinationChoice of antibioticWhen to refer for specialist treatment.