Azithromycin versus doxycycline: management of female urogenital and rectal Chlamydia trachomatis infections.

Nil.

A prospective study of the clinical characteristics of patients with herpes simplex and varicella zoster keratitis, presenting to a New Zealand emergency eye clinic.

PURPOSE: To identify the demographic and clinical associations of patients presenting with herpetic keratitis in New Zealand compared with presentations of presumed microbial keratitis. METHODS: A prospective, 6-month, observational case series of presumed microbial keratitis (including marginal keratitis), specifically identifying all cases of herpes simplex and varicella zoster keratitis attending an emergency eye clinic was conducted. Main outcome measures included demographics, presenting signs and symptoms, and medical, ocular, and drug history. RESULTS: A total of 140 cases of herpetic keratitis were identified, which comprised 125 cases of herpes simplex virus (89%) and 15 cases of varicella zoster virus (11%). Herpes simplex keratitis was associated with a history of keratitis (n = 58, phi = 0.24, P < 0.0001), Maori ethnicity (n = 27, phi = 0.26, P < 0.0001), respiratory disease (n = 18, phi = 0.14, P = 0.009), corticosteroid use (n = 23, phi = 0.22, P < 0.0001), and cardiovascular disease (CVD) (n = 10, phi = 0.11, P = 0.03). Inverse association was observed between herpes simplex keratitis and ocular surface disease (n = 8, phi = -0.16, P < 0.002) and Asian ethnicity (n = 4, phi = -0.11, P = 0.04). Varicella zoster keratitis was associated with CVD (n = 3, phi = 0.15, P = 0.03). CONCLUSIONS: Patients with asthma, CVD, on long-term corticosteroid inhalers or creams, or of Maori ethnicity need particular assessment to investigate herpes simplex as a possible cause of keratitis. Clinicians prescribing inhaled corticosteroids or topical corticosteroid creams should be aware of possible association with herpes simplex keratitis.

Topical antibiotics for the management of bacterial keratitis: an evidence-based review of high quality randomised controlled trials.

BACKGROUND: Severe bacterial keratitis (BK) typically requires intensive antimicrobial therapy. Empiric therapy is usually with a topical fluoroquinolone or fortified aminoglycoside-cephalosporin combination. Trials to date have not reached any consensus as to which antibiotic regimen most effectively treats BK. METHODS: A systematic review and meta-analysis using Cochrane methodology was undertaken to evaluate the effectiveness of topical antibiotics in the management of BK. Outcomes included treatment success, time to cure, serious complications of infection and adverse effects. RESULTS: A comprehensive search for trials resulted in 27 956 abstracts for review. This eventually resulted in 16 high quality trials involving 1823 participants included in the review. Treatment success, time to cure and serious complications of infection were comparable among all antibiotic treatments included in the review. Furthermore, there was no evidence of difference in the risk of corneal perforation with any included antibiotics or antibiotic classes. Fluoroquinolones significantly reduced risk of ocular discomfort and chemical conjunctivitis but increased the risk of white precipitate formation compared with aminoglycoside-cephalosporin. Fortified tobramycin-cefazolin was approximately three times more likely to cause ocular discomfort than other topical antibiotics. CONCLUSIONS: Results of this review suggest no evidence of difference in comparative effectiveness between fluoroquinolones and aminoglycoside-cephalosporin treatment options in the management of BK. There were differences in safety profile, however. Fluoroquinolones decreased the risk of ocular discomfort and chemical conjunctivitis while ciprofloxacin increased the risk of white corneal precipitate compared with aminoglycoside-cephalosporin.

Effectiveness of Topical Antifungal Drugs in the Management of Fungal Keratitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Fungal keratitis (FK) typically requires intensive therapy with topical antifungal agents. To date, evidence from clinical trials has been conflicting with respect to the most effective topical antifungal drug in the treatment of FK. Therefore, a systematic review and meta-analysis of randomized controlled trials (RCTS) using the Cochrane methodology was undertaken to evaluate the effectiveness of topical antifungals in management of FK. Outcomes included time to cure, treatment failure, complications of infection, visual acuity and adverse effects. A comprehensive search for studies was undertaken resulting in inclusion of 8 RCTs, predominantly from India, involving a total of 793 participants, the majority of whom were infected with filamentous fungi. Topical voriconazole was more likely to result in therapeutic keratoplasty compared with natamycin [relative risk (RR) 1.89 95% CI: 1.14, 3.12] with a number needed to treat of 13 (95% CI: 7, 50). Final visual acuity was significantly better with natamycin compared with voriconazole [weighted mean difference (WMD) 0.13, 95% CI 0.00, 0.27]. There was no difference in risk of treatment failure across all topical antifungal treatments studied (chlorhexidine gluconate, econazole, miconazole, natamycin, silver sulphadiazine and voriconazole). This study suggests treatment failure was comparable among antifungal treatments reviewed. However, natamycin resulted in better visual acuity following acute infection, compared with voriconazole. Voriconazole had a significantly greater risk of therapeutic keratoplasty compared with natamycin in the populations studied.

Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials.

BACKGROUND: There is lack of consensus from randomized controlled trials on the efficacy of antivirals in the management of herpes zoster. Therefore, a systematic review and meta-analysis was undertaken to provide better understanding of effectiveness of antivirals in management of herpes zoster. METHODS: A total of 12 randomized controlled trials with 7,277 patients were included in the review. Trials compared one antiviral to another (aciclovir, valaciclovir, famciclovir or brivudin) for a minimum of 7 days in immunocompetent patients presenting with herpes zoster diagnosed within 72 h of symptom onset. Primary outcome was reduction in pain. RESULTS: Compared with aciclovir, valaciclovir showed significant reduction in herpes-zoster-associated pain up to 112 days. The largest risk reduction in pain (36%) was seen at 21-30 days (relative risk [RR] 0.64, 95% CI 0.59, 0.70) with number needed to treat to benefit (NNT) of 3 (95% CI 2.7, 3.8). Famciclovir was also superior to aciclovir with a 46% reduction in risk of pain at 28-30 days (RR 0.54, 95% CI 0.48, 0.68) with NNT of 3 (95% CI 2, 5). Time to lesion healing and adverse effect profile was comparable. CONCLUSIONS: Evidence from quality trials have shown significant reduction in risk of pain with valaciclovir and famciclovir for management of herpes zoster including ophthalmicus. Valaciclovir or famciclovir should be preferred treatment options in patients with herpes zoster as they both provide significant reduction in risk of herpes-zoster-associated pain. Furthermore, the superior pharmacokinetics and more convenient dosing regimens with the use of valaciclovir and famciclovir clearly make them the preferred treatment option.