Meta-analysis of six clinical phase III studies comparing lomefloxacin 0.3% eye drops twice daily to five standard antibiotics in patients with acute bacterial conjunctivitis

Red Eye: A Guide for Non-specialists

BACKGROUND

Red eye can arise as a manifestation of many different systemic and ophthalmological diseases. The physician whom the patient first consults for this problem is often not an ophthalmologist. A correct assessment of the urgency of the situation is vitally important for the planning of further diagnostic evaluation and treatment.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed in August 2016 as well as on the authors' own clinical and scientific experience.

RESULTS

Primary care physicians typically see 4-10 patients per week who complain of ocular symptoms. Most of them have red eye as the major clinical finding. A detailed history, baseline ophthalmological tests, and accompanying manifestations can narrow down the differential diagnosis. The duration and laterality of symptoms (uni- vs. bilateral) and the intensity of pain are the main criteria allowing the differentiation of non-critical changes that can be cared for by a general practitioner from diseases calling for elective referral to an ophthalmologist and eye emergencies requiring urgent ophthalmic surgery.

CONCLUSION

The differential diagnosis of red eye can be narrowed down rapidly with simple baseline tests and targeted questioning. Patients with ocular emergencies should be referred to an ophthalmologist at once, as should all patients whose diagnosis is in doubt.

Development of a UPLC-MS/MS method for the determination of lomefloxacin in rabbit aqueous humor and its application to a pharmacokinetic study

Lomefloxacin is a kind of synthetic fluoroquinolone antibiotic, which is used for the treatment of infectious diseases. In this study, a rapid and efficient liquid chromatography-tandem mass spectrometric assay was developed to determine the concentration of lomefloxacin in rabbit aqueous humor quantitatively. Aqueous humor samples were extracted by protein precipitation. Ofloxacin was chosen as internal standard. The chromatographic separation was achieved on a Kinetex C18 (50mm×2.10mm, 2.6μm, Phenomenex Corp, USA) column, with a gradient of methanol (0.1% formic acid) and water (0.1% formic acid). Multiple reaction monitoring (MRM) with positive ionization mode was used for the mass analysis. The validation of this method was based on the European Medicines Agency (2011) [1] and US FDA Guidelines (2001) [2]. The calibration range of aqueous humor samples was 5-1200ng/mL with r=0.9990 (n=6). For all QC samples, Inter-and intra-run precisions were less than 15% and accuracies were between 80%-120%. In conclusion, the assay was rapid, sensitive and able to determinate the lomefloxacin in rabbit aqueous humor accurately. At the same time, this method was successfully applied to study the pharmacokinetics of lomefloxacin hydrochloride eye drops and lomefloxacin hydrochloride ophthalmic gel in rabbit aqueous humor.

Therapeutic Effectiveness in the Treatment of Experimental Bacterial Keratitis with Ion-activated Mucoadhesive Hydrogel

PURPOSE

To investigate the therapeutic effectiveness of ion-activated mucoadhesive hydrogel system in the treatment of experimental bacterial keratitis.

MATERIALS AND METHODS

Mucoadhesive systems were prepared using gellan or sodium alginate alone and combined with sodium carboxymethylcellulose (NaCMC) to enhance the gel bioadhesion properties. The in vivo antimicrobial efficacy of selected mucoadhesive systems was studied in an experiment on bacterial keratitis in rabbit's eyes and compared with that of the marketed conventional eyedrops.

RESULTS

Ocular tolerance was studied in the eye of albino rabbits and tested formulations were non-irritant with no sign of inflammation. Better improvement in experimental bacterial keratitis in rabbit eyes was observed in animals treated with mucoadhesive hydrogel formulation (GG5 and GS5) compared with marketed drug solution.

CONCLUSION

The developed system is a viable alternative to conventional eyedrops of GTN due to its ability to enhance bioavailability through its longer precorneal residence time.

Bacteriological profile and drug susceptibility patterns in dacryocystitis patients attending Gondar University Teaching Hospital, Northwest Ethiopia

Background

Bacterial pathogens isolated from dacryocystitis patients are diverse and complex in terms of their distribution, prevalence, and antimicrobial susceptibility pattern. The clinical importance of microbial causes of dacryocystitis and pattern of drug resistance has not been reported in northwest Ethiopia. Moreover, the management of dacryocystitis is based on only clinical observation Therefore, this study attempted to identify and define clinical and microbiological characteristics of microbial agents of dacryocystitis and its antibiotic susceptibility patterns.

Methods

A cross sectional study was conducted from January 2011-January 2012 among dacryocystitis patients attending ophthalmology outpatient department of Gondar University teaching Hospital. Sociodemographic and clinical data collection, microbiological analysis and antibiotic susceptibility test patterns were done following standard procedures.

Results

From the total of 51 dacryocystitis cases, bacterial origins were isolated among 31(60.8%) cases. The dominant isolates were Coagulase negative Staphylococci (CNS) 9(29.0%), Staphylococcus aureus (S. aureus) 6(19.4%), and Pseudomonas species 3(9.7%). S. pneumoniae, Entrobacter species, K. pnemoniae and H. influenzae were each accounted 6.5% isolation rate. Among the commonly prescribed antimicrobials tested for susceptibility pattern; amoxicillin 38.7%, ciprofloxacin 25.8%, chloramphinicol 25.8%, co-trimoxazole 25.8%, and ampicillin 19.4% were resistant to the overall bacterial isolates identified. Only Citrobacter species were sensitive to all antibiotics tested but the rest bacterial isolates were resistant for at least to one, two, three, four and more antibiotics tested. Overall, 9(29.0%) of the bacterial isolates were resistant to only one antibiotics and resistance to two, three and four antibiotics each accounted 5(16.1%) rate.

Conclusions

Though the information derived from this study was very meaningful, further studies encompassing viral, fungal, parasitic and anaerobic bacterial origin are important to better define the spectrum and relative incidence of pathogens causing dacryocystitis. Microbiological analysis and antimicrobial susceptibility pattern is mandatory for the selection of a specific antimicrobial therapy and to the control of further resistance development of bacterial strains.

Efficacy and safety of lomefloxacin on bacterial extraocular disease in the horse

Lomefloxacin is a broad-spectrum fluoroquinolone antibiotic used for the treatment of bacterial extraocular disease. This study investigated the efficacy and safety of lomefloxacin eye drops for bacterial extraocular disease in horses. Lomefloxacin ophthalmic solution (0.3%) was instilled three times daily for 2–5 days in 65 horses diagnosed with bacterial extraocular disease based on clinical findings. Clinical observations and bacteriological examinations were performed at the start of treatment, 2 and 5 days after the start of treatment, and at the discontinuation or termination of treatment. Of the 65 horses, 64 were positive for bacteria, and 22 bacterial genera and 47 bacterial species were identified. The efficacy of lomefloxacin was evaluated in 63 horses; one horse with a negative culture and another with suspected bacterial contamination were excluded. Lomefloxacin was considered to be clinically effective in 54 horses. The major bacterial species identified were Staphylococcus aureus, Streptococcus equi subsp. zooepidemicus, Acinetobacter lwoffii, Staphylococcus xylosus, Staphylococcus vitulinus, Enterobacter agglomerans, Flavimonas oryzihabitans and Staphylococcus sciuri, with a cumulative disappearance rate of 80% or more at the termination of instillation. Excluding one horse that did not undergo a bacteriological examination, the remaining 62 horses were assessed for bacteriological outcome. Full or partial bacterial clearance was detected in 95% or more of the 62 horses. One of the 65 horses reported adverse events that had no causal relation with the eye drops. Our results showed that lomefloxacin is safe and effective for the treatment of bacterial extraocular disease in horses.

A review on composite liposomal technologies for specialized drug delivery

The combination of liposomes with polymeric scaffolds could revolutionize the current state of drug delivery technology. Although liposomes have been extensively studied as a promising drug delivery model for bioactive compounds, there still remain major drawbacks for widespread pharmaceutical application. Two approaches for overcoming the factors related to the suboptimal efficacy of liposomes in drug delivery have been suggested. The first entails modifying the liposome surface with functional moieties, while the second involves integration of pre-encapsulated drug-loaded liposomes within depot polymeric scaffolds. This attempts to provide ingenious solutions to the limitations of conventional liposomes such as short plasma half-lives, toxicity, stability, and poor control of drug release over prolonged periods. This review delineates the key advances in composite technologies that merge the concepts of depot polymeric scaffolds with liposome technology to overcome the limitations of conventional liposomes for pharmaceutical applications.

Optimization of gatifloxacin liposomal hydrogel for enhanced transcorneal permeation

The aim of this study was to prepare and characterize a topically effective prolonged-release ophthalmic gatifloxacin liposomal hydrogel formulation. Reverse-phase evaporation was used for the preparation of liposomes consisting of phosphatidylcholine (PC) and cholesterol (CH). The effect of PC:CH molar ratio on the percentage of drug encapsulated was investigated. The effect of additives, such as stearylamine (SA) or dicetyl phosphate (DP), as positive and negative charge inducers, respectively, was studied. Morphology, mean size, encapsulation efficiency, and in vitro release of gatifloxacin from liposomes were evaluated. For hydrogel preparation, carbopol 940 was applied. In vitro transcorneal permeation through excised albino rabbit cornea was also determined. Optimal encapsulation efficiency was found at the 5:3 PC:CH molar ratio; by increasing CH content above this limit, the encapsulation efficiency decreased. Positively charged liposomes showed superior entrapment efficiency over other liposomes. Hydrogel-containing liposomes with lipid content PC, CH, and SA in a molar ratio of 5:3:1, respectively, showed best release and transcorneal permeation. These results suggest that the encapsulation of gatifloxacin into liposomes prolonged the in vitro release, depending on composition of the vesicles. In addition, the polymer hydrogel used in the preparation ensured steady, prolonged transcorneal permeation. In conclusion, gatifloxacin liposomal hydrogel is a suitable delivery system for the improvement of the ocular bioavailability of gatifloxacin.

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

INTRODUCTION

Bacterial conjunctivitis is characterized by hyperemia and discharge of one or both eyes. These clinical signs appear quickly and are contagious. This study compares the clinical efficacy (signs and symptoms) and safety of azithromycin 1.5% eye drops with tobramycin 0.3%.

PATIENTS AND METHODS

This was a multicenter, randomized, investigator-masked study including 1,043 patients with purulent bacterial conjunctivitis. Patients received either azithromycin twice daily for 3 days or tobramycin, 1 drop every 2 hours for 2 days, then four times daily for 5 days. The primary variable was clinical cure at the test-of-cure (TOC) visit (D9) on the worst eye. The cure was defined as bulbar conjunctival injection and discharge scores of 0. Clinical signs were evaluated at D0, D3, and D9.

RESULTS

In the azithromycin group 87.8% of patients and in the tobramycin group 89.4% were clinically cured at D9. Clinical cure with azithromycin was not inferior to tobramycin at D9: discharge was absent in 96.3% of patients treated with azithromycin and 95.1% with tobramycin. Azithromycin was well tolerated.

CONCLUSIONS

Azithromycin 1.5% for 3 days (six drops) was as effective as tobramycin for 7 days (36 drops). Furthermore, patients on azithromycin presented earlier clinical cure on Day 3 than patients on tobramycin. Azyter, with its convenient dosing (bid for 3 days), is a step forward in the management of purulent bacterial conjunctivitis.

Efficacy and safety of azithromycin 1.5% eye drops for purulent bacterial conjunctivitis in pediatric patients

BACKGROUND

Purulent bacterial conjunctivitis affects all ages with high frequency in newborns and children. In a subset of 150 children included in a large study having enrolled 1043 patients, our aim was to analyze in children, the efficacy and safety of azithromycin 1.5% eye-drops in the treatment of this disease.

METHODS

This multicenter, randomized, investigator-masked, parallel-group study, included 150 children and adolescents to study safety and compare azithromycin 1.5% eye drops twice daily for 3 days and tobramycin 0.3% 1 drop every 2 hours for 2 days then 4 times daily for 5 days. Out of 150 patients included, 58 had positive cultures and were studied for efficacy. Signs and symptoms were evaluated and cultures obtained at baseline, Days 3 and 9. Primary efficacy variable was the clinical cure (score 0 for bulbar conjunctival injection and purulent discharge) at the test of cure visit (day 9).

RESULTS

Both treatments were effective with a clinical and microbiologic cure of more than 80% of children on day 9. Azithromycin therapy provided a greater bacteriologic cure on day 3 than did tobramycin (P < 0.001) and eradicated bacteria that were defined as resistant, using classical antibiogram. No adverse effects were noted on the ocular surface.

CONCLUSIONS

Azithromycin 1.5% eye drops leads to a rapid clinical and microbiological cure.

Ciprofloxacin as ocular liposomal hydrogel

The purpose of this study was to prepare and characterize an ocular effective prolonged-release liposomal hydrogel formulation containing ciprofloxacin. Reverse-phase evaporation was used for preparation of liposomes consisting of soybean phosphatidylcholine (PC) and cholesterol (CH). The effect of PC/CH molar ratio on the percentage drug encapsulation was investigated. The effect of additives such as stearylamine (SA) or dicetyl phosphate (DP) as positive and negative charge inducers, respectively, were studied. Morphology, mean size, encapsulation efficiency, and in vitro release of ciprofloxacin from liposomes were evaluated. For hydrogel preparation, Carbopol 940 was applied. In vitro transcorneal permeation through excised albino rabbit cornea was also determined. Optimal encapsulation efficiency of 73.04 +/- 3.06% was obtained from liposomes formulated with PC/CH at molar ratio of 5:3 and by increasing CH content above this limit, the encapsulation decreased. Positively charged liposomes showed superior entrapment efficiency (82.01 +/- 0.52) over the negatively charged and the neutral liposomes. Hydrogel containing liposomes with lipid content PC, CH, and SA in molar ratio 5:3:1, respectively, showed the best release and transcorneal permeation with the percentage permeation of 30.6%. These results suggest that the degree of encapsulation of ciprofloxacin into liposomes and prolonged in vitro release depend on composition of the vesicles. In addition, the polymer hydrogel used in preparation ensure steady and prolonged transcorneal permeation. In conclusion, ciprofloxacin liposomal hydrogel is a suitable delivery system for improving the ocular bioavailability of ciprofloxacin.

Microbiological efficacy of 3-day treatment with azithromycin 1.5% eye-drops for purulent bacterial conjunctivitis

PURPOSE

Antibacterial efficacy of topically applied azithromycin 1.5% was compared with tobramycin 0.3% in a multicenter, randomized, investigator-masked study for the treatment of purulent bacterial conjunctivitis.

METHODS

A total of 1043 adults and children received either azithromycin twice daily for 3 days (n=524) or tobramycin every 2 hours while awake for 2 days, then four times daily for 5 days (n=519). Conjunctival swabbing was taken at days 0, 3, and 9, using alginate swabs resuspended in a dissolution-transport medium, providing rapid and reproducible results. Cagle's criteria were used to define the pathogenicity level for each isolated bacterium.

RESULTS

In the per-protocol set, the rate of bacteriologic resolution was 85.2% for azithromycin versus 83.8% for tobramycin on day 3, and 92.8% for azithromycin versus 94.6% for tobramycin on day 9. Azithromycin was demonstrated to be noninferior to tobramycin according to the 10% noninferiority margin. Although some bacteria were categorized as resistant to tested antibiotics, eradication was observed (for azithromycin: Acinetobacter, Enterobacteriaceae, Pseudomonas), highlighting the specific pharmacokinetics/pharmacodynamics of the ocular route.

CONCLUSIONS

In total, topical therapy with azithromycin 1.5% administered only twice daily for 3 days effectively eradicates most pathogenic bacteria associated with bacterial conjunctivitis. These microbiologic results are in accordance with the observed clinical outcome. This new anti-infective product has the advantage of a short treatment course which could lead to an improvement in patient compliance.

Postoperative lomefloxacin 0.3% prophylaxis in strabismus surgery

PURPOSE

To evaluate the efficacy of topical lomefloxacin 0.3% versus chloramphenicol 0.2% with polymyxin B 2500 U/ml in the treatment of patients after strabismus surgery.

METHODS

Seventy-nine consecutive patients who underwent strabismus surgery from April through October 2006 were randomized to receive topical lomefloxacin 0.3% (n = 45, 58 eyes) or chloramphenicol 0.2% with polymyxin B 2500 U/ml (n = 34, 40 eyes) postoperatively, in addition to topical dexamethasone 0.1% and diclophenac 0.1%. The groups were compared for clinical signs of local cellulitis and findings on conjunctival cultures.

RESULTS

From postoperative day 1 to day 28, rates of chemosis decreased from 96% to 9.5% in the lomefloxacin group and from 94% to zero in the chloramphenicol group; rates of hyperemia decreased from 100% to zero in both groups. Accordingly, rates of a cumulative clinical sign score (CCSS) decreased from 60% to zero in the lomefloxacin group and 50% to zero in the chloramphenicol group. Rates of positive bacterial cultures dropped from 59.6% preoperatively to 48.3% on day 14 in the lomefloxacin group and from 63% to 47% in the chloramphenicol group.

CONCLUSIONS

Topical lomefloxacin is a potent alternative to topical chloramphenicol eye drops after strabismus surgery for the control of pain, infection and discharge, chemosis, hyperemia, and conjunctival hemorrhage.

3-day treatment with azithromycin 1.5% eye drops versus 7-day treatment with tobramycin 0.3% for purulent bacterial conjunctivitis: multicentre, randomised and controlled trial in adults and children

AIM

To compare the efficacy and safety of Azyter, azithromycin 1.5% eye drops, for 3 days with tobramycin 0.3% for 7 days to treat purulent bacterial conjunctivitis.

METHODS

This was a multicentre, randomised, investigator-masked study including 1043 children and adults with purulent bacterial conjunctivitis. Patients received either azithromycin 1.5% twice-daily for 3 days or tobramycin 0.3%, 1 drop every two hours for 2 days, then four times daily for 5 days. Clinical signs were evaluated and cultures obtained at D0, D3 and D9 (where D refers to "day"). Primary variable was the clinical cure at the Test-of-Cure (TOC)-visit (D9+/-1), for patients with D0-positive cultures. The cure was defined as: bulbar conjunctival injection and discharge scores of 0.

RESULTS

Among 471 patients with D0-positivity in the per protocol set, 87.8% of the azithromycin 1.5% group and 89.4% of the tobramycin group were clinically cured at the TOC-visit. Azithromycin was non-inferior to tobramycin for clinical and bacteriological cure. Clinical cure was significantly higher with azithromycin 1.5% at D3. The safety profile of azithromycin was satisfactory with a good patient and investigator's acceptability.

CONCLUSIONS

Azithromycin 1.5% for 3 days was as effective and as safe as tobramycin for 7 days. Furthermore, more azithromycin than tobramycin patients presented an early clinical cure at Day 3. Due to its twice daily dosing regimen for 3 days, azithromycin represents a step forward in the management of purulent bacterial conjunctivitis, especially in children.

Effect of formulation factors on in vitro transcorneal permeation of gatifloxacin from aqueous drops

The purpose of this research was to optimize the formulation factors for maximum in vitro permeation of gatifloxacin from aqueous drops through excised goat cornea and to evaluate the permeation characteristics of drug from selected marketed eyedrop formulations. Permeation studies were conducted by putting 1 mL of formulation on the cornea (0.67 cm(2)) fixed between the donor and receptor compartments of an all-glass modified Franz diffusion cell and measuring gatifloxacin concentration in the receptor (containing normal saline under stirring) by spectrophotometry at 291.5 nm, after 120 minutes. Raising the drug concentration of the drops increased the drug permeation but decreased the percent permeation and the in vitro ocular availability. Raising the pH of the formulation from pH 5 to 7.2 increased both the drug permeation and the in vitro ocular availability. Eyedrops containing benzalkonium chloride (BAK; 0.01% wt/vol) and disodium edetate (EDTA; 0.01% wt/vol) showed maximum permeation, followed by Zymar, BAK (0.01% wt/vol), Gatilox, Gatiquin, and Gate (statistically significant P < .05 compared with control). In vitro titration of the formulations with 0.1N NaOH indicated the presence of a buffer in Zymar (pH 6) and Gate (pH 5.8), which may cause irritation and induce lacrimation, resulting in reduced ocular availability in vivo. Thus, formulation with BAK and EDTA, which is unbuffered, has a better likelihood of being absorbed in vivo. The BAK-EDTA formulation significantly (P < .05) increased the permeation of gatifloxacin through paired excised corneas of goat, sheep, and buffalo, compared with the control formulation. The goat cornea showed the greatest increase in permeation, followed by the sheep and buffalo corneas.

Fusidic acid viscous eyedrops - an evaluation of pharmacodynamics, pharmacokinetics and clinical use for UK optometrists

Recent changes in UK law have allowed UK-based optometrists to sell and supply fusidic acid viscous eyedrops, providing it is in the course of their professional activity and in an emergency. Alternatively, the optometrist may access fusidic acid viscous eyedrops, for a named patient, using a written order supplied to a pharmacy. This review provides details of the legal background to these changes, examines the common causes of a bacterial conjunctivitis, examines the mechanism of action of this narrow spectrum antibiotic as a bacteriostatic agent, reviews the susceptibility of common ocular isolates of bacteria to the drug and presents details of the expected pharmacokinetics of the viscous eyedrops. From this perspective, a systematic review is provided of the clinical studies which have investigated the use of fusidic acid viscous eyedrops and their outcome. The indicated use is generally for the treatment of bacterial conjunctivitis and/or blepharoconjunctivitis, especially that caused by Staphylococcus, but not Streptococcus or Haemophilus sp. (more likely associated with concurrent nasopharyngeal infections). The usual regimen for use is twice daily for 5-10 days, depending on severity, and can initially be used more intensively (four times per day). It may also be used for the management of corneal and conjunctival abrasions and foreign body injuries, or some cases of chronic blepharitis.

The evolution of antibiotic therapy for bacterial conjunctivitis and keratitis: 1970-2000

The editors of this Festschrift asked us to review the use of antibiotics for the treatment of bacterial conjunctivitis and keratitis over the past 25 years, a period coinciding with the life of the Castroviejo Corneal Society. We believe it is more appropriate to begin our review in the late 1960s. about the time that experimental and clinical studies and algorithms for the clinical care derived from these studies helped shape a more rigorous approach to therapy. Those years saw the introduction of antibiotics that were adapted for ophthalmic use, many of which are still being used today. We will give more weight to our review of keratitis than conjunctivitis.