The role of topical moxifloxacin, a new antibacterial in Europe, in the treatment of bacterial conjunctivitis.

This article discusses current practice in the treatment of conjunctivitis and how the use of topical moxifloxacin can increase therapeutic effectiveness, reduce treatment failures and, consequently, be cost effective and reduce the societal burden of the disorder. Current practice and effectiveness data were derived from the literature. Data on healthcare utilization as a result of treatment failure were collected by survey and the cost of treatment was defined using national costings. A decision-analytic model to assess cost effectiveness was developed and the impact on the healthcare budget was calculated to define the health economic impact. Bacterial conjunctivitis represents a significant health problem and accounts for an estimated 1-1.5% of primary-care consultations. The disorder is highly contagious and causes a substantial healthcare and societal burden. Bacterial conjunctivitis is generally self-limiting, resolving within 1-2 weeks. However, the use of antibacterials significantly improves clinical and microbiological remission, shortens symptom duration, and enables more effective use of healthcare resources, compared with placebo. From a health economic perspective this benefits the healthcare system and society, since fewer healthcare resources are needed and the adult affected, or the parent/caregiver of the child affected, can return to full work capacity sooner, reducing loss of productivity. Treatment strategies vary significantly between countries. Most patients are first seen in primary care, where 'wait-and-see', lubrification and antiseptic or antibacterial treatment is provided. In Europe, when antibacterials are prescribed most general practitioners (GPs) prescribe a broad-spectrum topical antibacterial. The most commonly used drugs are chloramphenicol and fusidic acid, with fluoroquinolones rarely reported as first-line treatment by GPs. At the specialist (ophthalmologist) level, or for second-line treatment at the GP level, topical antibacterials are frequently used. However, in most countries, topical fluoroquinolones, particularly those recently approved by the European Medicines Agency, such as topical levofloxacin and topical moxifloxacin, are rarely used and instead are reserved for use as a last resort. In other parts of the world topical lomefloxacin, gatifloxacin and/or besifloxacin are also available. The strategy of using novel topical fluoroquinolones as a last resort reflects a belief that the use of topical fluoroquinolones may enhance the development of resistance, jeopardizing future availability of antibacterial treatment for ocular infections. In fact, most cases of bacterial resistance arise as a result of systemic treatment. Thus, this concern should not be extrapolated to topical use of fluoroquinolones, which results in antibacterial concentrations at the ocular surface that can significantly exceed mutant prevention concentrations. In addition, with products such as topical moxifloxacin, a dual-step mutation is required for resistance to emerge. Moxifloxacin restricts the selection of resistant mutants, meaning that emergence of resistance is unlikely. The strategy of not using the most effective fluoroquinolones such as topical moxifloxacin may lead to more patients with no improvement or worsening of symptoms, requiring re-intervention, additional examination and new treatment; these outcomes are defined as 'treatment failures'. Treatment failures cause an extra societal burden and increased costs due to the extra healthcare resources required (additional GP/specialist visits, laboratory tests, additional treatment, etc.). Compared with non-fluoroquinolones, topical moxifloxacin has a higher potency and faster in vitro 'speed-to-kill'. It has also been shown that, within the fluoroquinolone class, topical moxifloxacin and besifloxacin achieve the highest mean concentrations in conjunctival tissue, have the longest residence times and display favourable area under the concentration-time curve from time zero to 24 hours (AUC(24))/minimum inhibitory concentration ratio required to inhibit the growth of 90% of organisms (MIC(90)) and thus favourable pharmacokinetic/pharmacodynamic characteristics. This can result in reduced time-to-cure and a lower number of treatment failures, leading to better disease management and a healthcare-economic benefit arising from the associated reduction in utilization of healthcare resources. The high potency and mean concentration in conjunctival tissue combined with the long residence time of topical moxifloxacin enables a dosing strategy of three times daily for 5 days. Topical moxifloxacin is also the first ophthalmic antibacterial in Europe provided as a multidose, self-preserved, topical solution, thus avoiding the risk of benzalkonium chloride preservative-related allergic reactions and swelling. In addition, topical moxifloxacin has a near neutral pH (6.8) and is well tolerated by patients. Given the characteristics of the novel topical fluoroquinolones, a change in the healthcare treatment strategy for acute infectious conjunctivitis is to be recommended. Topical application of fluoroquinolones, such as moxifloxacin multidose self-preserved solution, should be considered earlier in the treatment path for conjunctivitis. Notwithstanding the premium price attached to this novel topical antibacterial, use of topical moxifloxacin for bacterial conjunctivitis can be cost effective and even generate total healthcare budget savings by reducing both the costs of managing treatment failures and the use of clinicians' time to manage such failures.

[Neonatal conjunctivitis in a nursery and a neonatal unit]. / Neonatal konjunktivitt i en barselavdeling og en neonatalenhet.

After Credé prophylaxis was abandoned at our hospital in 1984 scrupulous clinical surveillance of all neonates for conjunctivitis, and bacterial cultures from purulent eye discharge, have become routine. During the two-year period 1 March 1987 to 28 February 1989, testing for Chlamydia trachomatis (EIA-technique) was added in all infants with clinical conjunctivitis. During the period concerned there were 332 cases of conjunctivitis among 4,520 live born infants, an incidence of 7.3%. The incidence was higher for infants staying in the nursery (8.2%) than for those admitted to the neonatal unit (3.5%) (p less than 0.01). 90% of the infections were diagnosed during the first week of life. 468 isolates were identified by routine bacteriological investigation, 452 gram-positives (96.6%), and 16 gram-negatives (3.4%). The following strains were found: Staphylococcus aureus 171 (51.5% of the patients), Staphylococcus epidermidis 153 (46.1%), Streptococcus viridans 106 (31.9%), diphteroids 11 (3.3%), beta-hemolytic streptococci seven (2.1%), Streptococcus pneumoniae two (0.6%), enterococci two (0.6%), Hemophilus influenzae six (1.8%), Escherichia coli five (1.5%), Proteus two (0.6%) and Branhamella catarrhalis one (0.3%). Not a single case of gonococcal ophthalmia was diagnosed. Positive tests for Chlamydia were found in 13 infants (3.9% of all infants with conjunctivitis), an incidence of 0.3% for the whole population of live born infants. Six of the chlamydia infections (46%) occurred within the first week of life. Expenses for chlamydia testing were estimated to be NOK 1,020 per positive test. Preventing conjunctivitis in our nursery and neonatal unit calls for strategies to protect newborn infants from colonization with pathogenic bacteria, especially S. aureus.(ABSTRACT TRUNCATED AT 250 WORDS)