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Three Part Question

In [patients with a confirmed diagnosis of chlamydial conjunctivitis] is [single dose therapy with azithromycin better than a 10 day course of doxycycline/erythromcin] at [eliminating infection]

Clinical Scenario

A 24 year old man presents to the emergency eye centre with a uniocular red eye. He has a mucopurolent disharge and a follicular (inclusion) conjunctivitis. An initial diagnosis of adenovirus infection is made, but swabs taken show chlamydial infection.
He is referred to the GUM clinic but does not test positive for genital infection.
You decide to start him on a 10 day course of doxycycline, but are advised that you could treat him with a single dose of Azithromycin.

Search Strategy

Medline 1966 - August 2006.
[chlamydia.mp. or Chlamydia/] and [conjunctivitis.mp. or Conjunctivitis/] limit to (humans and english language and abstracts) limit to "therapy (sensitivity)"

Search Outcome

123 papers found of which one was relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Katusic D, et al 2003 Croatia	Seventy-eight adult patients with incluson conjunctivitis. Patients with chlamydial conjunctivitis as indicated by a positive direct fluorescent antibody (DFA) test or cell culture were randomized to receive a single 1-g dose of azithromycin or doxycycline, 100 mg twice daily for 10 day. Patients were follopwed up at 10-12 days and 4-6 weeks.	PRCT Open trial	dropout rate	51/78 patients completed the study	Many patients lost to follow up.
			Eradication of chlamydia	23/25 of the azithromycin patients and 25/26 of the doxycycline patients achieved eradication.
			Resolution of clinical symptoms	15 (60%) of the azithromycin and 18 (69%) of the patients had resolution of symptoms by the end of the study.

Comment(s)

Chlamydial conjunctivitis should be considered in any patient with follicular conjunctivitis and especially if unilateral. Treatment is usually started before the results of the swab are known and usually consist of lubricating or antibiotic drops. If the swabs are positive for chlamydia the patient should be referred to the GUM clinic as this is a sexually transmitted disease from genital secretions from hand or direct innoculation. There are several RCTs that suggest that single dose Azithromycin is effective in genital infection with chlamydia and it is therefore no great surprise that the authors have found a similar effect here. However, this was an open trial with a high drop out rate and faith in the treatment is probably guided more by the known effect in genital infection as opposed to this trial.

Clinical Bottom Line

Single dose azithromycin is probably as effective as a 10 day course of doxycycline in the treatment of chlamydial conjunctivitis.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Damir Katusic MDa, Igor Petricek MD, , a, c, Zdravko Mandic MDc, Ivanka Petric MDc,Jasminka Salopek-Rabatic MScd, Vladimira Kruzic MDe, Katarina Oreskovic MD, PhDf, Jakov Sikic MDa and Goranka Petrice Azithromycin vs doxycycline in the treatment of inclusion conjunctivitis Am J Ophthalmology 2003;135:447-451