Fluoroquinolones or fortified antibiotics for treating bacterial keratitis: systematic review and meta-analysis of comparative studies

Objective: To review published clinical studies having compared fluoroquinolones with fortified antibiotics in the treatment of bacterial keratitis. Design: Systematic review of randomized and nonrandomized trials published between 1991 and 2011, and meta-analysis of efficacy results. Participants: Eight randomized and 5 nonrandomized studies comparing the efficacy and safety of fortified antibiotics or fluoroquinolones for treating bacterial keratitis. Methods: This study reviewed the efficacy and safety data. Meta-analysis of efficacy data considered all comparative studies, as well as the subsets of nonrandomized studies, of randomized studies, and of randomized studies limited to bacteriologically proven bacterial keratitis. Healing, defined as complete re-epithelialization within predefined time frame with the assigned treatment, was used as primary efficacy end point. Safety was assessed by the report of negative side effects and severe complications in the 2 treatment arms. Results: Fluoroquinolones prescribed as empiric initial treatment of bacterial keratitis are at least as effective as combined fortified antibiotics, with odds ratio based on random-effects model of 1.473 (0.902-2.405) for all studies, 2.374 (1.082-5.206) for nonrandomized studies, 1.050 (0.636-1.732) for randomized studies only, and 1.199 (0.477-3.011) for randomized studies restricted to patients in whom a bacterial infection was confirmed by microbiology. Reports of tolerance also appear in favor of fluoroquinolones. Conclusions: Based on these data, it seems reasonable to consider fluoroquinolone as the first choice for empirical treatment in most cases of suspected bacterial keratitis.