Cochrane Database of Systematic Reviews Antibiotics for trachoma (Review) Evans JR, Solomon AW Evans JR, Solomon AW. Antibiotics for trachoma. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001860. DOI: 10.1002/14651858.CD001860.pub3. www.cochranelibrary.com Antibiotics for trachoma (Review) Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 3 BACKGROUND .................................... 5 OBJECTIVES ..................................... 5 METHODS ...................................... 6 RESULTS....................................... 8 Figure1. ..................................... 10 Figure2. ..................................... 11 ADDITIONALSUMMARYOFFINDINGS . 15 DISCUSSION ..................................... 21 AUTHORS’CONCLUSIONS . 22 ACKNOWLEDGEMENTS . 22 REFERENCES ..................................... 23 CHARACTERISTICSOFSTUDIES . 28 DATAANDANALYSES. 73 Analysis 1.1. Comparison 1 Any antibiotic versus control (individuals), Outcome 1 Active trachoma at three months. 75 Analysis 1.2. Comparison 1 Any antibiotic versus control (individuals), Outcome 2 Ocular C.trachomatis infection at three months..................................... 76 Analysis 1.3. Comparison 1 Any antibiotic versus control (individuals), Outcome 3 Active trachoma at 12 months. 77 Analysis 1.4. Comparison 1 Any antibiotic versus control (individuals), Outcome 4 Ocular C. trachomatis infection at 12 months..................................... 77 Analysis 2.1. Comparison 2 Subgroup analysis: oral and topical antibiotics versus control (individuals), Outcome 1 Active trachomaatthreemonths. 78 Analysis 2.2. Comparison 2 Subgroup analysis: oral and topical antibiotics versus control (individuals), Outcome 2 Ocular C. trachomatis infection at three months. ....... 79 Analysis 2.3. Comparison 2 Subgroup analysis: oral and topical antibiotics versus control (individuals), Outcome 3 Active trachomaat12months. 80 Analysis 2.4. Comparison 2 Subgroup analysis: oral and topical antibiotics versus control (individuals), Outcome 4 Ocular C. trachomatis infection at 12 months. ..... 81 Analysis 3.1. Comparison 3 Oral versus topical antibiotics (individuals), Outcome 1 Active trachoma at three months. 82 Analysis 3.2. Comparison 3 Oral versus topical antibiotics (individuals), Outcome 2 Ocular C. trachomatis infection at threemonths................................... 83 Analysis 3.3. Comparison 3 Oral versus topical antibiotics (individuals), Outcome 3 Active trachoma at 12 months. 83 Analysis 3.4. Comparison 3 Oral versus topical antibiotics (individuals), Outcome 4 Ocular C. trachomatis infection at 12 months..................................... 84 Analysis 4.1. Comparison 4 Oral azithromycin versus topical tetracycline (individuals), Outcome 1 Active trachoma at threemonths................................... 84 Analysis 4.2. Comparison 4 Oral azithromycin versus topical tetracycline (individuals), Outcome 2 Ocular C. trachomatis infectionatthreemonths. 85 Analysis 4.3. Comparison 4 Oral azithromycin versus topical tetracycline (individuals), Outcome 3 Active trachoma at 12 months..................................... 86 Analysis 4.4. Comparison 4 Oral azithromycin versus topical tetracycline (individuals), Outcome 4 Ocular C. trachomatis infectionat12months. 86 Analysis 5.1. Comparison 5 Oral azithromycin versus control (communities), Outcome 1 Active trachoma at 12 months. 87 Analysis 5.2. Comparison 5 Oral azithromycin versus control (communities), Outcome 2 Ocular C. trachomatis infection at12months................................... 87 Analysis 6.1. Comparison 6 Oral azithromycin versus topical tetracycline (communities), Outcome 1 Active trachoma at 3 months..................................... 88 Antibiotics for trachoma (Review) i Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Analysis 6.2. Comparison 6 Oral azithromycin versus topical tetracycline (communities), Outcome 2 Ocular C. trachomatis infectionat3months.. 88 Analysis 6.3. Comparison 6 Oral azithromycin versus topical tetracycline (communities), Outcome 3 Active trachoma at 12months.................................... 89 Analysis 6.4. Comparison 6 Oral azithromycin versus topical tetracycline (communities), Outcome 4 Ocular C. trachomatis infectionat12months. 89 ADDITIONALTABLES. 89 APPENDICES ..................................... 98 WHAT’SNEW..................................... 103 HISTORY....................................... 103 CONTRIBUTIONSOFAUTHORS . 103 DECLARATIONSOFINTEREST . 103 SOURCESOFSUPPORT . 104 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 104 NOTES........................................ 104 INDEXTERMS .................................... 104 Antibiotics for trachoma (Review) ii Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Antibiotics for trachoma Jennifer R Evans1, Anthony W Solomon1 1Cochrane Eyes and Vision Group, ICEH, London School of Hygiene & Tropical Medicine, London, UK Contact address: Jennifer R Evans, Cochrane Eyes and Vision Group, ICEH, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. [email protected]. Editorial group: Cochrane Eyes and Vision Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 3, 2011. Review content assessed as up-to-date: 11 December 2010. Citation: Evans JR, Solomon AW.Antibiotics for trachoma. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001860. DOI: 10.1002/14651858.CD001860.pub3. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Trachoma is the world’s leading infectious cause of blindness. In 1997 the World Health Organization (WHO) launched an Alliance for the Global Elimination of Trachoma by the year 2020, based on the ’SAFE’ strategy (surgery, antibiotics, facial cleanliness and environmental improvement). Objectives To assess the evidence supporting the antibiotic arm of the SAFE strategy by assessing the effects of antibiotics on both active trachoma (primary objective) and on Chlamydia trachomatis (C. trachomatis) infection of the conjunctiva (secondary objective). Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 11), MEDLINE (January 1950 to December 2010), EMBASE (January 1980 to December 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (December 2010) and ClinicalTrials.gov (www.clinicaltrials.gov) (December 2010). We used the Science Citation Index to look for articles that cited the included studies. We searched the reference lists of identified articles and we contacted authors and experts for details of further relevant studies. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 12 December 2010. Selection criteria We included randomised trials that satisfied either of two criteria: (a) trials in which topical or oral administration of an antibiotic was compared to placebo or no treatment in people or communities with trachoma, (b) trials in which a topical antibiotic was compared with an oral antibiotic in people or communities with trachoma. A subdivision of particular interest was trials in which topical tetracycline or chlortetracycline and oral azithromycin were compared with each other, or in which one of these treatments was compared with placebo or no treatment, as these are the two WHO recommended antibiotics. We considered individually randomised and cluster- randomised trials separately. Data collection and analysis Two authors independently assessed trial quality and extracted data. We contacted investigators for missing data. Where appropriate, the effect estimates from the individual studies (risk ratios) were pooled using a random-effects model. Antibiotics for trachoma (Review) 1 Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Main results A total of 14 trials randomised individuals with trachoma to oral antibiotic, topical antibiotic, both, or control (no treatment or placebo) and were eligible for inclusion in this review (n = 3587). Overall, the quality of the evidence provided from these trials was low. Nine of the trials compared antibiotic treatment to control. Most of the studies found a beneficial effect of treatment on active trachoma and ocular chlamydial infection at three and 12 months follow up. There was considerable clinical and statistical heterogeneity between trials, which meant that it was difficult to reliably estimate the size of the treatment effect. It is likely to be in the region of a 20% relative risk reduction. Seven of the 14 trials compared the effectiveness of oral and topical antibiotics. There was no consistent evidence as to whether oral or topical antibiotics were more effective, although one trial suggested that a single dose of oral azithromycin was significantly more effective than unsupervised use of topical tetracycline A further eight trials assessed the effectiveness of community-based treatment. In five trials antibiotic treatment was compared to no (or delayed) treatment (57 communities), and in three trials oral antibiotic was compared