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A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis.

Thaver D, Zaidi AK, Critchley J, Azmatullah A, Madni SA, Bhutta ZA - BMJ (2009)

Bottom Line: To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever).Odds ratios with 95% confidence intervals were estimated.Data were limited for other comparisons, particularly for children.

View Article: PubMed Central - PubMed

Affiliation: Department of Paediatrics and Child Health, The Aga Khan University, PO Box 3500, Karachi 74800, Pakistan.

ABSTRACT

Objectives: To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever).

Design: Meta-analysis of randomised controlled trials.

Data sources: Cochrane Infectious Diseases Group specialised register, CENTRAL (issue 4, 2007), Medline (1966-2007), Embase (1974-2007), LILACS (1982-2007), selected conferences, reference lists, and ongoing trial register (November 2007). Review methods Trials comparing fluoroquinolones with chloramphenicol, cephalosporins, or azithromycin in culture-proven enteric fever were included. Two reviewers extracted data and assessed methodological quality. Odds ratios with 95% confidence intervals were estimated. Trials recruiting over 60% children were analysed separately from trials on adults. Primary outcomes studied were clinical failure, microbiological failure, and relapse.

Results: Twenty trials were included. Trials were small and often of limited methodological quality. Only 10 trials concealed allocation and only three were blinded. In trials on adults, fluoroquinolones were not significantly different from chloramphenicol for clinical failure (594 participants) or microbiological failure (n=378), but reduced clinical relapse (odds ratio 0.14 (95% confidence interval 0.04 to 0.50), n=467, 6 trials). Azithromycin and fluoroquinolones were comparable (n=152, 2 trials). Compared with ceftriaxone, fluoroquinolones reduced clinical failure (0.08 (0.01 to 0.45), n=120, 3 trials) but not microbiological failure or relapse. Compared with cefixime, fluoroquinolones reduced clinical failure (0.05 (0.01 to 0.24), n=238, 2 trials) and relapse (0.18 (0.03 to 0.91), n=218, 2 trials). In trials on children infected with nalidixic acid resistant strains, older fluoroquinolones (ofloxacin) produced more clinical failures than azithromycin (2.67 (1.16 to 6.11), n=125, 1 trial), but there were no differences with newer fluoroquinolones (gatifloxacin, n=285, 1 trial). Fluoroquinolones and cefixime were not significantly different (n=82, 1 trial).

Conclusions: In adults, fluoroquinolones may be better than chloramphenicol for preventing clinical relapse. Data were limited for other comparisons, particularly for children.

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Related in: MedlinePlus

Fig 1 Studies evaluated at each stage of the meta-analysis. (*Supplementary search includes: reference lists, authors’ files, contacting experts, selected conference proceedings, on-going trial register. †See Cochrane review49 for further details or analyses. ‡Includes sample size <5, comparing different formulations/routes of same fluoroqinolone, not enough information presented in published report. §Trials contributing to more than 1 category counted only once.)
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fig1: Fig 1 Studies evaluated at each stage of the meta-analysis. (*Supplementary search includes: reference lists, authors’ files, contacting experts, selected conference proceedings, on-going trial register. †See Cochrane review49 for further details or analyses. ‡Includes sample size <5, comparing different formulations/routes of same fluoroqinolone, not enough information presented in published report. §Trials contributing to more than 1 category counted only once.)

Mentions: Seventy potentially relevant trials were evaluated (fig 1 shows the numbers of studies evaluated at each stage). Details of the excluded studies and the reasons for exclusion are available.49 We excluded trials using norfloxacin60 61 62 since this is not recommended for treating enteric fever because of its low oral bioavailability.10 We included 20 trials in the present analysis—fluoroquinolones were compared with chloramphenicol (10 trials),63 64 65 66 67 68 69 70 71 72 ceftriaxone (three trials),73 74 75 cefixime (three trials),39 76 77 and azithromycin (four trials).40 78 79 80


A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis.

Thaver D, Zaidi AK, Critchley J, Azmatullah A, Madni SA, Bhutta ZA - BMJ (2009)

Fig 1 Studies evaluated at each stage of the meta-analysis. (*Supplementary search includes: reference lists, authors’ files, contacting experts, selected conference proceedings, on-going trial register. †See Cochrane review49 for further details or analyses. ‡Includes sample size <5, comparing different formulations/routes of same fluoroqinolone, not enough information presented in published report. §Trials contributing to more than 1 category counted only once.)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2690620&req=5

fig1: Fig 1 Studies evaluated at each stage of the meta-analysis. (*Supplementary search includes: reference lists, authors’ files, contacting experts, selected conference proceedings, on-going trial register. †See Cochrane review49 for further details or analyses. ‡Includes sample size <5, comparing different formulations/routes of same fluoroqinolone, not enough information presented in published report. §Trials contributing to more than 1 category counted only once.)
Mentions: Seventy potentially relevant trials were evaluated (fig 1 shows the numbers of studies evaluated at each stage). Details of the excluded studies and the reasons for exclusion are available.49 We excluded trials using norfloxacin60 61 62 since this is not recommended for treating enteric fever because of its low oral bioavailability.10 We included 20 trials in the present analysis—fluoroquinolones were compared with chloramphenicol (10 trials),63 64 65 66 67 68 69 70 71 72 ceftriaxone (three trials),73 74 75 cefixime (three trials),39 76 77 and azithromycin (four trials).40 78 79 80

Bottom Line: To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever).Odds ratios with 95% confidence intervals were estimated.Data were limited for other comparisons, particularly for children.

View Article: PubMed Central - PubMed

Affiliation: Department of Paediatrics and Child Health, The Aga Khan University, PO Box 3500, Karachi 74800, Pakistan.

ABSTRACT

Objectives: To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever).

Design: Meta-analysis of randomised controlled trials.

Data sources: Cochrane Infectious Diseases Group specialised register, CENTRAL (issue 4, 2007), Medline (1966-2007), Embase (1974-2007), LILACS (1982-2007), selected conferences, reference lists, and ongoing trial register (November 2007). Review methods Trials comparing fluoroquinolones with chloramphenicol, cephalosporins, or azithromycin in culture-proven enteric fever were included. Two reviewers extracted data and assessed methodological quality. Odds ratios with 95% confidence intervals were estimated. Trials recruiting over 60% children were analysed separately from trials on adults. Primary outcomes studied were clinical failure, microbiological failure, and relapse.

Results: Twenty trials were included. Trials were small and often of limited methodological quality. Only 10 trials concealed allocation and only three were blinded. In trials on adults, fluoroquinolones were not significantly different from chloramphenicol for clinical failure (594 participants) or microbiological failure (n=378), but reduced clinical relapse (odds ratio 0.14 (95% confidence interval 0.04 to 0.50), n=467, 6 trials). Azithromycin and fluoroquinolones were comparable (n=152, 2 trials). Compared with ceftriaxone, fluoroquinolones reduced clinical failure (0.08 (0.01 to 0.45), n=120, 3 trials) but not microbiological failure or relapse. Compared with cefixime, fluoroquinolones reduced clinical failure (0.05 (0.01 to 0.24), n=238, 2 trials) and relapse (0.18 (0.03 to 0.91), n=218, 2 trials). In trials on children infected with nalidixic acid resistant strains, older fluoroquinolones (ofloxacin) produced more clinical failures than azithromycin (2.67 (1.16 to 6.11), n=125, 1 trial), but there were no differences with newer fluoroquinolones (gatifloxacin, n=285, 1 trial). Fluoroquinolones and cefixime were not significantly different (n=82, 1 trial).

Conclusions: In adults, fluoroquinolones may be better than chloramphenicol for preventing clinical relapse. Data were limited for other comparisons, particularly for children.

Show MeSH
Related in: MedlinePlus