RANDOMIZED TRIAL OF 0.2-PERCENT CHLORHEXIDINE GLUCONATE AND 2.5-PERCENT NATAMYCIN FOR FUNGAL KERATITIS IN BANGLADESH

Aim-The management of suppurative keratitis due to filamentous fungi p resents severe problems in tropical countries. The aim was to demonstr ate the efficacy of chlorhexidine 0.2% drops as an inexpensive antimic robial agent, which could be widely distributed for fungal keratitis. Methods-Successive patients presenting to the Chittagong Eye Institute and Training Complex with corneal ulcers were admitted to the trial w hen fungal hyphae had been seen on microscopy. They were randomised to drop treatment with chlorhexidine gluconate 0.2% or the standard loca l treatment natamycin 2.5%. The diameters, depths, and other features of the ulcers were measured and photographed at regular intervals. The outcome measures were healing at 21 days and presence or absence of t oxicity. If there was not a favourable response at 5 days, 'treatment failure' was recorded and the treatment was changed to one or more of three options, which included econazole 1% in the latter part of the t rial. Results-71 patients were recruited to the trial, of which 35 wer e randomised to chlorhexidine and 36 to natamycin. One allocated to na tamycin grew bacteria and therefore was excluded from the analysis. No ne of the severe ulcers was fully healed at 21 days of treatment, but three of those allocated to chlorhexidine eventually healed in times u p to 60 days. Of the nonsevere ulcers, 66.7% were healed at 21 days wi th chlorhexidine and 36.0% with natamycin, a relative efficacy (RE) of 1.85 (CL 1.01-3.39, p = 0.04). If those ulcers were excluded where fu ngi were seen in the scraping but did not grow on culture, the estimat ed efficacy ratio does not change but becomes less precise because of smaller numbers. Equal numbers of Aspergillus (22) and Fusarium (22) w ere grown. The Aspergillus were the most resistant to either primary t reatment. Conclusions-Chlorhexidine may have potential as an inexpensi ve topical agent for fungal keratitis and warrants further assessment as a first line treatment in situations where microbiological faciliti es and a range of antifungal agents are not available.