| EMPIRIC
ANTIINFECTIVE THERAPY IN OPHTHALMOLOGY |
| Initial
selection suggestions. Appropriate cultures with susceptibility
testing must be done to allow proper modification of therapy. |
| Condition |
Common
Organisms |
Selection |
Alternate |
| Blepharitis |
Staphylococcus
aureus Staphylococcus epidermidis |
Bacitracin ung
Sulfacetamide sodium 10% gtts
Azithromycin 1%
|
Topical erythromycin, fusidic acid, azithromycin, oral tetracyclines (avoid in children), macrolides in pediatric patients (erythromycin, azithromycin) |
| Cat
Scratch Disease |
Bartonella henselae |
Ciprofloxacin:(avoid in children) 250-750 mg PO bid; 200-400 mg IV q 12 hours
Rifampicin: Adult dose:10-20 mg/kg/day PO/IV; Pediatric dose: 10-20 mg/kg PO/IV qd; not to exceed 600 mg |
Oral trimethoprim/sulfamethoxazole: 6-8mg/kg/day for 7 days
Gentamicin sulfate : 5mg/kg/24hrs IV/IM
Azithromycin: for patients weighing >45.5kg 500mg on 1st day, 250mg daily from day 2-5; patients weighing <45.5kg 10mg/kg on 1st day followed by 5mg/kg from day 2-5
|
Cellulitis,
orbital
Children |
Staphylococcus aureus
Streptococcus pneumonia
Haemophilus influenzae anaerobic bacteria
Polymicrobial |
Ticarcillin-clavulanate: covers most Gram-positive and Gram-negative organisms and most anaerobes; 200mg/kg/day po in 4 divided doses.
Ceftriaxone100mg/kg/day iv in 2 divided doses plus vancomycin 40mg/kg/day iv in 2 -3 divided doses
Nafcillin or oxacillin plus cefuroxime
Ampicillin/sulbactam:
100-200 mg/kg/day in 4 divided doses (do not exceed 4g/day)
Fungal infection requires IV antifungal therapy along with surgical debridement |
Piperacillin tazobactam, or cefotaxime
Metronidazole for anarerobes |
Cellulitis,
orbital
Adults |
Streptococcus pyogenes Streptococcus pneumoniae Staphylococcus aureus, MRSA
Gram-negative bacteria anaerobic bacteria
Fungal: Aspergillus, Mucormycosis |
Ticarcillin-clavulanate: covers most Gram-positive and Gram-negative organisms and most anaerobes; 200mg/kg/day po in 4 divided doses.
Ampicillin/sulbactam: 1.5-3g iv q 6 hrs or cefuroxime: 1-2g iv q 12h plus vancomycin 1g iv q 12h; cefoxitin, cefotetan
Fungal: Surgical debridement, iv amphotericin B |
Vancomycin, cefotaxime, clindamycin, and trimethoprim/sulfamethoxazole double-strength for susceptible penicillinase and nonpenicillinase-producing strains of methicillin-resistant S.aureus
Metronidazole for anaerobes |
| Cellulitis,
preseptal |
Traumatic or spread from adjacent infection eg., sinuses:
Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae, Herpes simplex
Herpes zoster |
Mild: amoxicillin/clavulanate 500mg po q 8 hrs, oral Cefaclor 20-40 mg/kg/day in 3 divided doses (maximum 1g/day in children) Adults: 250-500 mg po q 8h)
Moderate to severe:
IV Ampicillin/sulbactam 100-200 mg/kg/day
Viral: oral acyclovir, valcyclovir, famcyclovir |
Trimethoprim/sulfamethoxazole (Bactrim)
Children: 8-12 mg/kg/day trimethoprim with 40-60 mg/kg/day sulfamethoxazole po in 2 divided doses
Adults:160-320 mg trimethoprim with 800 to 1600 mg sulfamethoxazole po bid
ampicillin/sulbactum: IV ampicillin/sulbactam 100-200 mg/kg/day
Moxifloxacin 400mg po or iv (avoid in children)
Ceftriaxone: 100mg/kg/day iv in 2 divided doses for children, Adults: 1-2 g iv q 12h
Vancomycin (MRSA)
Children: 40mg/kg i.v. 3-4 divided doses
Adults: 0.5-1 g iv q 12 hours |
Chronic Conjunctivitis, adult |
Chlamydia |
Oral doxycycline 200mg bid, azithromycin: 500mg po on 1st day, then 250 mg/day |
Moxifloxacin 400mg qd, erythromycin 250-500mg po qid
(use erythromycin in pregnancy;
for neonates: topical tetracycline ointment 4 times daily for 4 weeks and oral erythromycin for 4 weeks) |
Acute Conjunctivitis
(adult or child) |
Streptococcus pneumonia, Staphylococcus aureus, Haemophilus influenzae |
Topical fluoroquinolones or trimethoprim/polymixin B
Oral: amoxicillin/clavulanate if H.influenzae -oral 20-40 mg/kg/day in 3 divided doses |
|
Hyperacute Conjunctivitis |
Neisseria gonorrhoeae |
Ceftriaxone: 1 gram im or iv,
topical gentamicin or bacitracin (fluoroquinolone-resistance is widespread)
Treat for possible chlamydial co-infection |
Oral fluoroquinolones may not be effective
Oral azithromycin for possible chlamydia infection-1000mg on 1st day, 250mg daily from day 2-5;
Cefoxitin, cefotaxime, or spectinomycin
|
| Conjunctivitis, viral |
Adenovirus, (coxsackie and enterovirus if acute hemorrhagic conjunctivitis |
None |
NSAIDS, irrigate with povidone iodine 5% (under current investigation) |
| Conjunctivitis
(Neonatal) |
Chlamydia
Neisseria gonorrhoeae Staphylococcus aureus
Streptococcus pneumoniae Gram-negative bacteria |
Chlamydia: oral erythromycin elixir 50mg/kg/day for 2-3 weeks, and topical erythromycin, oral
ceftriaxone: 25-50 mg/kg iv or im ( do not exceed 125 mg) as a single dose
Gonorrhoeae: ceftriaxone im or iv
Gram-positive bacteria: bacitracin ung
Gram-negative bacteria: ciloxan ung |
Cefotaxime iv, or im- 100mg as a single dose |
Dacryoadenitis |
Staphylococcus aureus Streptococcus species Neisseria gonorrhoeae, viral (mumps, influenza, herpes zoster, infectious mononucleosis) |
Mild to Mod: amoxicillin/clavulanate, oral cephalexin
Mod to Severe: ticarcillin/clavulanate, cefazolin |
Erythromycin: 250-500mg po qid
Cephalexin; 500mg qid |
Dacryocystitis
(children) |
Haemophilus influenzae
|
Afebrile: amoxicillin/clavulanate oral 20-40 mg/kg/day in 3 divided doses
Febrile: cefuroxime iv 50-100 mg/kg/day in 3 divided doses |
Cefaclor 20-40 mg/kg/day in 3 divided doses, |
Dacryocystitis
(adult) |
Staphylococcus
Streptococcus
diphtheroids |
Afebrile: oral cephalexin 500mg q 6hours
Febrile: cefazolin iv 1 gram q 8h |
Oral amoxicillin/clavulanate: 500 mg q 8 hours |
Acute postoperative
Endophthalmitis |
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Gram-negatives |
Intravitreal injection:
amikacin 400 mcg & vancomycin 1.0 mg, moxifloxacin 50mcg |
ceftazidime 2.25 mg & vancomycin 1.0 mg or clindamycin 1.0 mg or cefazolin 2.25 mg, iv moxifloxacin 400mg iv or po |
Endophthalmitis
(traumatic) |
Staphylococcus epidermidis
Staphylococcus aureus Streptococcus species Bacillus species
Gram-negative bacteria Fungi |
intravitreal injection:
amikacin 400 mcg
vancomycin 1.0 mg
Fungal: voriconzole 50 mcg, amphotericin B, capsofungin |
ceftazidime 2.25 mg & vancomycin 1.0 mg or clindamycin 1.0 mg
or cefazolin 2.25 mg
plus systemic fluoroquinolone (moxifloxacin 400mg iv or po) |
Endophthalmitis
(post filter surg) |
Streptococcus species Haemophilus influenzae |
intravitreal:
amikacin 400 mcg
vancomycin 1.0 mg |
ceftazidime 2.25 mg & vancomycin 1.0 mg or clindamycin 2.25 mg
or cefazolin 2.25 mg, plus systemic fluoroquinolone |
Keratitis
Bacterial |
Staphylococcus aureus Pseudomonas aeruginosa Streptococcus species
Moraxella species
Serratia marcescens
Gram-negative bacteria
Atypical mycobacteria (post –LASIK) |
Mild to Mod: topical moxifloxacin 0.5%, gatifloxacin 0.3%, besifloxacin 0.6%
Severe: topical fluoroquinolone & cefazolin or vancomycin(MRSA), consider oral fluoroquinolone
Atypical Mycobacteria: amikacin, clarithromycin, |
4th generation fluoroquinolone & cefazolin 50mg/ml
fortified tobramycin 15 mg/ml & vancomycin 25-50 mg/ml(MRSA)
4th generation fluoroquinolone |
Keratitis
Fungal |
Yeast-Candida
Filamentous:Aspergillus, Fusarium |
Yeasts: amphotericin B 0.15%
Filamentous: natamycin 5% |
voriconazole 1%
fluconazole 0.2%
posaconazole (100mg/ml)
oral: fluconazole, voriconazole, or posaconazole
|
Keratitis
Viral |
Herpes simplex
Herpes zoster |
Topical: trifluridine (Viroptic), ganciclovir ophthalmic gel 0.15% (Zirgan)
Oral: acyclovir, valacyclovir, famciclovir |
Topical: acyclovir, vidarabine
Oral: famciclovir, ganciclovir |
Keratitis
Amebic |
Acanthamoeba |
PHMB 0.02% & 0.1% propamidine isethionate (Brolene) PHMB 0.02% & Hexamidine (Desmodine) 0.1% |
chlorhexidine 0.02% & 0.1% propamidine isethionate (Brolene),
Neomycin, Hexamidine 0.1%,
Itraconzole, plus oral Itraconazole or voriconazole |
Prophylaxis
Cataract |
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus
Gram-negatives |
povidone iodine 5%
topical 4th generation fluoroquinolone |
Cefazolin 50mg/ml subconjunctival injection
intracameral moxifloxacin(100 micrograms) |
Prophylaxis
Intraocular trauma |
Staphylococcus epidermidis
Staphylococcus aureus
Streptococcus species
Bacillus species
Fungus |
Topical 4th generation fluoroquinolone
IV aminoglycoside and cefazolin
Fungal: iv voriconazole, fluconazole, amphotericinB |
vancomycin or clindamycin and
amikacin or ceftazidime; oral or iv moxifloxacin; azithromycin (effective against B.cereus) |
