4.04 - Opthalmology Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Blepharitis


Chronic Blepharitis (Including Associated With Rosacea)


Doxycycline 100 mg q12H PO for 2 weeks, then 100 mg q24H



Duration: 2 - 6 weeks (long term for anti-inflammatory effects).

Meibomian Abscess (Internal Hordeolum)
Staphylococcus aureus


Cloxacillin 500 mg IV / PO q6H till resolution

Cefazolin 1 - 2 gm IV q8H
OR
Cefalexine 500 mg PO q6H

 


Stye (External Ordeolum)
Staphylococcus aureus

 


Systemic antibiotics not indicated


 

Cellulitis


Orbital (Post Orbital): 
Haemophilus influenza
Strep pneumonia
Strep anginosus / milleri
group
Staph aureus
Aerobic Gram negative
Anaerobe

Ceftriaxone 2 gm IV q24H
+ Metronidazole 500 mg IV q8H

Then,
Co-amoxiclav 625 mg PO q8H

Co-amoxiclav 1.2 gm IV q8H

Duration: Minimum 2 weeks.

IV for 3 to 14 days depending on clinical response, PO for further 10 days.

If high risk for MRSA, suggest to add Vancomycin 15 - 20 mg/kg IV q8 - 12H.

Surgical drainage is required if there is worsening of signs and symptoms.


Periorbital (Preseptal):
< 5 years:
Staph aureus
Strep pneumonia
Strep anginosus / milleri
group
Haemophilus influenza Type B in Unvaccinated
> 5 years:
Staphylococcal most likely


Cloxacillin PO 1 gm q6H

OR

Cephalexin PO 500 mg q6H 

 

 

 

 

 


Co-amoxiclav 625 mg PO q8H

Clindamycin 300 mg PO q6H (For patients with history of penicillin allergy)



For patients < 5 years who did not complete vaccination: Co-amoxiclav 625 mg PO q8H.


Dacryocystitis


Acute severe:

Staphylococcus aureus
Streptococcus pyogenes



Cloxacillin 1000 mg PO q6H



Cefalexin 500 mg PO q6H

OR

Cefazolin 2 gm IV q8H


Aspiration and drainage is recommended.

Duration: 7 - 10 days or till resolution.

Conjunctivitis


Mild 


Chloramphenicol
eye drop 
+ Chloramphenicol eye ointment

Tobramycin / Dexamethasone eye drop
OR Gentamycin 0.3% eye drop
+ Tobramycin / Dexamethasone eye ointment

 


Severe

Ciprofloxacin eye drop 0.3%
1 - 2 drops every 2 hours into the conjuctival sac for 2 days and 1 - 2 drops every 4 hours for next 5 days


Moxifloxacin eye drop 0.5%
1 drop 2 - 3 times daily for 7 days

 

Chlamydia Conjunctivitis (Acute and Trachoma)


Chlamydia trachomatis

Azithromycin 1 gm PO single dose   

Doxycycline 100 mg PO q12H for 21 days


Neisseria Gonococcal Conjunctivitis


Neisseria gonorrhoeae



Ceftriaxone 1 gm IV or IM single dose
±
Azithromycin 1 gm PO single dose 



Add Azithromycin if 
Chlamydia trachomatisto is suspected. 

Neisseria meningitides consider ‘chemoprophylaxis’ or treatment for meningococcal disease.

Opthalmianeonatorium: treat mothers and sexual partners.

Cornea


Keratitis: Dendritic Ulcer
Commonly: HSV (Dendritic Ulcer).
Others:
VZV 
Staph aureus 
Strep pyogenes 
Strep pneumonia
Enterobactericaea 
P. aeruginosa


Chloramphenicol eye ointment

Acyclovir eye ointment for Varicella opthalmicus




Fluorescein staining for presumptive diagnosis, NAT for rapid confirmation.

Consider long term Acyclovir for recurrent HSV keratitis.

Contact Lense:
P. aeruginosa
Fungi
Mycobacterium
Acanthamoeba


Tobramycin / Gentamicin eye drop


 

Retinitis


Acute Retinal Necrosis
CMV, VZV, HSV


Acyclovir 10 mg/kg IV q8H 5 - 7 days, then 800 mg PO 5 times/day

 


Duration: 6 weeks
(For CMV refer to HIV opportunistic infection management).

Progressive Outer Retinal Necrosis (PORN)

Acyclovir 10 mg/kg IV q8H 1 - 2 weeks, then 800 mg PO q8H

 

Endophthalmitis

 
Empirical (Haematogenous) 
Streptococci
Staphylococci
Gram negative bacilli

 
Adjunct Ceftriaxone 2 gm IV q24H 
+ Vancomycin 15 - 20 mg/kg IV q8 - 12H
   
Duration: 4 - 6 weeks. 

Intravitreal Vancomycin and Ceftazidime. 

Vitrectomy and lense removal in chronic post ocular surgery.

 
Post Ocular Surgery: Early 
Penetrating Trauma

 
Adjunct Vancomycin  
15 - 20 mg/kg IV q8 - 12H 
+ Ceftazidime 2 gm IV q8H

 

Opthalmic Zoster


Opthalmic Zoster

Acyclovir 800 mg PO
5 times/day


Acyclovir 10 mg/kg IV q8H


Duration: 7 days.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Keratitis


Older Child:
Staph aureus
Moraxella catarrhalis
Streptococcus pneumoniae
Pseudomonas aeruginosa
Klebsiella pneumonia
 

 
Topical eye drops:
Chloramphenicol
Fusidic Acid
Gentamicin
 
Topical eye drops:
0.3% Ciprofloxacin
Polymyxin B
 
Choice depends on causative organism and clinical suspicions.

Ps aeruginosa keratitis usually associated with contact lens use.
 
Herpes simplex Virus

 
Topical Acyclovir
5 times/day for 10 - 14 days; Continue ≥ 3 days post-healing
+
Aciclovir 100 mg PO (1 - 24 months old); 200 mg PO (2 - 18 years old) 5 times/day for 7 - 14 days

   
 
Varicella zoster Virus
 
Topical antimicrobials to prevent secondary bacterial infection
+
Aciclovir 100 mg PO (1 - 24 months old); 200 mg PO (2 - 18 years old)
5 times/day

   
Severe cases may benefit from steroid eye drops.

Fungal:
Candida spp (most common)
Fusarium spp
Aspergillus spp

 
Topical antifungals:
1% Fluconazole
1% Miconazole
 
0.15 - 1% Topical Amphotericin B
 
Use in conjunction with systemic anti-fungal.

Endophthalmitis

 
Post-Traumatic / Operative
Acute (within 48 - 72 hours):
CONS
Staph aureus
Streptococci
Pseudomonas spp
Bacillus spp
Candida (usually C. parapsilosis)
Aspergillus (rare)

Delayed:
CONS
Propionibacterium acnes
Candida
Aspergillus

Endogenous (Haematogenous):
Streptococci
Staphylococci

Candida
Bacillus spp
Enteric Gram negative bacilli

 
Intravitreal injection:
Ceftazidime OR
Vancomycin
 
Intravitreal injection:
Vancomycin
PLUS
Aminoglycoside (Gentamicin / Amikacin)
 
Intravitreal injection of gentamicin may cause retinal injury.

Ultimate choice of antimicrobial depends on smear taken at operation for microscopy, stain, C&S.











Systemic antibiotics, depending on organism suspected or isolated.

Early starting of anti-fungal has better prognosis.

Conjunctivitis

 
Bacterial:
Haemophilus influenzae
Moraxella catarrhalis
S pneumoniae
Staph aureus
Strep viridians
Pseudomonas
 

Chloramphenicol eye drops q4 - 6H during daytime; ointment at night x 7 days

Gentamicin eye drops
Fusidic ointment

 

Tetracycline eye drops during day and ointment once during night.
 

Ciprofloxacin or Norfloxacin seems to be most wide-spectrum for bacterial conjunctivitis.

Erythromycin / Gentamicin eye drops for Chlamydia trachomatis conjunctivitis in neonates. Systemic antibiotics may be needed when associated with otitis media.

Immunocompromised patients with AdV infection may need systemic Cidofovir.

Chlamydia trachomatis
 
Ciprofloxacin / Norfloxacin eye drops


Viral:
Adenoviruses
Varicella zoster virus
 
Local infection: no suitable topical antibiotic.
Topical Acyclovir for VZV.

Orbital Cellulitis

 
Bacterial:
Streptococci
Staph aureus
Haemophilus influenza b
Pseudomonas
Klebsiella
Enterococcus


 
Ceftriaxone 25 - 40 mg/kg IV q12H
+ Metronidazole 7.5 mg/kg IV q8H
 
Co-amoxiclav 25 mg/kg (Amoxicillin component) IV q8H
+ Clindamycin 10 mg/kg IV q6H
 
 
Fungal:
Mucor
 
Amphotericin B (conventional)
1 - 1.5 mg/kg IV q24H
 
Liposomal Amphotericin B
3 - 5 mg/kg IV q24H

Posaconazole 200 mg PO q6h (> 12 years old)

Caspofungin 70 mg/m2 (max 70 mg) IV q24H x 1 day; then 50 mg/m2 (max 50 mg) IV q24H

Voriconazole
Patient > 2 years old:
9 mg/kg IV q12H for 2 doses on Day 1; then maintenance 9 mg/kg IV q12H
(Maximum single dose:
350 mg)

 
Fungal orbital / facial cellulitis more often in immunocompromised.

Posaconazole is not available in UMMC

Caspofungin is fungistatic.
 
Aspergillus
 
Amphotericin B (conventional)
1 - 1.5 mg/kg IV q24H

Retinitis


Cytomegalovirus (CMV)

Initial Therapy:
Ganciclovir 5 mg/kg IV q12H for 14 - 21 days

Secondary Prophylaxis:
Ganciclovir 5 mg/kg IV q24H for 6 months
OR
Valganciclovir 16 mg/kg
q24H for 21 days


Initial Therapy:
Foscarnet* 60 mg/kg IV q8H for 14 - 21 days,
then 90 - 120 mg/kg daily for chronic suppressive therapy

Repeat induction regimen if CMV retinitis progresses while on therapy.

Ganciclovir implant as sustained release can last 4 - 6 months.

Use of Valacyclovir for prophylaxis not FDA approved.

* Foscarnet not available in UMMC formulary.

Herpes simplex
Chorioretinitis

Acyclovir 10 mg/kg IV q8H for 5 - 10 days;

Followed by
Acyclovir 100 mg (1 - 24 months old); 200 mg (2 - 18 years old) 5 times daily PO for 4 - 6 weeks

   

Toxoplasma gondii

Pyrimethamine PO:
2 mg/kg q24H for 2 days; then 1 mg/kg q24H for 6 months;
Followed by 1 
mg/kg/day 3 times per week for 6 months
+
Sulphadiazine 50 mg/kg PO q12H for 12 months

 
Total duration of therapy with Pyrimethamine + Sulphadiazine is 12 months.

Add Folinic Acid 10 
25 mg PO daily while on treatment, and continue for 1 week after discontinuation.