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Endophthalmitis, Bacterial: Treatment & Medication
Updated: Feb 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Bacterial endophthalmitis is an ocular emergency, and urgent treatment is required to reduce the potential of significant visual loss.
- All patients should have therapy consisting of intravitreal and topical antibiotics, topical steroids, and cycloplegics.
- The Endophthalmitis Vitrectomy Study (EVS) identified that the use of periocular and intravenous antibiotics are not required in endophthalmitis following cataract surgery. Medical therapy was found to be statistically as effective as surgical intervention when the presenting vision was hand motion or better. Use caution in interpreting the data from the EVS; apply it cautiously to non–cataract-related endophthalmitis.
- When the inflammation is severe, systemic and periocular therapy may be used in non–cataract-induced, delayed onset, filtering bleb–associated, and posttraumatic endophthalmitis.
- In endogenous endophthalmitis, systemic, topical, and possibly periocular therapy is usually required.
Surgical Care
Surgical intervention is usually performed urgently except in the delayed onset category where elective surgery may suffice.
- Indications for surgical therapy
- Acute pseudophakic postoperative - When the presenting vision is light perception or worse
- Delayed onset or chronic postoperative - If marked inflammation or a subcapsular plaque is identified, surgical removal is required.
- Filtering bleb associated - If marked inflammation is present. Take care not to disturb the bleb if some function still exists. To allow the possibility of a shunt valve to be placed at a later time, make an attempt to minimize the disturbance to the superior conjunctiva. If the patient is aphakic, performing the pars plana vitrectomy from the temporal side using a limbal approach may be required.
- Posttraumatic - If marked inflammation or rapid onset occurs
- Technique
- A 3-port core pars plana vitrectomy with intravitreal antibiotic injections is performed. If visualization is poor from anterior segment pathology, then a 2-port limited pars plana vitrectomy or endoscopic guided 3-port pars plana vitrectomy may be performed.
- An increased risk for retinal tears and detachments occur when the vitreous close to the retina is removed aggressively due to the higher probability of retinal necrosis.
- Intravitreal antibiotics usually are given after the completion of the vitrectomy; however, if an air-fluid exchange is to be performed, the antibiotics may be mixed into the vitrectomy solution. Dilute the antibiotics in the vitrectomy solution carefully to prevent possible toxic retinopathy from incorrect dosages.
Consultations
- In most exogenous cases of endophthalmitis, the ophthalmologist may manage the case sufficiently; however, in cases of less common or extremely virulent bacteria, consulting an infectious disease specialist may aid in the selection of antibiotics.
- When endogenous cases of endophthalmitis are suspected, an internist should be consulted to look for a source.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications. Various routes for drug administration are available. Intravitreous is the most effective.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Vancomycin (Vancocin, Vancoled, Lyphocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment. DOC for gram-positive organisms.
Adult
Topical: 50 mg/mL q1h
Intravitreal: 1 mg/0.1 mL
Periocular: 25 mg
Systemic: 1 g IV q12h
Pediatric
Topical: Administer as in adults
Intravitreal: Administer as in adults
Systemic: 10 mg/kg/dose IV q6h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Corneal toxicity; in systemic administration ototoxicity, nephrotoxicity reversible neutropenia may occur; adjust dose in renal insufficiency; caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime)
First-line choice for intravitreal gram-negative coverage. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
Topical: 50 mg/mL q1h
Intravitreal: 2.25 mg/0.1 mL
Periocular: 100 mg
Systemic: 1 g IV q12h
Pediatric
Not established
Can cause false-positive results in glucose-urine testing with copper reduction test (Benedict or Fehling solution); false-negative results in ferricyanide test; positive Coombs test; nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Amikacin (Amikin)
Second-line choice for intravitreal injection for gram-negative coverage. For gram-negative bacterial coverage of infections resistant to gentamicin and tobramycin. Effective against Pseudomonas aeruginosa.
Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition. Use the patient's IBW for dosage calculation.
Adult
Topical: 13.6 mg/mL
Intravitreal: 0.4 mg/0.1 mL
Systemic: 75 mg/kg IV q12h
Pediatric
Administer as in adults
Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not intended for long-term therapy; caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission
Ciprofloxacin (Cipro, Ciloxan)
Fluoroquinolone with activity against pseudomonas, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and consequently growth. Provides gram-positive coverage. Uncertain benefit in noncataract causes.
Adult
Topical: 1 gtt qid to q1h
Systemic: 750 mg PO q12h
Pediatric
Not established
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisolone acetate (Pred Forte)
Treats acute inflammations following eye surgery or other types of insults to eye.
Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.
In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely. Dosage dependent on severity of inflammation.
Adult
1 gtt qid to q1h
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)
Dexamethasone (Ocu-Dex)
For various allergic and inflammatory diseases. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Optional; clinical data are controversial on benefit.
Adult
Intravitreal: 0.4 mg/0.1 mL
Pediatric
Not established
None reported
Documented hypersensitivity; active bacterial, viral, or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may increase hazard of secondary ocular infection; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)
Triamcinolone (Aristocort)
Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Periocular: 40 mg
Pediatric
Not established
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in decreased skin circulation; prolonged use, applications over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria
Cycloplegics
Reduces ciliary spasm that may cause pain. Cycloplegic agents are also mydriatics, and the practitioner should make sure that the patient does not have glaucoma. This medication could provoke an acute angle-closure attack.
Atropine (Isopto, Atropair, Atropisol)
DOC; acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and cycloplegia.
Adult
Topical: 1 gtt bid
Pediatric
Not established
Coadministration with other anticholinergics have additive effects; pharmacologic effects of atenolol and digoxin may increase with atropine; antipsychotic effects of phenothiazines may decrease with this medication; tricyclic antidepressants with anticholinergic activity may increase effects of atropine
Documented hypersensitivity, thyrotoxicosis, narrow-angle glaucoma, and tachycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with Down syndrome and/or children with brain damage to prevent hyperreactive response; caution also in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, hypertension, peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in prostatic hypertrophy, prostatism can have dysuria and may require catheterization
More on Endophthalmitis, Bacterial |
| Overview: Endophthalmitis, Bacterial |
| Differential Diagnoses & Workup: Endophthalmitis, Bacterial |
 Treatment & Medication: Endophthalmitis, Bacterial |
| Follow-up: Endophthalmitis, Bacterial |
| Multimedia: Endophthalmitis, Bacterial |
| References |
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Further Reading
Keywords
bacterial endophthalmitis, bacterial infection in the eye, bacteria in the eye, bacterial eye infection, eye infection, ocular infection
