Ophthalmologic Manifestations of Escherichia Coli Treatment & Management

  • Author: Donny W Suh, MD, FAAP; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Mar 9, 2012
 

Medical Care

Ocular treatment

Cycloplegic treatment is with scopolamine 0.25%.

Antibiotic treatment is as follows:

  • E coli conjunctivitis: Topical ciprofloxacin, ofloxacin, gatifloxacin, levofloxacin, moxifloxacin, or 0.3% tobramycin ophthalmic solutions are applied approximately 6-8 times daily until the infection appears to be resolved.
  • Smaller and peripheral corneal infiltrate: Intensive topical therapy infiltrate/ulcers; topical ciprofloxacin, ofloxacin, gatifloxacin, levofloxacin, moxifloxacin, or 0.3% tobramycin ophthalmic solutions are applied every hour while awake until the infection appears to be resolved. Reassess on a daily basis.
  • Large and central infiltrate: Fortified tobramycin, gentamicin (15 mg/mL), or fluoroquinolone (eg, ciprofloxacin, gatifloxacin, levofloxacin, moxifloxacin) 1 drop every 5 minutes for 5-7 doses, then repeat every other hour for 24 hours alternating with fortified cefazolin (50 mg/mL) or vancomycin (25 mg/mL) 1 drop every 5 minutes for 5-7 doses, then repeat every other hour for 24 hours; patient needs daily evaluation.[2] Consider subconjunctival antibiotics of gentamicin or tobramycin (20-40 mg).
  • Endophthalmitis: Intravitreal injection of gentamicin or tobramycin 100-300 µg can be used. Amikacin can also be used at 400 µg. Intravitreal injection consists of total 0.1 mL. Intravitreal steroids are controversial. For eyes with corneal thinning, place a corneal shield without a patch. Contact lenses should not be worn. Oral pain and nausea medication may be given. Oral fluoroquinolone (ciprofloxacin 500 mg PO bid) should be considered because it penetrates the posterior segment well. Topical steroids in combination with antibiotics may reduce the massive inflammatory response of the eye, which is often as destructive as the infection.

Systemic treatment

The choice of an appropriate antimicrobial agent in E coli infections depends on the site, type, and severity of infection. A number of antibiotics are effective against E coli, but no particular drug is uniformly active against all strains of E coli; therefore, sensitivity testing should guide the choice of antibiotics. Antimicrobial resistance occurs through plasmid-mediated determinants, several of which can be found in the same plasmid. These multiresistant plasmids can be transferred by conjugation.

For less severe E coli infections, the initial treatment of choice may be ampicillin (2-4 g/d intravenous [IV] or intramuscular [IM]). Other penicillins with β -lactamase inhibitor, cephalosporins, nitrofurantoin, and trimethoprim/sulfamethoxazole may also be considered.

For more severe infections, ampicillin/sulbactam could be given (3 g IV q6h). Imipenem/cilastatin, ciprofloxacin IV, or cefotaxime may also be considered.

Kanamycin is generally indicated for the initial treatment of serious E coli infections. Severe urinary tract infections that seem to be resistant to other antimicrobial agents have responded to daily doses of kanamycin (15 mg/kg IM in divided doses q6-8h).

Alternative treatment may be a total daily dose of parenteral gentamicin (3-5 mg/kg in divided doses q8h). In severe infections that appear to be resistant to kanamycin and gentamicin, amikacin is indicated. Amikacin is given daily (15 mg/kg in 2-3 equally divided doses).

In severe cases of sepsis, a combination of antibiotics is given, which includes ampicillin and an aminoglycoside; the choice of which is based on knowledge of local susceptibility patterns. Ampicillin/sulbactam or cefotaxime (a potent third-generation cephalosporin) is a suitable alternative, especially if an aminoglycoside-resistant nosocomial organism is suspected.

Neomycin appears to be most effective against E coli gastroenteritis. An oral daily dose of 25 mg/kg is usually indicated for 1-2 days.

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Surgical Care

Penetrating corneal transplant may be needed for corneal perforation.

Posterior vitrectomy may be needed to reduce the infective load and provide sufficient material for diagnostic culture and pathology.

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Consultations

Consultations with anterior segment surgeons and/or a retinal specialist may be warranted.

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Diet

Diet is normal, but if surgery is indicated, convert to nothing by mouth (NPO).

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Activity

Bed rest should be initiated. Admit to the hospital for monitoring if necessary under the following conditions:

  • Sight-threatening infection
  • Patient not able to administer medication
  • Risk of noncompliance
  • Patient not able to return daily
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Contributor Information and Disclosures
Author

Donny W Suh, MD, FAAP  Clinical Assistant Professor, Pediatric Ophthalmology Service, University of Nebraska Medical Center; Pediatric Ophthalmologist, Adult Strabismus Specialist, Wolfe Eye Clinic, PC; Consulting Staff, Blank Children's Hospital, Mercy Medical Center of Des Moines, Iowa Methodist Hospital of Des Moines, and Marshalltown Medical Center

Donny W Suh, MD, FAAP is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, and American Medical Association

Disclosure: Alcon Honoraria Speaking and teaching

Specialty Editor Board

Kilbourn Gordon III, MD, FACEP  Urgent Care Physician

Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J James Rowsey, MD  Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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