Ophthalmologic Manifestations of Escherichia Coli Treatment & Management
- Author: Donny W Suh, MD, FAAP; Chief Editor: Hampton Roy, Sr, MD more...
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.  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.
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.
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.
Consultations with anterior segment surgeons and/or a retinal specialist may be warranted.
Diet is normal, but if surgery is indicated, convert to nothing by mouth (NPO).
Bed rest should be initiated. Admit to the hospital for monitoring if necessary under the following conditions:
Patient not able to administer medication
Risk of noncompliance
Patient not able to return daily
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