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Is there life after fluoroquinolones?
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As an eye care community, we are quite proud of our accomplishments, and for good reason. Through the years clinicians and industry have partnered to conceptualize, develop and provide technologies far beyond imagination. One need look no further than the advances in ophthalmic lenses, contact lenses, diagnostic equipment, pharmaceuticals or surgical instrumentation to witness this exponential growth. Or better yet, simply ask a patient. Most patients are equally impressed, enjoying treatment options far beyond what was available just a short time ago.
Fluoroquinolones effective
Progress, however, can be a double-edged sword. With success oft times comes complacency, which is dangerous at best. Consider the issue of topical ophthalmic antibiotics, for instance. It seems like just yesterday when the fluoroquinolone antibiotics arrived. We welcomed them with much fanfare – an innovative mechanism of action, an impressive spectrum of efficacy, less toxicity, commercial availability and cost effectiveness. Indeed, the fluoroquinolones ushered in a new generation of treatment for ocular bacterial infection. And yes, they have met – and exceeded – most clinicians’ expectations.
So what’s the problem? Pure and simple: resistance. With each year, an increasing number of bacterial strains exhibit fluoroquinolone resistance. Granted there are newer fluoroquinolones, such as trovafloxacin, on the horizon. But it may be years before we see a new category of topical ophthalmic antibiotics.
Prophylactic use can cause resistance
Exactly how has resistance become such an issue? In reality, it may have nothing to do with ophthalmic use at all, given that fluoroquinolones have been prescribed in general medicine for a considerably longer period of time. It is conceivable that bacterial resistance is the result of widespread fluoroquinolone use in other medical disciplines. How ever, our aggressive use of fluoroquinolones in perioperative surgical care may contribute to resistance as well.
In an effort to eliminate postoperative endophthalmitis and infectious keratitis, many clinicians are prescribing fluoroquinolones for days prior to and weeks after cataract and refractive surgery. It is equally possible that this practice – while effective prophylaxis – contributes to bacterial resistance.
Finally, it may simply be that bacterial resistance is due to indiscriminate fluoroquinolone use in treating “garden variety” conjunctivitis. True, “shotgun fluoroquinolone” treatment of conjunctivitis is appealing for many reasons. It’s easy to implement and extremely effective the majority of the time. However, giving bacteria a frequent glimpse of our “top gun” may only come back to haunt us in due time.
Discretionary use preserves value
Don’t get me wrong. I’m a huge proponent of the fluoroquinolones and equally inclined to reach for them at a moment’s notice. But as in all therapeutic endeavors, a healthy balance is critical for proper prescribing. First, use discretion when prescribing fluoroquinolones perioperatively. Indeed, the jury is still out on whether a fluoroquinolone 3 days prior to ophthalmic surgery is any greater prophylaxis than simply using it the day of the procedure. While the consensus is that fluoroquinolones are imperative postoperatively, be careful not to overprescribe. Using a fluoroquinolone four times daily for 1 week is prudent after most cataract and refractive procedures, but is there any additional benefit in using the drop until the bottle is empty?
Second, carefully consider the use of fluoroquinolones in nonsurgical cases. Undoubtedly, a primary care physician-referred patient whose infectious conjunctivitis has not responded to an aminoglycoside may quite possibly require a fluoroquinolone.
Likewise, a contact lens wearer with potential ulcerative keratitis mandates a fluoroquinolone. But what about mild bacterial conjunctivitis without corneal involvement? A fairly compelling case can be made for initiating first line treatment with an aminoglycoside or polymyxin-trimethoprim antibacterial.
In the final analysis, the fluoroquinolones are the best topical ophthalmic antibiotics available. Our job is to balance proper indications with potential overuse. For this reason, we must always prescribe fluoroquinolones judiciously, competently and with an eye toward the future.