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Sight-threatening infections need fortified antibiotics
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Most bacterial infections and some corneal ulcers seen in general practice can be resolved with the use of a newer-generation fluoroquinolone. But what happens if a clinician encounters an organism that appears to be resistant or sight-threatening?
Fortified antibiotics should be the first step in treating some forms of sight-threatening infectious keratitis, as well as moderate to severe corneal ulcers, according to corneal expert Paul C. Ajamian, OD, FAAO, center director of Omni Eye Services of Atlanta.
“Any infectious ulcer that looks like a serious sight-threatening ulcer, not an infiltrate, should probably be hit with fortified antibiotics right off the bat,” Dr. Ajamian told Primary Care Optometry News in an interview. “If you look at a nasty corneal ulcer and it’s central and it’s eating through the layers of the cornea, you just know that a fourth-generation fluoroquinolone is not going to handle it.”
Bacterial keratitis, on the other hand, usually responds to the newer generation fluoroquinolones such as Alcon’s Vigamox (0.5% moxifloxacin ophthalmic solution) and Allergan’s Zymar (0.3% gatifloxacin ophthalmic solution), which are both approved by the Food and Drug Administration to treat bacterial conjunctivitis.
As a standard practice, clinicians usually treat bacterial keratitis with the anti-infectives and should wait 24 to 48 hours before deeming the infection non-responsive to treatment, according to J. James Thimons, OD, a PCON Editorial Board member who practices in Fairfield, Conn.
“By 36 hours the tissue should start to respond,” Dr. Thimons said. “You should see a decrease in lymph node response. If the eye gets worse, then you have to alter your therapy.”
History, culturing
John A. McCall Jr., OD, a private practitioner from Crockett, Texas, and a PCON Editorial Board member, says getting a patient’s history and symptoms is key in determining which course of treatment to use.
“Find out how long the patient has been in pain or discomfort,” he said during an interview with PCON. “If it’s less than 72 hours and you have a severe corneal ulcer, you need to go directly to fortified antibiotics. If the symptoms and clinical appearance are milder and have been going on for more than 4 to 5 days, you’re dealing with a fairly mild infection, and a fourth-generation fluoroquinolone will generally knock it out.”
Image: McCall JA |
Eric D. Donnenfeld, MD, a cornea specialist in private practice in Long Island, N.Y., and Fairfield, Conn., agreed. “Certain histories or presentations warn the clinician that this patient may need more than the conventional fourth-generation fluoroquinolones,” Dr. Donnenfeld told PCON. “Most importantly, any history of refractive surgery such as LASIK or PRK in which the patient has previously received fourth-generation fluoroquinolones suggests that the organism responsible for the infection is not going to respond and is probably going to be resistant.
“In refractive surgery, these infections are most commonly methicillin-resistant Staphylococcus aureus (MRSA),” he continued, “and will require an antibiotic that is effective against MRSA such as fortified vancomycin.”
Dr. Donnenfeld said taking an extensive patient history and culturing are key in this type of infection, especially because it is difficult to tell right away if it is resistant.
“If an ulceration does not respond, then it is appropriate to go to fortified antibiotics after a culture has been performed,” Dr. Donnenfeld said. “The first step in deciding which fortified medication to use is to establish what organism you are trying to treat. Cultures are the best way of doing it, but sometimes corneal scraping will give us information. When I think that a patient needs more than just conventional antibiotics, I routinely scrape and culture. It’s nice to do both.
Culturing helps the clinician determine which organism to treat, the doctors agreed.
“Culturing really is the standard of care,” Bruce E. Onofrey, OD, RPh, FAAO, FOGS, director of primary eye care services at Lovelace Medical Center in Albuquerque, N.M., and a PCON Editorial Board member, said in an interview. “I would never treat a sight threatening ulcer without culturing it first. I’m encouraging more optometrists to culture or have a relationship with someone that has the ability to culture. You’re really delaying treatment otherwise.”
Culturing should always be done before treatment, Dr. McCall stressed. “Even if you treat it for a day, you may have killed your chance to get a culture,” he said.
Dr. McCall noted that when treating a corneal ulcer, “it will feel better before it clinically looks better.”
What about steroids?
Dr. Donnenfeld said he will move on to a steroid when he believes the infection has been well treated and the residual inflammation is causing the clinical appearance.
“In general, patients who have responded to the antimicrobial will have a marked decrease in pain and photosensitivity and will have no further progression of their corneal ulceration but may still have an infiltrate that requires anti-inflammatory therapy to resolve,” he said. “Any patient with worsening of the clinical appearance and significant pain should be considered infectious and not be started on steroids, because steroids can make these infections worse.”
Obtaining fortified antibiotics
How do these doctors go about getting fortified antibiotics for their patients? Dr. Onofrey is a pharmacist, so he mixes them himself. Many clinicians send their prescriptions to Leiter’s in San Jose, Calif., which has overnight service. Dr. Donnenfeld and Dr. McCall also mix their own.
“[My practice obtains] fortified antibiotics and we keep them in the freezer where they last for approximately a year. They are readily available by thawing,” Dr. Donnenfeld said.
Dr. Ajamian stressed doing your homework ahead of time. “It’s really important to know where the compounding pharmacies in your community are,” he said. “There are only two in Atlanta, and we know them both and we know one has an emergency on-call service They can do that by asking their local pharmacist, ‘What if I need to fortify something? How do I do itw?’ Leiter’s is fine for non-emergent drugs, but most of the ulcers we see need to be treated immediately.”
For Your Information:
- Paul C. Ajamian, OD, FAAO, can be reached at Omni Eye Services of Atlanta, 5505 Peachtree Dunwoody Road, Atlanta, GA 30342; (404) 257-0814; e-mail ajamian@aol.com. Dr. Ajamian is a paid consulant for Alcon and Allergan.
- J. James Thimons, OD, is a Primary Care Optometry News Editorial Board member. He can be reached at Ophthalmic Consultants of Connecticut, 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 257-7336; fax: (203) 330-4958; e-mail: jthimon@sbcglobal.net. PCON could not determine if Dr. Thimons has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- John A. McCall Jr., OD, is a Primary Care Optometry News Editorial Board member, a private practitioner and senior vice president of vendor relations for Vision Source. He can be reached at 711 East Goliad Ave., Crockett, TX 75835; (936) 544-3763; fax: (936) 544-7894; e-mail: jmccall@visionsource.com. Dr. McCall has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any of the companies mentioned.
- Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and Connecticut and co-chairman of Cornea and External Disease at Nassau University Medical Center. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; (516) 766-2519; fax: (516) 766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a paid consultant for Allergan and Alcon.
- Bruce E. Onofrey, OD, RPh, FAAO, FOGS, is director of primary eye care services, Lovelace Medical Center, Albuquerque, N.M., and a member of the Primary Care Optometry News Editorial Board. He can be reached at Lovelace at Journal Center, 5150 Journal Center Blvd., NE, Albuquerque, NM 87109; (505) 275-4226; e-mail Eyedoc3@aol.com. Dr. Onofrey has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any of the companies mentioned.