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Day 2 of PCON Symposium features antibiotics, dry eye, pediatric conjunctivitis
NEW YORK – Day 2 of the Fourth Annual Primary Care Optometry News Symposium here featured presentations on fourth-generation fluoroquinolones, effective approaches to dry eye and conjunctivitis treatment for children.
Robert E. Prouty, OD, FAAO; Kirk Smick, OD, FAAO; and J. James Thimons, OD, FAAO, discussed contemporary wisdom in the area of antibiotic treatment. According to Dr. Prouty, resistance trends in topical antibiotics demonstrate the need to embrace the newest generation of antibiotics. He cited a 20% to 25% increase in resistance to fluoroquinolones within the last decade. “The resistance to Ciloxan (ciprofloxacin, Alcon) and Ocuflox (ofloxacin, Allergan) developed in no time at all,” he said. “Apparently, the bacteria forgot to read the textbooks. The fourth-generation fluoroquinolones have left the others in the dust.”
Dr. Prouty said the fourth-generation drugs differ structurally from their predecessors in their inclusion of the 8-methoxy group, which is not present in third-generation fluoroquinolones. “The 8-methoxy group enhances gram-positive coverage,” he said.
Gram-positive coverage is an especially important factor in antibiotic treatment, Dr. Thimons added. He referenced in-vivo reports of live organisms cultured from patients.
“Ninety-three percent were gram-positive,” he said. “The drugs we need must be a potent gram-positive force.”
Dr. Smick discussed the role of preservatives in topical ocular solutions, citing studies showing advantages and disadvantages of preservatives such as benzalkonium chloride (BAK). Zymar (gatifloxacin, Allergan) contains BAK, while Vigamox (moxifloxacin, Alcon) does not.
“You can find studies to support either side,” he said. “But I think the takeaway is that we should be using fourth-generation fluoroquinolones. You can’t make a mistake in choosing one or the other. The point is, use one of them.”
In a presentation titled, “A Systematic and Effective Approach To Treating Dry Eye,” Paul M. Karpecki, OD, FAAO, and J. James Thimons, OD, FAAO, emphasized the importance of the managing this disease. According to Dr. Karpecki, about 10,000 Americans will turn 50 between now and 2014. “This is essentially our practice for the next 20 years,” he said. “Dry eye was very frustrating back when we had fewer options, but now there are a lot of factors we can control and modify.”
Dr. Thimons discussed the role of diet in dry eye, emphasizing the ratio between omega- 3s and omega-6s. “In this country, we have a diet that is markedly imbalanced,” he said. “Sjogren’s patients have a lower dietary intake of omega-3s, including EPA, DHA and matched controls.”
Dr. Thimons said that the only country with a healthy ratio of omega-3s and omega-6s is Tahiti, which boasts a 1:1 ratio. “They don’t eat food that has already been processed,” he said. “Everything there is fresh and green. What they don’t eat at the end of the day is given to the dogs.”
Dr. Karpecki discussed his recommendations for staged treatment of dry eye. He said his first step would be Lotemax (loteprednol etabonate, Pharmos), with taper. In step two he adds Restasis (cyclosporine, Allergan).
Dr. Thimons discussed the appropriate recommendations of vitamin E, in light of revised suggestions by the American Heart Association. “Optometrists need to go back to the shop and re-evaluate their formulas,” he said.
Dr. Thimons also spoke on the topic of treating conjunctivitis in children. “I think one of the biggest problems in treating kids is fear of treating kids,” he said. “But this is certainly an area where we can expand our practices.”
He said one of the most difficult challenges in differentiation is making sure the infection is not an initial outbreak of the herpes simplex virus. “This is the most common infectious disease in childhood,” he said. “By age 15, 95% of children have had an episode.”
Getting a blood titer on the child’s mother for HSV is one way of differentiating, Dr. Thimons said.
He also discussed some of the fundamental differences in pediatric infections and adult infections. “In adults, 75% of cases are caused by gram-positive organisms,” he said. “In kids, about 60% are caused by gram-negative.”
He cited a study by A. Sheikh et.al that found that 164 million school days are missed for infectious diseases, and 3 million are related to conjunctivitis. He stressed the importance of expeditious treatment so children can return to school and not infect other children.
In addition, Dr. Thimons said that fomite infection is the number one cause of spread of infection. “Hand-washing education has been found to decrease sick days by 50% to 60%,” he said.