Penicillin most commonly prescribed antibiotic in optometry
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ORLANDO — Augmentin is a good go-to antibiotic choice for ocular infections, according to Nate Lighthizer, OD, FAAO, during his presentation on oral treatments for anterior segment disease here at Vision Expo East.
“It’s a good do-everything drug,” he said. Augmentin (amoxicillin/clavulanate, GlaxoSmithKline) works in men and women, it is pregnancy-safe and good for both gram-positive and gram-negative infections.
The most common dosage is 875 mg twice daily or 500 mg three times daily.
“You could use amoxicillin, but it’s been around for a long time, and there are some resistance issues,” Lighthizer said.
Two instances during which Augmentin should be avoided is in the case of a penicillin allergy or when treating MRSA, he said.
However, it can be used for hordeola, preseptal cellulitis and dacryocystitis. Penicillins are better for gram-negative infections, he noted.
Lighthizer said whenever he considers prescribing orals, he visualizes his choices: penicillin (Augmentin), cephalosporin (Keflex [cephalexin, Lilly]), macrolide (Z-Pak [azithromycin, Pfizer]), fluoroquinolone (Levaquin [levofloxacin, Ortho-McNeil-Janssen] and ciprofloxacin) and sulfa (Bactrim DS 800 mg-160 mg [trimethroprim-sulfamethoxazole, Hoffmann-La Roche]).
“I encourage you to prescribe oral antibiotics, but should you hand them out for everything?” Lighthizer asked attendees. “That can promote resistance. The big thing is that the Infectious Diseases Society of America suggests that 5 to 7 days is long enough to treat a bacterial infection. If you see no clinical improvement, reconsider your diagnosis or consider switching to another antibiotic.
“I don’t think 5 days is long enough; I go with 7 days,” he added.
Lighthizer also noted that children may need 10 to 14 days to respond.
Oral cephalosporins are also commonly used for anterior segment infections, Lighthizer continued. While first-generation cephalosporins are not a good choice for gram-negative organisms, “most eyelid bugs are gram-positive, so you’re usually OK,” he said.
He noted a 10% chance that patients allergic to penicillins are also allergic to first-generation cephalosporins and vice versa. However, current data say the incidence is lower.
Lighthizer said he reserves azithromycin for chalazia and hordeola.
“If warm compresses or doxycycline don’t work, I use this,” he said. “I’ve had a 70% success rate with a Z-Pak.”
Lighthizer said intense pulsed light is also a good off-label, nonsurgical treatment for chalazia.
“If you go to surgery, it’s incision and curettage with Kenalog injection [triamcinolone, Bristol Myers Squibb],” he added.
Fluoroquinolones are commonly used topically in eye care, but not much orally, Lighthizer said. “They are better for gram-negative organisms, but we don’t use them a lot orally,” he said. “They are pregnancy category C (which means weigh the risks vs. the reward), and they are contraindicated in those over 65 and younger than 18,” due to increased risk of tendonitis and tendon rupture.
Bactrim is the oral of choice for MRSA, Lighthizer said.
“Oral vancomycin is my favorite if you can get it; besifloxacin would be next best if you could get it orally,” he said. “Then you fall to Bactrim.”
In the case of a patient with an allergy to penicillin and/or sulfa, “I’d probably go to a reasonably priced second-generation cephalosporin or roll the dice with a Z-Pak,” Lighthizer said. “Or 100 mg twice a day of doxycycline as well.”
He added: “Polytrim [polymyxin B/trimethoprim, Allergan] is a very good antibiotic. The combination kills gram-positive and gram-negative organisms.”
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Lighthizer N. Oral pharmaceuticals for anterior segment disease. Presented at: Vision Expo East; Orlando, Florida; June 2-5, 2021.
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