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Treatment of Ocular Infections in Hospitalized Adults

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Treatment of Ocular Infections in Hospitalized Adults TREATMENT OF OCULAR INFECTIONS IN HOSPITALIZED ADULTS Clinical Setting Empiric Therapy Duration Comments Periorbital Cellulitis Severe infection • Appropriately tailor therapy based on culture results, if warranting hospital obtained. 1st line: admission, or failing Vancomycin (see nomogram, AUC goal 400-600)* outpatient oral • For culture negative or not obtained, transition to oral + Ampicillin-sulbactam 3 g IV q6h* antibiotics therapy when patient is afebrile with clinical improvement and hemodynamically stable for 48 hours: Transition to oral antibiotics • 1st line: Staphylococcus PCN allergy without anaphylaxis, angioedema, or urticaria: can be considered if Amoxicillin-clavulanate 875 mg BID* aureus Vancomycin IV (see nomogram, AUC goal 400-600)* significant improvement + TMP-SMX 2 DS tabs PO BID* + Ceftriaxone 2 g IV q24h within 24-48 hours. • PCN allergic, without anaphylaxis, angioedema, or Streptococcus urticaria: pneumonia Severe PCN or cephalosporin allergy (anaphylaxis, angioedema, Antibiotic duration for severe Cefpodoxime 400 mg PO BID* hives): periorbital cellulitis is + TMP-SMX 2 DS tabs PO BID* Streptococcus Vancomycin IV (see nomogram, AUC goal 400-600)* typically about 10 days, but • Severe PCN allergic patients who do not tolerate milleri group + Aztreonam 2 g IV q8h* should be guided by clinical cephalosporins: resolution. Recommend the addition of anaerobic coverage with Clindamycin 450 mg PO TID Streptococcus metronidazole 500 mg PO q8h if dental infection presumed to + TMP-SMX 2 DS tabs PO BID* pyogenes be initial source in the setting of PCN allergy and regimen without ampicillin-sulbactam. Haemophilus For sulfa allergy, doxycycline 200 mg PO x1, then 100 mg influenzae PO BID can be substituted for TMP-SMX Oral anaerobes Clinical Setting Empiric Therapy Duration Comments Uncomplicated Orbital cellulitis (without abscess or bony destruction): If rapid and dramatic improvement (Afebrile, normal WBC, normal vitals, Ophthalmology and ID consult is strongly recommended. exam improved with significant decrease in • Appropriately tailor therapy based on abscess culture Orbital cellulitis results, if obtained. 1st line: swelling, redness, and Vancomycin IV (see nomogram, AUC goal 400-600)* pain), transition to oral Staphylococcus antibiotics can be • For culture negative or not obtained, or no bone + Ampicillin-sulbactam 3 g IV q6h* aureus considered after 24-48 involvement presumed, transition to oral therapy when hours. patient is afebrile with clinical improvement and Streptococcus PCN allergy without anaphylaxis, angioedema, or urticaria: hemodynamically stable for 48 hours: pneumonia Vancomycin IV (see nomogram, AUC goal 400-600)* Antibiotic duration is • 1st line: + Ceftriaxone 2 g IV q24h typically at least 2 weeks, Amoxicillin-clavulanate 875 mg BID* Streptococcus and should be guided by + TMP-SMX 2 DS tabs PO BID* milleri group Severe PCN or cephalosporin allergy (anaphylaxis, angioedema, clinical resolution. • PCN allergic, without anaphylaxis, angioedema, or hives): urticaria: Streptococcus Vancomycin IV (see nomogram, AUC goal 400-600)* Cefpodoxime 400 mg PO BID* pyogenes + Aztreonam 2 g IV q8h* Complicated Orbital cellulitis + TMP-SMX 2 DS tabs PO BID* (with abscess or significant • Severe PCN allergic patients who do not tolerate Recommend the addition of anaerobic coverage with bony destruction): Haemophilus cephalosporins: metronidazole 500 mg PO q8h if dental infection presumed to If abscess is drained, influenzae Clindamycin 450 mg PO TID be initial source in the setting of PCN allergy and regimen antibiotic duration is + TMP-SMX 2 DS tabs PO BID* without ampicillin-sulbactam. typically 2-3 weeks, and Oral anaerobes should be guided by clinical resolution. For sulfa allergy, doxycycline 200 mg PO x1, then 100 mg PO BID can be substituted for TMP-SMX If significant ethmoid bony destruction, would recommend at least 4 weeks of therapy, guided by clinical resolution. Page 2 of 6 Clinical Setting Empiric Therapy Duration Comments Orbital cellulitis with INTRACRANIAL EXTENSION 1st line: Vancomycin IV (see nomogram, AUC goal 400-600)* Staphylococcus + Ceftriaxone 2 g IV q12h* aureus + Metronidazole 500 mg IV q8h Streptococcus PCN allergy without anaphylaxis, angioedema, or urticaria: Duration depends on source Ophthalmology Consult is required, and ID consult is strongly pneumonia Vancomycin IV (see nomogram, AUC goal 400-600)* control and clinical recommended. + Ceftriaxone 2 g IV q12h improvement, typically 6-8 • Appropriately tailor therapy based on abscess culture Streptococcus + Metronidazole 500 mg IV q8h weeks. results, if obtained. milleri group Severe PCN or cephalosporin allergy (anaphylaxis, angioedema, Streptococcus hives): pyogenes Vancomycin IV (see nomogram, AUC goal 400-600)* + Aztreonam 2 g IV q6h* Haemophilus + Metronidazole 500 mg IV q8h influenzae Oral anaerobes Endophthalmitis prophylaxis in • Endophthalmitis prophylaxis is warranted in patients with patients with penetrating trauma to the globe of the eye. penetrating trauma • Prophylaxis regimen should be the same whether to the globe of the prophylaxis is initiated pre- or post- repair. eye (open globe) 1st line: To 48 hours post repair. • The major difference in spectrum between levofloxacin Moxifloxacin 400 mg IV/PO q24h and moxifloxacin is a lack of activity against Pseudomonas Staphylococcus spp with moxifloxacin. While moxifloxacin is more potent in vitro against Staphylococcus and Streptococcus, the Streptococcus spp clinical relevance is unclear. Bacillus cereus Page 3 of 6 Clinical Setting Empiric Therapy Duration Comments Ophthalmology and Infectious Diseases consultation is strongly recommended Bacterial Endophthalmitis Treatment for endogenous endophthalmitis usually consists of a combination of intravitreal and systemic antibiotics. Systemic Post-surgical antibiotics should be targeted towards the infecting pathogen, • S. epidermidis by the direction of the Infectious Diseases consult service. (60-70%) Systemic antibiotics with adequate intravitreal penetration are • S. aureus, recommended (see comments). streptococci, • A general rule is that agents that readily penetrate the and Post-surgical and post-traumatic endophthalmitis is usually central nervous system also penetrate the vitreous. enterococci treated with intravitreal antibiotics alone. If systemic Post-surgical and post- Intravenous administration of beta-lactams is necessary to (5%–10%) antibiotics are deemed necessary, the below empiric regimens traumatic infection: achieve therapeutic levels. 3rd and 4th generation • Gram- are recommended (in combination with intravitreal antibiotics). Minimum 7-10 days; cephalosporins are preferred over 1st generation agents. negative Definitive treatment should be based on results of culture, as dependent on resolution of Levofloxacin, moxifloxacin and linezolid also rapidly species (~5%) available. findings achieve therapeutic levels. The difficulty in reliably • P. acnes (rapidly) achieving therapeutic concentrations with (delayed Intravitreal antibiotics: Endogenous infection: systemic antibiotics necessitates early intravitreal therapy disease) 1. vancomycin 1 mg/0.1 mL (0.1 mL) intravitreal Should be based on in ALL patients. 2. ceftazidime 2.25 mg/0.1 mL (0.1 mL) intravitreal duration required to treat • If intravitreal therapy is not able to be administered, this Post-traumatic 3. amikacin 0.4 mg/0.1 ml (0.1 mL); instead of ceftazidime if endogenous source should be communicated to Infectious Diseases so that • Staphylococci, PCN allergy the need for a brief course of antibiotics which do rapidly streptococci, penetrate the vitreous (linezolid, quinolones) may be B cereus 1st line: considered prior to transitioning to the listed Vancomycin IV (see nomogram, AUC goal 400-600)* empiric/definitive regimens. Endogenous + Cefepime 2 g IV q8h* • Endocarditis is the source in PCN allergy without anaphylaxis, angioedema, or urticaria: 40% of cases Vancomycin IV (see nomogram, AUC goal 400-600)* • Staphylococci, + Cefepime 2 g IV q8h* gram-negative bacilli, Severe PCN or cephalosporin allergy (anaphylaxis, angioedema, streptococci hives): Vancomycin IV (see nomogram, AUC goal 400-600)* + Levofloxacin 750 mg IV/PO q24h* Page 4 of 6 Clinical Setting Empiric Therapy Duration Comments Ophthalmology and Infectious Diseases consultation is strongly recommended Intravitreal antifungal therapy: Voriconazole 100 micrograms/0.1 mL (0.1 mL) OR Amphotericin B 5 micrograms/0.1 mL (0.1 mL) Empiric systemic antifungal therapy, Candida suspected/confirmed: • Treatment consists of a combination of intravitreal and Note: Therapy may include Micafungin in addition to the systemic antifungal therapy below. See comment. • Micafungin is not recommended for the treatment of endophthalmitis due to poor vitreous penetration, thus Fluconazole 800 mg IV/PO daily* fluconazole/voriconazole should be added, as appropriate per the treatment algorithm, if micafungin is Empiric systemic therapy, Candida species confirmed, being used for the treatment of candidiasis/candidemia. susceptibilities pending: See candidemia guidelines. Candida: Candida albicans • Antimicrobial Dosing guidelines Typically, 4-6 weeks. Candida dubliniensis • Weight-based dosing recommendations for adult obese Candida Candida parapsilosis patients Duration is dependent on Endophthalmitis Candida tropicalis • Therapeutic drug monitoring is recommended for resolution of eye lesions Candida lusitaniae voriconazole. Please see Recommendations for based on serial C. glabrata
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