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Ophthalmic Infections Guideline

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Ophthalmic Infections Guideline 372FM.5 OPHTHALMIC INFECTIONS Contents Page Storage of Swabs and Media in Ophthalmology, Stoke Mandeville Hospital ................................. 1 1. Conjunctivitis .......................................................................................................................... 1 a) Bacterial Conjunctivitis ...................................................................................................... 1 b) Viral Conjunctivitis ............................................................................................................. 2 c) Chlamydia Conjunctivitis ................................................................................................... 3 2. Neonatal Conjunctivitis (‘Ophthalmia Neonatorum’) ............................................................... 4 3. Blepharitis .............................................................................................................................. 5 4. Preseptal and Orbital Cellulitis ............................................................................................... 5 a) Preseptal ........................................................................................................................... 5 b) Orbital ............................................................................................................................... 6 5. Keratitis .................................................................................................................................. 6 a) Bacterial Corneal Abscess (Keratitis) ................................................................................ 7 b) Herpes Simplex Keratitis ................................................................................................... 8 c) Acanthamoeba Keratitis .................................................................................................... 8 d) Fungal Keratitis ................................................................................................................. 9 e) Post-operative Endophthalmitis ....................................................................................... 10 6. Management of Acute Endophthalmitis (post-operative endophthalmitis) ............................ 10 Protocol for Obtaining Ocular Samples for Microscopy and Culture and Subsequent Intravitreal Antibiotic Injection in Presumed Bacterial Endophthalmitis. ..................................................... 11 7. Endogenous Endophthalmitis .............................................................................................. 13 a) Bacterial .......................................................................................................................... 13 b) Fungal ............................................................................................................................. 14 8. References .......................................................................................................................... 15 Storage of Swabs and Media in Ophthalmology, Stoke Mandeville Hospital The following items are stored in the refrigerator in treatment room on ward 14 in the Mandeville building: Bacterial culture media: Blood/chocolate Fungal culture media: Sabouraud agar Chlamydia/viral swabs with transport media Microscope slides Ophthalmology staff are responsible for maintaining the stock of materials and ensuring these are in date. Bacterial culture plates should be inoculated (but not spread) by the ophthalmology clinician. If urgent microbiological sampling is required on a patient seen in Wycombe Ophthalmology Outpatients, the patient will need to be sent to the Ophthalmology Department at Stoke Mandeville Hospital where immediate plating of the specimen can take place. 1. Conjunctivitis a) Bacterial Conjunctivitis This is usually self-limiting (41% resolve within 6 - 10 days without antibiotic therapy) but antibiotic treatment speeds recovery. Conjunctival Swabbing This need not be performed routinely for cases where the diagnosis is clear. The exception to this is in the case of pregnant and lactating women (please see below). If the patient has had severe symptoms for more than a week and has not responded to a first-line antibiotic, check and reinforce the frequency of instillation of treatment and consider taking conjunctival swabs for bacteria, viruses and chlamydia. Fluorescein drops should not be instilled if it is intended to swab the eye. Guideline 372FM.5 1 of 16 Uncontrolled if printed Treatment First line: self-care. Second line: Chloramphenicol 0.5% eye drops, 6 hourly (consider 2 hourly initially for more marked infections for the first 48 hours then reduce to 6 hourly). Chloramphenicol 1% eye ointment, applied every 6 - 8 hours, may be prescribed in place of drops. Third line: If the patient is allergic to chloramphenicol or compliance with frequent instillation considered a likely issue, prescribe fusidic acid 1% eye drops 12 hourly (although this has a narrower spectrum of antibacterial activity). Fourth line: If the patient does not respond to these agents, then a history regarding compliance should be sought, the diagnosis should be re-evaluated and swabs taken (see above). If the condition is still clinically deemed to be bacterial conjunctivitis moxifloxacin 0.5% (preserved) eye drops every 2 hours for 48 hours then every 6 hours (unlicensed dose). Preservative allergy: Chloramphenicol 1% eye ointment is the first line agent. If drops are required, use preservative-free drops, e.g. single-use, preservative free chloramphenicol 0.5%. Therapy can be modified on receipt of bacteriology results. Duration of treatment: Topical treatment should be continued for 48 hours after the symptoms have resolved, which usually means a course lasts 5 - 7 days. Management of Pregnant and Lactating Women Swabbing should be performed from the outset so that treatment decisions are based on complete and relevant information. As the condition is self-limiting, there is the option of not treating. In pregnancy and lactation the evidence suggests that fusidic acid 1% ointment 12 hourly is an appropriate choice. Cefuroxime 5% eye drops (preservative-free, unlicensed*) is an alternative. Advice to Patients Patients should be advised about general hygiene measures to avoid the spread of infection: Frequent hand washing, avoidance of sharing flannels and towels. b) Viral Conjunctivitis Management and Treatment If confirmation of viral diagnosis is required, a swab should be taken using the Chlamydia/viral specimen collection kit. Rub the conjunctival mucosa as hard as can be tolerated to obtain mucosal cells, then break off the swab in the transport media and send to the laboratory. Symptomatic relief may be given with the use of ocular lubricants, e.g. carbomer 980 0.2% eye gel - 1 drop when required up to 6 hourly. There is no evidence that the use of topical antibiotics for the secondary prevention of bacterial conjunctivitis is beneficial. However, in severe cases, topical treatment can be given as per the bacterial conjunctivitis protocol. For treatment of keratitis – see section 5. Adenovirus/Enterovirus Self-limiting with improvement of symptoms and signs within 5 - 14 days. Herpes Simplex Virus (HSV) – if keratitis, see section 5 - Usually subsides without treatment within 4 - 7 days unless complications occur. - Topical and/or oral antiviral treatment recommended for HSV conjunctivitis to prevent corneal infection. - First line: Aciclovir 3% ointment 5 times a day for 7 days (or continue for at least 3 days after complete healing) and/or aciclovir 400 mg PO 5 times a day for 5 days. - Second line: Ganciclovir 0.15% eye gel 5 times a day. Guideline 372FM.5 2 of 16 Uncontrolled if printed Varicella (Herpes) Zoster Virus (VZV) - immunocompetent - Shingles affecting the ophthalmic branch of the trigeminal nerve; typical unilateral dermatomal pain, virtually always followed by a rash. Severe ocular complications can occur but are rare. Mild conjunctival involvement is common. - Seek an ophthalmological opinion within the first three weeks (as ocular inflammation may occur late). - Give early treatment with oral aciclovir 800 mg five times daily for 7 days to reduce the long term ocular complication rate. - Do not use topical steroids without ophthalmological guidance. - If the conjunctiva is more severely involved, the cornea looks hazy or the patient complains of decreased vision, an ophthalmological opinion is required (urgency dependent on severity). Infection Control Adenoviral/enteroviral conjunctivitis is extremely contagious. Avoid sharing personal items, use meticulous hand washing and avoid close personal contact for approximately two weeks. For patients with adenoviral conjunctivitis, dispose of unclean contact lenses. The slit lamp (including the on-off switch) must be cleaned thoroughly with alcohol swabs after examination of the patient. Usual hand hygiene guidance applies. c) Chlamydia Conjunctivitis This typically affects sexually active young adults. The eye lesions usually present about one week following sexual exposure and may be associated with a non-specific urethritis or cervicitis. Symptoms Patients almost invariably have bilateral involvement with a mucopurulent discharge, redness and discomfort but presentation with a unilateral ptosis can also occur. Signs Large opalescent follicles are found in the conjunctival fornices. Follicles can also occur at the limbus and on the bulbar conjunctiva as the disease develops.
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