OCULAR INFECTIONS I. EXTERNAL EYE INFECTIONS A. Blepharitis Etiology: Preferred Regimen: unclear, but may include P: Usually, topical antibiotic ointment of no S. aureus and S. benefit epidermidis as well as A: Topical antibiotics may provide symptomatic associated seborrhea, relief. rosacea, dry eye If associated acne rosacea:
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  1 OCULAR INFECTIONS National Antibiotic Guidelines I.   EXTERNAL EYE INFECTIONS A.   Blepharitis Etiology:   Preferred Regimen:   unclear, but may include S. aureus and S. epidermidis  as well as associated seborrhea, rosacea, dry eye  P:  Usually, topical antibiotic ointment of no benefit A:  Topical antibiotics may provide symptomatic relief. If associated acne rosacea:  Doxycycline  100mg PO bid x 2 weeks and then q24h  Comments: Do lid margin care with baby shampoo and warm water q24h using a clean washcloth, gauze pad, or cotton swab (50:50 mixture). Apply artificial tears if with associated dry eyes. Avoid eyeliner, mascara, false eye lashes and eye lash extensions. Treatment involves patient education about disease chronicity and need for long term commitment to lid hygiene with regular application of warm compresses, gentle lid massage and lid washing. Topical antibiotic steroid combination during the acute phase for around 2 to 4 weeks. Antibiotic alone to prevent recurrences for 3 to 6 months. B.   Hordeolum (Stye) EXTERNAL HORDEOLUM:  S. aureus Preferred Regimen:  No antibiotic Comments: Warm moist compress (40-45 degree Celsius) continuously using cotton, gauze or face towel over the affected area for 10 to 15 minutes; may repeat as often as necessary. INTERNAL HORDEOLUM:  S. aureus , including methicillin-sensitive and  – resistant strains ã   External hordeolum: External infection of the superficial sebaceous gland (eyelash follicle) ã   Internal hordeolum: Infection of the meibomian glands, and is also called meibomianitis.  2 OCULAR INFECTIONS National Antibiotic Guidelines Preferred Regimen: PEDIATRICS   ADULTS   Cloxacillin  100-150mg/kg/d PO div q6h For MSSA:   Cloxacillin  250-500mg PO q6h PLUS  hot packs For MRSA, community-associated: Cotrimoxazole  800/160mg PO 2 tabs bid For MRSA, hospital-acquired: Linezolid  600mg PO bid Comments: Topical antibiotic ointment (erythromycin, tobramycin) or topical antibiotic-steroid ointment (tobramycin-dexamethasone) 3 to 4 times a day. The decision to use an antibiotic-steroid combination will depend on the judgment call of the physician on the degree of inflammation involved. Incision and drainage if with pointing abscess. Incision and curettage for chalazion. Can be acute, subacute, or chronic. Rarely drain spontaneously and may need Incision and Drainage with culture   II.   ORBITAL CELLULITIS A.   Orbital Cellulitis in Children Etiology:   S. aureus, Streptococci Grp A B, hemolytic streptococcus or S. pyogenes, S. pneumoniae, M. catarrhalis   uncommon causes :  Aeromonas hydrophila, P. aeruginosa, Eikenella corrodens, H. influenzae type B, Anaerobes (odontogenic source), Gram negative bacilli (post-trauma)   Preferred Regimen:   1st line 2nd line Vancomycin 45-60mg/kg/d IV in 4 div doses (Max: 4g/d) PLUS Ceftriaxone  100mg/kg/d IV/IM in 1-2 doses (Max: 4g/d) If with odontogenic source, ADD: Metronidazole  30mg/kg/d IV/PO in 4 div doses (Max: 4g/d) OR   Vancomycin  45-60 mg/kg/d IV in 4 div doses (Max: 4g/d) PLUS   Piperacillin-Tazobactam  240-300 mg/kg/d IV in 3-4 doses (piperacillin component) (Max: 16g piperacillin/d) Linezolid  <12 y: 30 mg/kg/d IV in 3 doses ≥12 y: 1200 mg/d IV in 2 doses   PLUS   Cefotaxime  100-200 mg/kg/d IV in 3-4 doses (Max: 2g/d)  3 OCULAR INFECTIONS National Antibiotic Guidelines For children with serious allergy to PCN and/or cephalosporins: Vancomycin   PLUS   Ciprofloxacin  20-30mg/kg/day in 2 div doses (Max: 1.5g PO qd/800mg IV qd) or   Levofloxacin   ≥ 6 mos. to < 5 yrs.: 10mg/kg/dose q12h ≥ 5 years:10 mg/kg/dose q24h (Max: 500mg)  DOT:  7-14 days depending on clinical response Comments: Orbital cellulitis is serious and potentially life threatening. It is best to obtain specimen for culture and sensitivity testing prior to treatment initiation. Surgical consultation is recommended. ARSP 2015 showed increased resistance of S. aureus  to Oxacillin at 62.6%. Orbital cellulitis is a serious infection with risk of cavernous sinus thrombosis. Antibiotics with MRSA coverage should be promptly started. For confirmed MSSA, shift to Oxacillin. B.   Orbital Cellulitis in Adults Etiology: S. pneumoniae, H. influenzae, M. catarrhalis, S. aureus, Anaerobes (odontogenic source), Streptococcus sp.  (Group A), Gram-negative bacilli (post-trauma), Mucormycosis (in patients with diabetic ketoacidosis), Invasive Aspergillus sp (severe neutropenia, HIV) Preferred Regimen: Stage 1: Amoxicillin-clavulanate  500mg PO tid x 10-14d Stage II  –  IV: If MRSA is not considered: Piperacillin-Tazobactam  4.5g IV q8h OR   Ciprofloxacin  400mg IV q8-12h PLUS Clindamycin  600mg IV q8h  If MRSA considered: Vancomycin  1g IV q12h PLUS Ceftriaxone  1g IV q12h PLUS Metronidazole  1g IV q12h Stage I:  preseptal cellulitis, anterior lid swelling; CT normal. Stage II:  edema, chemosis, proptosis, limited extra-ocular motion; CT with mucosal swelling but no fluid collection. Stage III:  occasional visual loss, CT subperiosteal abscess, globe displacement, extraocular muscles involved. Stage IV:  ophthalmoplegia with visual loss; CT with proptosis, abscess formation & periosteal rupture.  4 OCULAR INFECTIONS National Antibiotic Guidelines (if odontogenic source) Option for MRSA if Vancomycin intolerant: Linezolid 600 mg IV q12h  DOT:  10-21 days depending on clinical response; 4-6 weeks if bone changes are suggestive of osteomyelitis. For serious allergy to penicillins and/or cephalosporins : Vancomycin  1g IV q12h PLUS Ciprofloxacin  400mg IV q12h OR 500 to 750 mg PO bid OR   Levofloxacin  500 to 750 mg IV or PO qd Comments: Close consultation with ophthalmology and /or ENT is required. Surgical debridement is warranted with abscesses or if medical management fails to lead to an improvement in the first 24-36 hours. III.   DACRYOCYSTITIS (LACRIMAL SAC) Etiology:  Acute dacryocystitis:  Alpha –  hemolytic streptococci, S. epidermidis, S. aureus  Chronic dacryocystitis: S. pneumoniae, H. influenzae, P. aeruginosa, S. viridans, Enterobacteriaceae Preferred Regimen:   PEDIATRICS ADULTS Vancomycin  40mg/kg/d IV div 3-4 doses PLUS   Ceftazidime  100mg/kg/d IV div 3 doses (if Gram-negative dacryocystitis is entertained). Mild infection limited to lacrimal sac and lid: Cephalexin  500mg PO qid OR   Amoxicillin-clavulanate  875mg PO bid OR Cotrimoxazole  2 DS tablets PO bid With signs or symptoms of orbital cellulitis: Vancomycin  15-20mg/kg/d IV q8-12h PLUS Ceftriaxone  2g IV q24h or   Cefepime  2g IV q6h if pseudomonal infection is suspected Documented MSSA infection: Oxacillin  2g IV q6h OR Cefazolin  2g IV q8h  DOT:  7-14d Comments: Ophthalmologic consultation is needed and surgery may be required to do culture studies (to detect MRSA). Empiric systemic antibiotic therapy is based on Gram ã   Can be acute or chronic ã   Due to obstruction of the lacrimal duct.
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