The optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. |
This article reviews systemic antimicrobial options currently available for the treatment of different categories of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments. |
Introduction
Methods
Common Organisms in Endophthalmitis
Systemic Antimicrobials Currently Available for the Treatment of Endophthalmitis
Glycopeptide antibiotics
Vancomycin
Cephalosporins
Third-Generation (Ceftriaxone, Ceftazidime) and Fourth-Generation (Cefepime) Cephalosporins
Beta-Lactams
Imipenem
Aminoglycosides
Amikacin
Macrolides
Clarithromycin
Fluoroquinolones
Antibiotic Combinations
Trimethoprim–Sulfamethoxazole
Antifungals
Amphotericin B
Voriconazole
Caspofungin
Role of Systemic Antimicrobials (Antibiotics and Antifungals) in the Management of Different Etiologies of Endophthalmitis
Type of endophthalmitis | Role of systemic antimicrobials |
---|---|
Endophthalmitis after open-globe injuries | Usually given for endophthalmitis prophylaxis or treatment |
Endogenous fungal endophthalmitis | Yes (antifungals) |
Endogenous bacterial endophthalmitis | Yes (antibiotics) |
Post-cataract surgery endophthalmitis | Rarely in USA but frequently in other countries |
Post-intravitreal injection endophthalmitis | Rarely in USA but more frequently in other countries |
Filtering bleb-associated endophthalmitis | Rarely in USA but more frequently in other countries |
Post-keratitis endophthalmitis | Rarely in USA but more frequently in other countries |
Endophthalmitis After Open-Globe Injuries
Endogenous Fungal Endophthalmitis
Endogenous Bacterial Endophthalmitis
Post-Cataract Surgery Endophthalmitis
Post-Intravitreal Injection Endophthalmitis
Filtering Bleb-Associated Endophthalmitis
Post-Keratitis Endophthalmitis
Complications and Side-Effects of Systemic Antimicrobials
Type of endophthalmitis | Systemic antimicrobial | Recommended dose | Side-effects and potential complications |
---|---|---|---|
Endogenous fungal endophthalmitis, endophthalmitis associated with open-globe injury with organic matter (fungal or suspected fungal etiology) | Voriconazole (Vfend®; Pfizer Ltd.) | 200 mg PO bid for 2–4 weeks | Hepatitis, cholestasis, fulminant hepatic failure, photosensitivity, skin cancer, hallucinations, anaphylactoid reactions with fever and hypertension, QT prolongation with ventricular tachycardia, transient visual disturbance (altered/enhanced visual perception, blurred or colored visual change or photophobia), hypoglycemia, electrolyte disturbance and pneumonitis |
Fluconazole (Diflucan®; Pfizer Ltd.) | 200 mg PO bid for 2–4 weeks | Vomiting, diarrhea, rash, abdominal pain, headache, skin rash, alopecia, increased liver enzymes, severe hepatotoxicity, exfoliative dermatitis, QT prolongation, and seizures | |
Itraconazole (Sporanox®; Janssen) | 200 mg PO bid for 2–4 weeks | Nausea, vomiting, diarrhea, abdominal discomfort, constipation, allergic rash, hepatitis, edema, hypokalemia, hypertension, headache, delirium, peripheral neuropathy, tremors | |
Ketoconazole (Nizoral®; Janssen) | 200 mg PO bid for 2–4 weeks | Mild nausea, vomiting, or stomach pain, skin rash, headache, dizziness, breast swelling, impotence, hepatotoxicity, adrenal crisis | |
Amphotericin B (Fungizone®; ER Squibb & Sons) | 0.25–1.0 mg/kg IV every 6 h as tolerated | High fever, shaking chills, hypotension, anorexia, nausea, vomiting, headache, dyspnea and tachypnea, drowsiness, and generalized weakness, renal toxicity, electrolyte imbalances (hypokalemia and hypomagnesemia), hepatotoxicity, cardiac arrhythmias, blood dyscrasias (leukopenia, thrombopenia) | |
Caspofungin (Cancidas®; Merck & Co., Inc.) | 70 mg daily loading dose, followed by 50 mg daily | Hepatotoxicity, Stevens–Johnson syndrome, toxic epidermal necrolysis | |
Endogenous bacterial endophthalmitis, Endophthalmitis associated with open-globe injury with non-organic matter (bacterial or suspected bacterial etiology) | Vancomycin (Vancocin®; Pfizer) | 1 g IV bid | Nephrotoxicity, “red man” syndrome, rash, immune thrombocytopenia, fever, neutropenia, dose dependent decrease in platelet count, IgA bullous dermatitis |
Ceftazidime (Fortaz®; GlaxoSmithKline) | 1 g IV bid | Nausea, vomiting, diarrhea, risk of cross-allergenicity with aztreonam | |
Amikacin (Amikin®; Taj) | 7.5–15 mg/kg/day IV/IM divided q8–12h | Allergic reaction, tubular necrosis, renal failure, deafness due to cochlear toxicity, vertigo due to damage to vestibular organs, rarely neuromuscular blockade | |
Gentamicin (Garamycin®; Taj) | 2 mg/kg load then 1.7 mg/kg q8h | Same as amikacin | |
Imipenema (Primaxin®; Merck & Co., Inc.) | 0.5–1.0 g q6–q8h | Seizures, renal tubular toxicity | |
Gatifloxacin (Tequin®; Bristol-Myers Squibb (no longer manufactured)) | 200–400 mg IV/PO q24h | False positive urine drug screen for opiates, not approved for use under age 16 years based on joint cartilage injury in immature animals, CNS toxicity, skin rash, dysglycemia, thrombocytopenia, photosensitivity, QT prolongation | |
Ciprofloxacin (Cipro®; Bayer) | 750 mg PO q12h | Same as gatifloxacin | |
Moxifloxacin (Avelox®; Bayer) | 400 mg IV/PO q24h | Tendinopathy, Achilles tendon rupture, allergic reactions, myasthenia gravis | |
Levofloxacin (Levaquin®; Janssen) | 250–750 mg IV/PO q24h | Same as moxifloxacin | |
Linezolid (Zyvox®; Pharmacia and Upjohn) | 600 mg IV/PO q12h | Reversible myelosuppression, lactic acidosis, peripheral neuropathy, optic neuropathy, risk of severe hypertension if taken with foods rich in tyramine, rhabdomyolysis | |
Trimethoprim–sulfamethoxazole (Bactrim DS®; Sun Pharmaceuticals) | 160 mg/800 mg PO bid | Nausea, vomiting, vertigo, peripheral neuritis, Stevens–Johnson syndrome, toxic epidermal necrolysis | |
Chronic endophthalmitis caused by non-tuberculous mycobacteria | Clarithromycin (Biaxin®; Abbott) | 250–500 mg PO BID for 2–4 weeks | QT prolongation, rhabdomyolysis if given with statins, fatal pancytopenia/renal failure if given with colchicine, hypotension/renal injury if given with calcium channel blockers |