, Nidhi Relhan Batra1, Stephen G. Schwartz2 and Andrzej Grzybowski3, 4
(1)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
(2)
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Naples, Florida, USA
(3)
Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland
(4)
Institute for Research in Ophthalmology, Poznan, Poland
Antimicrobial Routes
Intravitreal antimicrobials :
For presu‑med bacterial cases (in separate syringes):
Vancomycin 1 mg/0.1 mL (for coverage of gram-positive organisms)
Ceftazidime 2.25 mg/0.1 mL (for coverage of gram-negative organisms)
For presumed fungal cases:
Amphotericin B 0.005 mg/0.1 mL
Voriconazole 0.1 mg/0.2 mL
For presumed bacterial cases: Vancomycin and ceftazidime in separate syringes
For presumed fungal cases: Amphotericin B or voriconazole without intravitreal steroids
Amikacin may be substituted for ceftazidime (EVS proven efficacy).
Ceftriaxone (2 mg/0.1 mL) may be substituted for ceftazidime if more readily available.
Dexamethasone 4 mg/0.1 mL may be considered for acute-onset bacterial cases but should be avoided in suspected fungal endophthalmitis and delayed-onset (chronic) endophthalmitis until the organism is identified.
Periocular/subconjunctival antimicrobials and steroids : Periocular antibiotics may be helpful in bleb-related endophthalmitis.
Systemic antimicrobials :
For endogenous fungal endophthalmitis
Voriconazole 200 mg PO bid for 2–4 weeks
Fluconazole 200 mg PO bid for 2–4 weeks
Itraconazole 200 mg PO bid for 2–4 weeks
Ketoconazole 200 mg PO bid for 2–4 weeks
Amphotericin B 0.25–1.0 mg/kg IV every 6 hours as tolerated
For endogenous bacterial endophthalmitis
Vancomycin 1 g IV bid plus ceftazidime 1 g IV bid
Systemic fluoroquinolones for susceptible organisms
Topical antimicrobials:
Antibiotic topical therapy:
Fortified vancomycin: 25 mg/mL (2.5%) or 50 mg/mL (5%)
Fortified ceftazidime: 50 mg/mL (5%)
Fortified cefazolin: 50 mg/mL (5%)
Fortified gentamicin: 14 mg/mL (1.4%)
Fortified tobramycin: 14 mg/mL (1.4%)
Fortified amikacin: 8 mg/mL (2.5%)
Fortified linezolid: 2 mg/mL (0.2%)
Fortified imipenem–cilastin: 10 mg/mL (1%)
Antifungals eye drops:
Fortified amphotericin B: 1.5 mg/mL (0.15%)
Fortified voriconazole: 10 mg/mL (1%)
Itraconazole
Intrastromal antimicrobials:
Amphotericin B: 5–10 μg/0.1 mL
Voriconazole: 50 μg/0.1 mL
Antimicrobial Dosages (Table 5.1)
Table 5.1
Commonly used antimicrobial agents and recommended doses
Intravitreal | Subconjunctival | Topical (mg/mL) | Intravenous/oral | ||
|---|---|---|---|---|---|
Antibiotics | Vancomycin | 1 mg/0.1 mL | 25 mg/0.25 mL | 25 | 1 g IV bid |
Ceftazidime | 2.25 mg/0.1 mL | 100 mg/0.5 mL | 50 | 1 g IV bid | |
Amikacin | 0.4 mg/0.1 mL | 25 mg/0.5 mL | 8 | – | |
Antifungal | Amphotericin B | 0.005 mg/0.1 mL | – | 1.5 (0.15%) | 0.25–1.0 mg/kg IV every 6 h |
Voriconazole | 0.05 mg/0.1 mL | – | 10 (1%) | 200 mg PO |
Preparation of Antimicrobials
Preparation of Intravitreal Antimicrobials (Table 5.2)
They are prepared in a volume of 10 mL or greater and labeled in a sealed sterile vial. The treating physician will then withdraw the appropriate dose in a tuberculin syringe for injection.
Table 5.2
Preparation of intravitreal antimicrobial agents
Intravitreal antimicrobials |
Vancomycin (1 mg/0.1 mL) • Start with vancomycin 500 mg vial (powder). • Add 10 mL of 0.9% sodium chloride for injection, USP (no preservatives) or balanced salt solution (BSS). • Inject 2 mL of the above solution into a sterile empty vial. • Add 8 mL of 0.9% sodium chloride for injection, USP (no preservatives) or BSS. • Seal this vial. |
Ceftazidime (2.25 mg/0.1 mL) • Start with ceftazidime 500 mg vial (powder). • Add 10 mL of 0.9% sodium chloride for injection, USP (no preservatives) or BSS. • Inject 1 mL of the above solution into a sterile empty vial. • Add 1.2 mL of 0.9% sodium chloride for injection, USP (no preservatives) or BSS. • Seal this vial. |
Amikacin (0.4 mg/0.1 mL) • Start with amikacin 500 mg/2 mL (solution). • Inject 0.16 mL of this solution into a sterile empty vial. • Add 9.84 mL of 0.9% sodium chloride for injection, USP (no preservatives). • Seal this vial. |
Amphotericin B (0.005 mg/0.1 mL) • Start with amphotericin B 50 mg vial. • Add 10 mL sterile water for injection, USP (no preservatives). • Inject 0.1 mL of the above solution into a sterile empty vial. • Add 9.9 mL of sterile water for injection, USP (no preservatives) to the above solution. • Seal this vial. |
Voriconazole (0.05 mg/0.1 mL) • Start with voriconazole 200 mg vial and reconstitute with 19 mL of sterile water for injection, USP (no preservatives). • Withdraw 1 mL of this solution and dilute with 19 mL of sterile water for injection, USP (no preservatives). • Transfer this solution into two sterile empty vials. • Seal these vials. |
Preparation of Subconjunctival Antibiotics (Table 5.3)
Table 5.3
Preparation of subconjunctival antibiotics
Antibiotic
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