Antimicrobial Treatment: Routes/Dosages/Preparation/Adverse Effects, Antimicrobial Resistance, and Alternatives

Abstract

Intravitreal antimicrobials:For presumed 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 mLVoriconazole 0.1 mg/0.2 mLFor presumed bacterial cases: Vancomycin and ceftazidime in separate syringesFor presumed fungal cases: Amphotericin B or voriconazole without intravitreal steroidsAmikacin 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 endophthalmitisVoriconazole 200 mg PO bid for 2--4 weeksFluconazole 200 mg PO bid for 2--4 weeksItraconazole 200 mg PO bid for 2--4 weeksKetoconazole 200 mg PO bid for 2--4 weeksAmphotericin B 0.25--1.0 mg/kg IV every 6 hours as toleratedFor endogenous bacterial endophthalmitisVancomycin 1 g IV bid plus ceftazidime 1 g IV bidSystemic fluoroquinolones for susceptible organismsTopicalantimicrobials: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{\%})ItraconazoleIntrastromalantimicrobials:Amphotericin B: 5--10 $μ$g/0.1 mLVoriconazole: 50 $μ$g/0.1 mL