-Dr.Prathibha.M.Chachadi

for·ti·fy  (fôrt-f) v. for·ti·fied, for·ti·fy·ing, for·ti·fies

v.tr. To make strong, as: a. To strengthen and secure (a position) with fortifications.

b. To reinforce by adding material

Most of the available ophthalmic antibiotics are in the concentration of 0.3% which is not sufficient to attain minimum inhibitory concentration for organisms, especially the resistant , non healing ulcers.

For moderate to severe corneal ulcers intensive antibiotic treatment is needed, which reinforces the need for fortified antibiotics to halt the progression of ulcer and promote healing

Is started in the initial empirical treatment as conventional method ( vs monotherapy with quinolones)

Once culture reports are available for specific organisms- pseudomonas; staphylococci; candida; pneumococcus-streptococcus

Conventionally active corneal ulcer needs intensive treatment where the drops are applied topically- 1 hourly for 24-48 hrs( stabilised); 2hrly- during day & 4 hrly in night till healing ; 4-6 hrly.

BACTERIA TYPE(GRAM STAIN)

DRUG OF CHOICE(FORTIFIED)

ALTERNATIVE DRUGS(FORTIFIED/ NON -FORTIFIED)

GRAM POSITIVECOCCI Cefazolin- 50mg/ml 0r 100mg/ml

Vancomycin -25mg/mlBacitracin- 10000 u/mlCiprofloxacin Ofloxacin Levofloxacin

GRAM POSITIVE BACILLI Penicillin G-100000 u/mlTobramycin -14mg/ml

Vancomycin 25-50mg/mlBacitracin -10000 u/mlGentamicin -14mg/ml

GRAM NEGATIVE COCCI Ceftriaxone-50mg/ml or 100mg/ml

Ofloxacin Levofloxacin Ciprofloxacin

GRAM NEGATIVE BACILLI

Tobramycin -14mg/mlAmikacin -10mg/mlTicarcillin -6mg/ml

Gentamicin -14mg/mlPolymyxin B-50000 u/mlCiprofloxacinOfloxacin Levofloxacin

NO ORGANISM SEEN BUT BACTERIA SUSPECTED

Cefazolin- 50mg/ml or 100mg/ml +Tobramycin -14mg/ml

Gentamicin-14mg/ml(OR)Amikacin-10mg/ml +Vancomycin -25mg/ml (OR)Bacitracin 10000 u/ml

ORGANISM

PSEUDOMONAS

TOPICAL

Tobramycin -14mg/ml(OR)Amikacin 10mg/ml/ a quinolone

SUBCONJUNCTIVAL

Tobramycin -40mgAmikacin -25mgTicarcillin -100mg

STAPHYLOCOCCUS Cefazolin -50mg/mlVancomycin – 25-50 mg/mlBacitracin 10000 u/ml

Cefazolin 100mgOxacillin 100mgVancomycin 25mg

PROTEUSENTEROBACTERE.COLIKLEBSIELLAACINETOBACTER

Tobramycin -14mg/mlGentamicin -14mg/mlAmikacin -10mg/mlCeftriaxone -50mg/ml

Tobramycin -40mgAmikacin – 25mgCarbenicillin -100mg

1.AMIKACIN- (atypical mycobacteria; post lasik infectious keratitis)( poor corneal penetration)

topical 100 mg/ml +9ml tears 10mg/ml subconjunctival 100mg/ml +1ml tears 50mg/mlShelf life 30 Days

2. BACITRACIN – 6ml(10ml) of tear drops TOPICAL 3ml 3ml

1 vial of bacitracin 1 vial of bacitracin

(50000 u) (50000 u)

6ml(10ml) of tear drops

(1ml- 10000u) SUBCONJUNCTIVAL 0.5ml (5000u) SHELF LIFE 7 Days(4 deg)

3.CEFAZOLIN -(non penicillinase gram+) (

topical 1g/10ml +2ml tears(100mg/ml+2ml) 33mg/mlAlso 500mg +10ml; 50mg/mlAlso 1g/7.5ml 133mg/mlSubconjunctival 100mg/mlShelf life 10 Days ( yellow ; discard)

GENTAMICIN topical 80mg/2ml +3.6ml of tears 14mg/mlSubconjunctival 40mg/mlShelf life 30 Days

Penicillin G topical 1 vial- 5 million u +5ml of tears- 1

million u/ml 5ml+2.5 ml- 333333u/mlSubconjunctival 1 million u/mlShelf life 7 Days

TOBRAMYCIN – topical - 80mg/2ml + 0.3 % tobramycin e/d(5ml) - 13.6mg/mlSubconjunctival - 40mgShelf life - 30 days

VANCOMYCIN – Topical - 500mg/10ml + 5ml of tears – 25mg/mlSubconjunctival – 25mgShelf life – 14 days

Amphotericin B- topical – 50mg+10ml- 5mg/ml(STOCK

SOLUTION)1.5 ml of stock solution+ 3.5 ml of tears-

0.15%Refrigerate; not exposed to light ; look for

turbidity, precipitation, contamination

Original Article British Journal of Ophthalmology. 84(4):378-384, April 1,

2000.Gangopadhyay, Nibaran; Daniell, Mark; Weih, LeAnn; Taylor, Hugh R

Abstract: AIM: To compare the clinical efficacy of commercially available fluoroquinolone drops with the use of combined fortified antibiotics (tobramycin 1.3%-cefazolin 5%) in treatment of bacterial corneal ulcer

CONCLUSIONS: Monotherapy with fluoroquinolone eye drops for the treatment of bacterial corneal ulcers led to shorter duration of intensive therapy and shorter hospital stay compared with combined fortified therapy (tobramycin-cefazolin). This finding may have resulted from quicker clinical response of healing as a result of less toxicity found in the patients treated with fluoroquinolone. However, as some serious complications were encountered more commonly in the fluoroquinolone group, caution should be exercised in using fluoroquinolones in large, deep ulcers in the elderly.

Methods. We developed an in vitro epithelial wound-healing model to evaluate the toxicity of antibiotics. An excimer laser was used to create an epithelial defect 1.5 mm in diameter, 70 [mu]m in depth on the central area of porcine cornea. The intact animal globes were maintained in the incubator by a perfusion system. Fortified antibiotics: 10% piperacillin, 5% cefazolin, 0.5% chloramphenicol, 5% vancomycin, 1% amikacin, 2% gentamicin, and 0.1% amphotericin B were applied to the wound in three applications. The wounds were evaluated 24 h after setup with fluorescein stain and a scoring system. Results. The 0.1% amphotericin B and 2% gentamicin disturbed the corneal epithelial healing rate significantly. The remaining antibiotics did not interfere with the epithelial healing rate in our study design. Conclusion. Fortified antibiotic eyedrops demonstrated ealvaried degrees of influence on corn epithelial wound healing. When antibiotic eyedrops are used, both the efficacy and toxicity of the antibiotics should be the major concern. If efficacy is equivalent, less-toxic agents should be given preference.

Effect of Fortified Antibiotic Solutions on Corneal Epithelial Wound Healing. Basic Investigation Cornea. 19(2):204-206, March 2000.Lin, Chang-Ping M.D.; Boehnke, Matthias M.D. Abstract: Purpose. To evaluate the influence of fortified antibiotic eyedrops on corneal epithelial wound healing

IJO ORIGINAL ARTICLE Year : 2007  |  Volume : 55  |  Issue : 1  |  Page : 15-19 Activity of newer fluoroquinolones against gram-positive and gram-negative bacteria isolated from ocular infections: An in vitro comparison

Background: To determine the antibacterial activity of newer fluoroquinolones and compare their activity between ciprofloxacin-susceptible and resistant bacterial isolates from patients with keratitis and endophthalmitis

Conclusions: Levofloxacin, gatifloxacin and moxifloxacin are statistically more effective against gram-positive bacteria, the latter two being equally effective. Ciprofloxacin remains the most effective fluoroquinolone against gram-negative bacteria.

PARSON’S TEXT BOOK OF OPHTHALMOLOGY INDIAN JOURNAL OF OPHTHALMOLOGY

CURRENT OPHTHALMOLOGY Year : 1994  |  Volume : 42  |  Issue : 4  |  Page : 171-192   Current perspectives in infectious keratitis

Agrawal Vinay1, Biswas Jyotirmay2, Madhavan HN2, Mangat Gurmeet3, Reddy Madhukar K4, Saini Jagjit S3, Sharma Savitri4, Srinivasan M5

  SYMPOSIUM Year : 2008  |  Volume : 56  |  Issue : 3  |  Page : 215-220  

Medical management approach to infectious keratitis

Gokhale Nikhil S Gokhale Eye Hospital and Eyebank, Anant Building, Gokhale Road (S), Dadar West, Mumbai-400 028, India