OCULAR INFECTIONS

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: External infection of the superficial sebaceous gland

(eyelash follicle)
• Internal hordeolum: Infection of the meibomian glands, and is also called
meibomianitis.

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

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Preferred Regimen:
PEDIATRICS ADULTS
Cloxacillin 100-150mg/kg/d PO For MSSA: Cloxacillin 250-500mg PO q6h
div 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 Linezolid
doses (Max: 4g/d) <12 y: 30 mg/kg/d IV in 3 doses
PLUS ≥12 y: 1200 mg/d IV in 2 doses
Ceftriaxone 100mg/kg/d IV/IM in 1-2 PLUS
doses (Max: 4g/d) Cefotaxime 100-200 mg/kg/d IV
If with odontogenic source, ADD: in 3-4 doses (Max: 2g/d)
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)

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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

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.

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: If MRSA considered:

Piperacillin-Tazobactam 4.5g IV q8h Vancomycin 1g IV q12h PLUS
OR Ciprofloxacin 400mg IV q8-12h Ceftriaxone 1g IV q12h PLUS
PLUS Clindamycin 600mg IV q8h Metronidazole 1g IV q12h

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(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)

• Can be acute or chronic

• Due to obstruction of the lacrimal duct.

Etiology:
Acute dacryocystitis: Alpha –hemolytic streptococci, S. epidermidis, S. aureus
Chronic dacryocystitis: S. pneumoniae, H. influenzae, P. aeruginosa, S. viridans,
Enterobacteriaceae

Preferred Regimen:
PEDIATRICS
Vancomycin 40mg/kg/d IV div 3-
4 doses PLUS
Ceftazidime 100mg/kg/d IV div
3 Cotrimoxazole 2 DS tablets PO bid
doses (if Gram-negative
dacryocystitis is entertained).
ADULTS
Mild infection limited to lacrimal sac and
lid: Cephalexin 500mg PO qid OR
Amoxicillin-clavulanate 875mg PO bid OR
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

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stain of the aspirate, age of the child, severity of the infection, presence and type
of complications. Adjust therapy based on culture results.

Hospitalization may be considered in cases of suppurative bacterial infection with

associated lacrimal gland abscess. Oral agents may be used for less severe cases.

A. Canaliculitis (Lacrimal apparatus)

Etiology: Actinomyces, Staphylococci, Streptococci; rarely Arachnia

fusobacterium, Nocardia sp., Candida sp. (all rare)

Comments:
Apply hot packs to punctal area qid. Referral to ophthalmologist for removal of
granules and local irrigation with an antibiotic solution.

IV. CONJUNCTIVITIS

A. Conjunctivitis of the Newborn by day of onset post-delivery

1ST DAY POST-DELIVERY: CHEMICAL DUE TO SILVER NITRATE PROPHYLAXIS

Preferred Regimen: No antibiotic
Comments:
Chemical prophylaxis is rare since usual prophylaxis involves use of erythromycin
ointment 0.5% x 1 application OR tetracycline 1% ointment x 1 application

DAYS 2 TO 4: N. gonorrhoeae
Preferred Regimen:
Ceftriaxone 25-50mg/kg IV x 1 dose not to exceed 125mg.
Topical Gentamicin, Ciprofloxacin 6-8x/d
Comments:
Hyperpurulent discharge is observed. Irrigate conjunctiva with saline to remove
discharge as often as needed. Treat neonate for concomitant Chlamydia
trachomatis infection. Treat the mother and sexual partner. Topical treatment is
inadequate. Ophthalmologic consult is advised.

DAYS 3-10: Chlamydia trachomatis

Preferred Regimen:
1st line: Erythromycin base or ethylsuccinate syrup 12.5mg/kg q6h x 14d
2nd line: Azithromycin 20mg/kg PO q24h x 3d
Comments:
Diagnosed by antigen detection. Treat the mother and sexual partners. No topical
treatment is needed.

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DAYS 2-16: Herpes simplex types 1, 2

Preferred Regimen: Aciclovir 60mg/kg/d IV div q8h x 14d
Comments:
Topical anti-viral therapy under the direction of an ophthalmologist

B. Viral Conjunctivitis (Pink eye)

Etiology: Adenovirus 3 & 7 in children

Preferred Regimen: No antibiotic

Consider short course topical antibiotic-steroid drops one to two drops every 3 to
4 hours for 7 to 14 days in cases with severe inflammation, membranes or
epithelial defects.

Comments:
Highly contagious. If symptomatic, artificial tears may help. If with ocular pain and
photophobia, suspect keratitis (rare). Cold moist compresses as often as needed.
Although adenoviral conjunctivitis is self-limiting, topical antibiotic-steroid is given
to those with severe symptoms. marked swelling and with membrane formation
which can lead to permanent conjunctival scarring (these are cases that have to
be referred).

C. Bacterial (non-gonococcal) conjunctivitis

Etiology: Preferred Regimen:

S. aureus, S. Eye drops: Levofloxacin OR Tobramycin OR
pneumoniae, Erythromycin OR Fusidic acid 1 drop tid - qid x 5-
S. viridans, 7d
H. influenzae, Eye drops: Tobramycin OR Levofloxacin 2 drops
Moraxella sp. qid x 5-7d

Comments:
Ointment is preferred over drops for children, those with poor compliance, and
those in whom it is difficult to administer eye medications. However, ointments
blur vision for 20 minutes after the dose is administered. Fluoroquinolones offer
the best spectrum of activity for empiric therapy. It is the preferred agent in
contact lens wearers. Remove discharge by irrigation with saline.

D. Gonococcal Conjunctivitis

Etiology: Preferred Regimen:

N. gonorrhoeae A: Ceftriaxone 1g IV/IM x 1 dose PLUS
Azithromycin 1g PO x 1 dose for presumptive
Chlamydia co-infection PLUS

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Chlamydia trachomatis Topical Levofloxacin or Tobramycin or

(presumptive co- Erythromycin ointment qid x 2-3 weeks or until
infection) resolution of symptoms.

Comments:
Ophthalmology consult recommended because it can progress to corneal
perforation. Irrigate conjunctiva with saline to remove discharge as often as
needed. Test patient for HIV and syphilis. Treat sex partner.

V. KERATITIS

A. Herpes Keratitis

Etiology: Preferred Regimen:

Herpes simplex 1 P and A:
and 2 Ganciclovir 0.15% or Aciclovir 3% ophthalmic
ointment, 5x/d until corneal ulcer heals, then tid x 7d

Comments:
Serious and often sight threatening so prompt ophthalmologic consultation is
essential for diagnosis, antimicrobial, and adjunctive therapy. 30% recur within 1y.
For those aged 12y and older with recurrent infections (>2x a year), Aciclovir 400
mg bid for 12 months may be given to prevent recurrences. Oral antiviral drugs
are not necessary.

B. Varicella zoster opthalmicus

Etiology: Varicella zoster virus

Preferred Regimen:
P: Aciclovir 10mg/kg IV (most effective within 72h from appearance of vesicles)
A: Famciclovir 500mg PO tid OR Valaciclovir 1g PO tid OR Aciclovir 800mg PO
5x/d x 10d
Apply tobramycin-dexamethasone ointment 2 to 3 times a day to lesions on the
eyelids until resolution of lid lesions.

C. Acute bacterial keratitis (no comorbidity)

Etiology: Preferred Regimen:

S. aureus, S. pneumoniae, P: Gram-negative: Tobramycin eye drops
S. pyogenes, Haemophilus sp., 1-2 drops q4h

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Also for children: P. Gram-positive: Levofloxacin 0.5% eye

aeruginosa, Moraxella spp. drops
A: Gram-positive: Levofloxacin 0.5% eye
drops
Dry cornea / diabetes, Refer to ophthalmologist
immunosuppression:
S. aureus, S. epidermidis, S.
pneumoniae, S. pyogenes,
Enterobacteriaceae, Listeria sp.

Comments:
Obtain specimen for Gram stain and culture studies and adjust treatment
accordingly. Topical steroids are never used in isolation. NEVER patch the eye.
Bacterial keratitis can be a vision-threatening disease: prompt consultation with
an ophthalmologist is essential. Consider systemic antibiotic for large (>6 mm)
corneal ulcer, corneal perforation or scleritis due to Pseudomonas aeruginosa and
other Gram-negative enteric bacteria.

D. Bacterial keratitis secondary to contact lens use

Etiology: P. aeruginosa

Preferred Regimen:
PEDIATRICS ADULTS
Tobramycin 0.3% ophthalmic Ciprofloxacin 0.3% eye drops OR
solution 1-2 drops qh x 24h then taper Levofloxacin 0.5% eye drops OR
based on clinical response. Tobramycin 0.3% solution
Give 1 drop qh x 24-72h then taper
based on clinical response

Comments:
Referral to ophthalmologist is recommended. Discontinue contact lens use.

E. Fungal keratitis

Etiology: Preferred Regimen:

Aspergillus, Fusarium, Candida Refer to ophthalmologist

Comments:
Obtain specimen for fungal wet mount and cultures. Empiric therapy is not
recommended for fungal keratitis. It is important to try to identify organism from
corneal scrapings. NEVER give topical steroid. NEVER patch the eye. Daily

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debridement is advised to enhance penetration of anti-fungal agents. Topical

cycloplegic (atropine sulfate 1%) one drop 3 times a day until free of pain.

F. Keratitis, Protozoan

Etiology: Preferred Regimen:

Acanthamoeba sp. Refer to ophthalmologist

Comments:
Corneal infection usually associated with trauma or soft contact lens use. NEVER
patch the eye. Discontinue contact lens use. Topical broad-spectrum antibiotics to
prevent secondary bacterial infection. Avoid topical and subconjunctival steroids.
Topical cycloplegic (atropine sulfate 1%) one drop 3 times a day until free of pain.

G. Keratitis, Non-tuberculous Mycobacterial (Post-Lasik surgery)

Etiology: Preferred Regimen:

Mycobacterium chelonae, Refer to ophthalmologist
M. abscessus, M.
massiliense

Comments:
Ophthalmologic consultation recommended. Prolonged course of therapy.
Treatment regimen is as for extrapulmonary tuberculosis (see National Antibiotic
Guidelines on Tuberculosis).

VI. ENDOPHTHALMITIS

A. Endophthalmitis, Hematogenous

Etiology: S. pneumoniae or other streptococci, N. meningitidis. S. aureus, K.

pnemoniae or other gram-negative organisms, Candida sp. (rare), Bacillus cereus
(heroin use)
(locally usually due to penetrating or perforating globe injury by pointed material
e.g. BBQ stick, walis tingting, wires)

Preferred Regimen: Refer to ophthalmologist

Comments: Intravitreal administration of antimicrobials is essential. Immediate

referral to vitreo-retinal surgeon.

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B. Endophthalmitis, Post-cataract surgery

Etiology:
Early, acute: S. epidermidis, S. aureus, Streptococcus sp., Enterococcus sp., Gram-
negative bacilli, Candida albicans
Low grade, chronic: Propionibacterium acnes, S. epidermidis, S. aureus (rare),
Fungi

Preferred Regimen: Refer to ophthalmologist

Comments:
Immediate ophthalmologic consult is needed. If only light perception or worse,
perform immediate vitrectomy. May require removal of lens material.

C. Endophthalmitis, Candida

• Endogenous: occurs in ~15% of patients with candidemia

• Exogenous: occurs following ocular surgery or traumatic injury.

Etiology: Preferred Regimen:

Candida sp.
Chorioretinitis without Fluconazole 800mg PO (12 mg/kg)
vitritis loading dose, then 400-800mg (6- 12 mg/kg
For fluconazole- qd) OR Voriconazole 400mg IV bid for 2
/voriconazole-susceptible doses loading dose (6 mg/kg), then 300 mg
isolates (4 mg/kg) IV/PO bid

For fluconazole- Refer to ophthalmologist

/voriconazole-resistant
isolates

With macular involvement Refer to ophthalmologist

Chorioretinitis with vitritis Refer to ophthalmologist

(Endophthalmitis)

Comments:
The extent of ocular infection (chorioretinitis with or without macular involvement
and with or without vitritis) should be determined by an ophthalmologist. For
fluconazole–susceptible isolates, fluconazole is preferred over voriconazole.
Vitrectomy should be considered to decrease the burden of organisms and to
allow the removal of fungal abscesses that are inaccessible to systemic antifungal
agents.

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D. Endophthalmitis, Post-traumatic

Etiology: Bacillus sp., S. epidermis, Gram-negative bacilli, Streptococci, Fungi

Preferred Regimen: Refer to ophthalmologist

Comments:
Vitrectomy often necessary. Consider prophylactic administration of systemic +
intravitreal antibiotics in high risk injuries (soil contamination, >24h delay in
wound closure, intraocular foreign body).

VII. RETINITIS

A. Acute Retinal Necrosis

• Vision loss, usually in immunocompetent individuals, which progresses

rapidly with retinal necrosis, vasculitis and uveitis; frequently results in
retinal detachment.
• Begins unilaterally but may involve the other eye (up to 50% of cases).

Etiology: Varicella-zoster virus, Herpes simplex

Preferred Regimen:
Aciclovir 10–12mg/kg IV q8h x 7–10d until disease stabilizes, then oral therapy for
a min of 6 weeks with: Aciclovir 800mg PO 5x/d OR Valaciclovir 1g PO tid OR
Famciclovir 500mg PO tid

Comments:
Ophthalmology consult imperative.

B. Retinitis, Cytomegalovirus (HIV/AIDS)

Etiology: Cytomegalovirus (CMV)

Preferred Regimen: Refer to ophthalmologist

Comments:
Watch for Immune Reconstitution Inflammatory Syndrome (IRIS) (e.g., Immune
Recovery Uveitis) in those on anti-retroviral therapy (ART). ART should not be
delayed owing to concern of IRIS.

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REFERENCES:
• Antibiotic Guidelines 2015-2016. Treatment Recommendations for Adult Inpatients.
Available at: http://www.hopkinsmedicine.org/amp/guidelines/antibiotic_guidelines.pdf
• Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults
and Adolescents. Available at: http://aidsinfo.nih.gov/guidelines.
• Liu C, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children.
Clin Infect Dis 2011: 52;1–38.
• Pappas P, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update
by the Infectious Diseases Society of America. Clin Infect Dis 2016;62(4): e1–50.
• The Sanford Guide to Antimicrobial Therapy 2014. Available at:
http://webedition.sanfordguide.com/.

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