Ocular Antibiotics

and Anti-Infectives
Regis P. Kowalski, MS, M(ASCP)
Research Professor of Ophthalmology

Executive Director of The Charles T

Campbell Laboratory

University of Pittsburgh, Pittsburgh, PA

The Charles T. Campbell

Ophthalmic Microbiology
Laboratory
Areas of Infection
Normal Flora

60 Streptococcus
Coagulase-negative staphylococcus
Diphtheroids
50 Staphylococcus aureus
Gram negatives
Percent Incidence

No growth
40

30

20

10

0
Newborns Children Adults
 Distribution of Bacteria Isolated from Endophthalmitis
(1993-2010) (N=518)
Gram-positives = 92.5%
Gram-negatives = 7.5%
Coagulase Negative
Staphylococcus
57.7% (299)
Streptococcus
species - 19.5% (101)

Other Gram
Negatives - 7.5% (39)

Other Gram
Positives - 4.8% (25)

Staphylococcus aureus - 10.5% (54)

 Treatment Administration
 Topical – Most common (conjunctivitis,
keratitis, blepharitis, prophylaxis)

 Intra-vitreal injection – endophthalmitis

 Systemic – not commonly used

 Subconjunctival – used to provide a

constant flow of anti-infective to ocular
surface.
 Antibacterials
 Antibiotics – No Topical Standards for
Interpreting Susceptibility

 Use Serum Systemic Susceptibility Standards -

But we must assume that “The antibiotic
concentrations reached in the ocular tissue by
topical therapy is equal to or greater than the
concentration of antibiotic in the blood serum”.

 Ocular antibiotics are developed from systemic

antibiotics for conjunctivitis, keratitis
 Antibiotics Parameters
 Concentration–dependent
fluoroquinolones, aminoglycosides
 Time-dependent
vancomycin, cefazolin
 Bactericidal – kill
FQs, vancomycin,
 Bacteristatic – inhibit
erythromycin, azithromycin, sulfa
 Antiseptics – PI – kill immediately
Susceptibility Parameters

Death and NO mutations

MPC

Death but possible mutations

MBC
No growth but viable
MIC

Growth
 Nature of Resistance of Bacteria
 A function of the anti-infective
mechanism,
 Target bacteria,
 The ocular tissue, and
 The treatment regimen.
 Problem with Resistance
 Organism acquires resistance to an
antibiotic.
 Resistance spreads to other patients
 No antibiotic to cover resistance
Class Mode of Action Primary Indication
besides conjunctivitis

Fluoroquinolones DNA synthesis keratitis, surgical prophylaxis

(ciprofloxacin, ofloxacin, bactericidal Broad-spectrum coverage
levofloxacin, gatifloxacin,
moxifloxacin) besifloxacin

Aminoglycosides protein synthesis keratitis, endophthalmitis

(gentamicin, tobramycin, cell wall surgical prophylaxis
amikacin) bactericidal Broad-spectrum coverage

Cephalosporins cell wall keratitis, endophthalmitis

(cefazolin, ceftazidime) bactericidal Gram-positive coverage

Glycopeptides cell wall keratitis, endophthalmitis

(vancomycin) bactericidal MRSA prophylaxis
Gram-positive coverage

Macrolides protein synthesis blepharitis

(erythromycin, azithro) bacteristatic Gram-positive coverage

Peptides cell wall blepharitis, keratitis

(bacitracin, polymycin B) bactericidal Bac – GMpos PB – GMneg

Sulfa drugs enzyme inhibitor keratitis, 2nd – line MRSA

(sulfacetamide) bacteristatic Broad-spectrum coverage
 Anti-Infective Test Batteries
Keratitis Endophthalmitis Conjunctivitis
bacitracin vancomycin bacitracin
vancomycin gentamicin erythromycin
ciprofloxacin ciprofloxacin gentamicin
ofloxacin ofloxacin ciprofloxacin
polymyxin B cefazolin ofloxacin
cefazolin amikacin trimethoprim
tobramycin ceftazidime polymyxin B
sulfisoxazole cefoxitin tobramycin
cefoxitin ampicillin sulfisoxazole
gentamicin clindamycin azithromycin
gatifloxacin gatifloxacin gatifloxacin
moxifloxacin moxifloxacin moxifloxacin
Antifungal Drugs
 Acanthamoeba Drugs
 Cationic Antiseptics (Chlorhexidine
and PHMB)
 Aromatic diamides (propamidine)
Thank You !!