Endophthalmitis ( post operative, post trauma, bleb-related, endogenous ) and penetrating eye injuries - Guideline for the Management of
|Last review: 03/07/2017|
|Next review: 03/07/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management of endophthalmitis (post operative, post trauma, bleb-related, endogenous) and penetrating eye injuries
Endophthalmitis ( post operative, post trauma, bleb-related, endogenous ) and penetrating eye injuries
Treatment – surgical
Treatment - empirical antimicrobial
Endogenous (haematogenous) endophthalmitis immunocompetent patient: intravitreal Vancomycin 1mg in 0.1ml AND Ceftazidime 2mg in 0.1ml. (Discuss empirical systemic antibacterials with microbiology). ADD oral Fluconazole 400mg 24-hourly if current or recent central venous catheter, injecting drug user or known candidaemia.
Endophthalmitis in immunocompromised patient: intravitreal Vancomycin 1mg in 0.1ml AND Ceftazidime 2mg in 0.1ml AND amphotericin 0.005mg in 0.1ml. Add voriconazole 400mg 12-hourly for two doses then 200mg 12-hourly. Empirical systemic antibacterial treatment should be discussed with microbiology.
Penetrating eye injury: intravitreal Vancomycin 1mg in 0.1ml AND Ceftazidime 2mg in 0.1ml AND amphotericin 0.005mg in 0.1ml intravitreally AND oral voriconazole 400mg 12-hourly for two doses then 200mg 12-hourly.
Consider repeating intravitreal antimicrobial injection at 48-72 hours depending on the clinical picture.
Intravitreal injections of dexamethasone 0.4mg in 0.1ml at the end of a vitrectomy have been found to produce a more rapid subsidence of the intraocular inflammation but without improving the long-term functional outcome and is not currently used in Leeds.
Recommendation: If there is no retinal view, a B scan ultrasound is required to diagnose choroidal effusion or retinal detachment before surgery. [Evidence level C]
Recommendation: An intravitreal tap (and anterior chamber tap where there is significant anterior chamber activity) should be performed within one hour of clinical diagnosis of acute bacterial endophthalmitis to obtain samples for microbiological identification and culture. [During this procedure intra-vitreal antimicrobials are instilled.]
Recommendation: General anaesthetic (GA) is favoured because the eye is often inflamed and painful, but organising a GA must not delay the procedure >1 hour from diagnosis. Acute bacterial endophthalmitis is a medical emergency.
Recommendation: For an aqueous tap 0.2mls of aqueous should be removed via the cataract section or a limbal paracentesis using a 27g needle.
Recommended vitreal biopsy procedure:
[Evidence level A]
NB. The microbiology laboratory should be told about the sample in advance and if a fungal infection is suspected this must be communicated clearly to the laboratory.
Recommendation: patients requiring admission for systemic antimicrobial therapy should have baseline full blood count and urea and electrolytes measured.
Recommendation: Blood culture (3 sets at different times) should be sent from patients suspected of having endocarditis prior to commencing systemic antimicrobials. N.B. intraocular antimicrobials can be administered prior to blood cultures.
Recommendation: For the purposes of surveillance inform colleagues of the occurrence of an episode of endophthalmitis (or suspected endophthalmitis). E-mail Fiona.Bishop@nhs.net and copy to all ophthalmology consultants & trainees.
A three port pars plana vitrectomy involves removal of the core vitreous gel with intravitreal antimicrobials once completed. Vitrectomy is the initial procedure of choice because the infected vitreous behaves like an abscess, impeding the activity of antimicrobials.
In most cases a vitreo-retinal surgeon will not be available to perform a vitrectomy within an hour of presentation, and a vitreous biopsy and injection should be undertaken.
|Empirical Antimicrobial Treatment|
Recommended empirical antimicrobials for:
NB Vancomycin and Ceftazidime must not be mixed in same syringe as physically incompatible.
Recommended second line intravitreal antimicrobials. Vancomycin 1mg in 0.1ml and amikacin 0.4mg/ml.
Endophthalmitis is usually confined to the infected eye so delivery of antimicrobials directly to the site of infection enables high local levels of antimicrobials and avoids the systemic side effects.
Systemic Vancomycin has very poor retinal penetration and must therefore be given by intravitreal injection: Eighteen patients with endophthalmitis following cataract surgery were given 1g of Vancomycin by IV infusion. One to five hours later the patients had a vitreous tap, intravitreal antimicrobials and the Vancomycin levels in the vitreous fluid were measured. Results were obtained for 15 patients. The mean Vancomycin level 3.5 to 5 hours after IV administration was 2.04 +/- 1.33 mg/L (range non-measurable to 4.5 mg/L). These levels were sub therapeutic and the authors conclude that the addition of IV Vancomycin in the treatment of endophthalmitis is not beneficial. ESCRS guidelines recommend intravenous use of the same drugs as given intra vitreally based on the theory that this should help to maintain adequate levels in the vitreous, however, this has not been shown to be beneficial and we feel that the real risks of toxicity and intravascular catheter-related infection outweigh any theoretical benefit.
Moorfields eye hospital use moxifloxacin 400mg once daily for 10 days in adults and use Ciprofloxacin (no dose given) in children.2 Moxifloxacin has marginally better activity against coagulase negtive staphylococci than Ciprofloxacin , but in a recent study of coagulase negative staphylococcal isolates from endophthalmitis cases in the USA, moxifloxacin was only active against 48% of isolates, too few to justify empirical use (Harper et al., 2007). In addition there is no evidence of efficacy.
The addition of systemic quinolones should be reserved for cases when the causative organism is known and shown to be susceptible.
Systemic amphotericin has very poor intra-vitreal penetration and serious systemic toxicity and is not therefore recommended. In animal experiments the vitreal concentration of Fluconazole reached 56% of the plasma concentration at steady state.7
|Directed Antimicrobial Treatment (when microbiology results are known)|
Review microbiology results regularly. Once the causative organism is known it may be appropriate to commence systemic therapy and subsequent intravitreal antimicrobials can be adjusted accordingly. If no microbial cause is identified, empirical therapy should be continued.
Late case endophthalmitis is milder and usually caused by Propionibacterium acnes. As it is often found enclosed in the synachised capsular sac it has a high rate of recurrence. This can be reduced by vitrectomy possibly combined with posterior capsulectomy. Oral medication is clarithromycin 250mg 12-h.1
Staphylococcus aureus, coagulase negative staphylococci,
Enterobacteriaceae or Pseudomonas aeruginosa
Recommendation: Initial therapy intravitreal amphotericin 0.005mg in 0.1ml
Recommendation: Voriconazole 0.05mg in 0.1ml is used second line intravitreal agent if treatment failure with amphotericin or if organism identification or sensitivities require voriconazole.2,6
Recommendation: Treat confirmed Candida endopthalmitis with high dose oral Fluconazole 400mg once a day (after 1 day of 12-hourly regimen for loading) for 6-12 weeks. If the isolate is found to be resistant to Fluconazole or is caused by filamentous fungi then voriconazole would be the recommended antimicrobial. 400mg 12-h for two doses then 200mg 12-h for up to 5 weeks.
If initial culture results are negative and the patient is deteriorating following empirical intravitreal a second sample should be collected at the time of repeated intravitreal injection.
|Duration of Treatment|
Intravitreal injection can be repeated according to the clinical picture at intervals of 48-72 hours.
|Switch to oral agent(s)|
|Systemic antimicrobials if required are usually given orally.|
Repeat doses of intravitreal antimicrobials are recommended if there is not significant resolution of inflammatory signs: vitreous opacifiation, hypoyon, pain and conjunctival injection, 48 hours after the initial treatment.
|Target patient group:||Adult patients with endophthalmitis|
|Target professional group(s):||Secondary Care Doctors
- ESCRS (European Society of cataract and refractive surgery) Guidelines on prevention, investigation and management of post-operative endophthalmitis. Version 2 “007. Editors Barry P et al.
- Moorfields eye hospital NHS foundation trust pharmacists handbook. 2006
- Ferencz J, Assia E, Diamantstein L and Rubinstein E. (1999). Vancomycin concentrations in the vitreous after intravenous and intravitreal administration for postoperative endophthalmitis. Arch Ophthalmol 117: 1023-1027.
- Smith A, Pennefather P, Kaye S, Hart C. Fluoroquinolones. Place in Ocular Therapy. (2001) Drugs. 61. 747-761.
- Lesk M, Ammann H, Marcil G, Vinet B, Lamer L, Sebag M (1993). The penetration of oral ciprofloxacin into the aqueous humor, vitreous, and subretinal fluid of humans. Am.J. Ophthalmol, 115: 623-8,
- Current clinical practice.
- Sunaric-Mégevand G and Pournaras C. Current approach to postoperative endophthalmitis. Br J Ophthalmol 97;81:1006-1015.
Ciulla, T. A., Comer, G. M., Peloquin, C. & Wheeler, J. (2005). Human vitreous distribution of linezolid after a single oral dose. Retina 25, 619-624.
Duke, S., Kump, L., Yuan, Y., West, W., Sachs, A., Haider, N. & Margalit, E. (2009). The Safety of Intraocular Linezolid in Rabbits. Invest Ophthalmol Vis Sci.
Harper, T., Miller, D. & Flynn, H. W., Jr. (2007). In vitro efficacy and pharmacodynamic indices for antibiotics against coagulase-negative staphylococcus endophthalmitis isolates. Ophthalmology 114, 871-875.
Prydal, J. I., Jenkins, D. R., Lovering, A. & Watts, A. (2005). The pharmacokinetics of linezolid in the non-inflamed human eye. Br J Ophthalmol 89, 1418-1419.
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies.
C. Expert consensus.
D. Leeds consensus.
Improving Antimicrobial Prescribing Group
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