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Ocular Pharm > Ocular Pharm: L3: Drugs to Treat Ocular Infections > Flashcards

Ocular Pharm: L3: Drugs to Treat Ocular Infections Flashcards

1
Q

What are the main things you should think about when Treating infections?

A
  1. Type of Organism
  2. Location
  3. Natural course of infection
  4. Patient’s immune status
  5. chances that organism is drug resistant
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2
Q

Ideal Antimicrobial Tx Strategy

  1. First establish what?
  2. Select drugs that are what to the organism?
  3. Select drug that is least what?
  4. Establish effective what at site of infection?
  5. Use appropriate what?
  6. Augment therapy with what?
  7. What do we do with the patient?
  8. When do you evaluate treatment effectiveness?
    a. What if it’s a more severe infection?
A
  1. Diagnosis
  2. sensitive
  3. Least toxic/safest active drug
  4. Dose level
  5. dosing schedule and duration
  6. w/physical procedures
  7. educate them!
  8. about 1 week
    a. 3 days if no substantial improvement, and sooner for severe infections
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3
Q

Antibacterial Drugs

  1. What kinds are there? (5)
A
  1. Cell wall inhibitors
  2. Cell membrane disruptors
  3. DNA synthesis inhibitors
  4. Folate Metabolism Inhibitors (Anti-metabolic)
  5. Protein Synthesis Inhibitors
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4
Q

Bacterial vs. Eukaryotic Cells

  1. What do bacterial cells have that Eukaryotic cells do NOT?
  2. Bacterial cells what what kind of membranes?
    a. Their membranes are what?

b. What do Eukaryotic cells have?
3. Bacterial Ribosomes differ from what?

  1. What can enter Eukaryotic Cells but not bacterial Cells?
    a. Why is this?
    b. What do bacterial cells need to do then?
  2. Bacterial cells have what kind of DNA?
    a. Eukaryotic?
    b. What do bacterial cells have to do more to their DNA than eukaryotic cells have to do?
A
  1. Cell wall
  2. Inner and Outer membranes
    a. They’re ANIONIC

b. 1 inner membrane. They’re ZWITTERIONIC
3. eukaryotic ribosomes
4. Folic Acid
a. Due to bacterial cell wall
b. They have to make it
5. Circular DNA
a. Linear
b. Have to unwind their DNA more

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5
Q

Cell Wall Inhibitors (1)

  1. Penicillins (Main one he had listed)?
    a. Bactericidal/Static?
    b. Spectrum range?

c. Sensitive to what? (Except if they’re Given with WHAT?)
d. Problem with the Older drugs?
e. Toxicity level? (high or low)?
f. MAJOR SIDE EFFECT?

A
  1. AMOXICILLIN

a. Cidal
b. Gram + to Extended Spectrum

c. Beta Lactamase Sensitive (unless u give it w/a Beta Lactamase Inhibitor, e.g. Clauvanate)
d. Resistance
e. Low
f. Sensitivity

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6
Q

Cell Wall Inhibitors (2)

  1. Cephalosporins (2 main ones he has listed)
    a. Cidal/Static?
    b. Range of spectrum?
    c. problem w/older drugs?
    d. Major side effect?
    e. Which generation drugs cross-react w/Penicillin?
A
  1. CEFTRIAXONE, and CEPHALEXIN
    a. Cidal
    b. Gram + in First generation, to Extended Spectrum in Fourth Generation
    c. Resistance
    d. Sensitivity
    e. 1st generation drugs
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7
Q

Cell Wall Inhibitors (3)

  1. Bacitracin
    a. Cidal/Static?
    b. Coverage?
    c. Administered how?
  2. VANCOMYCIN
    a. cidal/Static?
    b. Range?
    c. USED FOR what?
    d. Problems (2)?
  3. ETHAMBUTOL
    a. EFFECTIVE against what?
    b. Problems?
A
  1. Cidal
    b. Mainly Gram + coverage
    c. Topically (Nephrotoxicity)
  2. a. CIDAL
    b. Gram + coverage
    c. MRSA
    d. Nephro- and Ototoxicity
  3. a. TB Bacteria
    b. Optic Neuritis, Color Blindness, Nystagmus, Arthralgia
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8
Q

Cell Membrane Disruptors

  1. POLYMYXIN B
    a. Cidal/Static?
    b. Coverage?
    c. Used with other Drugs (like what)?
    d. Issues? (2)
  2. Gramicidin
    a. Cidal/Static?
    b. Coverage?
    c. Used with other drugs: Substitute for what?
    d. How is it administered? Why?
A
  1. a. Cidal
    b. Gram NEGATIVE
    c. like TRIMETHOPRIM as Polytrim
    d. Nephro and Oto Toxicity
  2. a. Cidal (but can be static depending on growth phase)
    b. Gram + coverage
    c. for Bacitracin
    d. Topical ONLY; will cause HEMOLYSIS otherwise
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9
Q

Protein Synthesis Inhibitors (1)

  1. Aminoglycosides (Main one he had highlighted?)
    a. What does it inhibit?
    b. static/cidal?
    c. How are they given?
    d. What 2 things can they cause?
    e. Coverage
  2. Tetracyclines (What 2)
    a. What do they inhibit?
    b. Static/cidal?
    c. Coverage?
    d. High Resistance in what?
    e. Toxicities?
A
  1. TOBRAMYCIN, gentamycin (Bolded = NB)

a. Protein Synthesis Inhibitor (30S)
b. Can be either
c. Topically or Parenterally (poor oral absorption)
d. Nephro and Oto toxicity
e. Gram + and -

  1. TETRACYCLINE, DOXYCYCLINE

a. Protein synthesis (30S)
b. Static
c. Broad spectrum
d. in Common Bacteria
e. Many; Discoloration of Developing TEETH (No for kids and pregnant women)

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10
Q

Protein Synthesis Inhibitors (2)

  1. CLINDAMYCIN
    a. What does it inhibit?
    b. Static/cidal?
    c. Coverage?
    d. Side effects?
  2. Macrolides:
    a. Inhibit what?
    b. Static/cidal?
    c. Main coverage use?
    d. High sTREP RESISTANCE to OLDER Drugs (like what)?
    e. side effects?
  3. Chloramphenicol
    a. Inhibitor of what?
    b. Static/cidal?
    c. Spectrum? Includes what?
    d. Toxicity?
A
  1. a. Protein synthesis (50S)
    b. Static
    c. Gram + and -, Anaerobes; Protozoa, Acne, MRSA
    d. Diarrhea
  2. (AZITHROMYCIN, Clarithromycin)

a. Protein Synthesis (50S)
b. Static
c. Mostly GRAM +
d. Erythromycin
e. Hypersensitivity; GI Effects; Reversible Hepatitis

  1. a. Protein Synthesis (50S)
    b. Static
    c. Broad; Including Non-Bacterial Microorganisms
    d. Aplastic Anemia
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11
Q

Folate Metabolism Inhibitors

  1. Sulfonamides (What 4)
    a. Static/cidal?
    b. Coverage?
    c. Oldest what? Problem?
    d. Often used in Combo w/what?; Why?

e. Main USE?
f. SIDE EFFECTS?

  1. TRIMETHOPRIM
    a. Static/cidal?
    b. Coverage?
    c. Mainly used in what?
    d. Toxicities mainly Associated with what?
A
  1. (SULFADIAZINE, SULFAMETHOXAZOLE, SULFISOXAZOLE, sulfacetamide)

a. Static
b. Gram + and -
c. Oldest ANTIBACTERIAL DRUGS; Widespread Resistance (The Demon under the Microscope)

d. w/TRIMETHOPRIM (more effective. they work together to block sequential steps in FOLATE SYNTHESIS)
e. Treating TOXOPLASMOSIS
f. Nephrotoxicity and Hypersensitivity (Stevens-Johnson Syndrome)

  1. a. Static
    b. Gram + and -
    c. in Combos
    d. w/Folic Acid Deficiency
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12
Q

DNA Synthesis Inhibitors

  1. Fluoroquinolones:
    a. Cidal/Static?
    b. Coverage?
    c. Low TOXICITY when used w/what route of administration?
    d. Side Effects?
    e. What is NEW and has NO ORAL EQUIVALENT?; Why is this good?
    f. Indicated for use in what 2 BACTERIAL INFECTIONS?
A
  1. *Don’t use 1st Generation anymore; 2nd Gen: OFLAXACIN and CIPROFLOXAXIN
    3rd: LEVOFLOXACIN
    4th: MOXIFLOXACIN, GATIFLOXACIN, and besifloxacin
    a. CIDAL
    b. Gram - w/some Gram + coverage in successive generations
    c. Topically
    d. Destructive Arthropathy (juvenile animal studies, not observed in humans) and TENDONITIS
    e. BesiFloxacin; Less chance to develop resistance (so not given orally and never will be)
    f. Bacterial Conjunctivitis and Bacterial Keratitis
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13
Q

Common Topical Antibacterials (1)

  1. Macrolides:
    a. Azithromycin (how is it given)
    b. Erythromycin
  2. Fluoroquinolones
    a. Besifloxacin
    b. Ciprofloxacin
    c. Gati-
    d. Levo
    e. Moxi-
    f. Oxy-
  3. Aminoglycosides
    a. Gentamycin
    b. Tobramycin
  4. Bacitracin
  5. Combos
    a. Neosporin
    b. Polysporin
    c. Polytrim
A
  1. a. Drops
    b. Ointment
  2. a. Suspension
    b. Drops, Ointment
    c-f. DROPS
  3. a. Drops, Ointment
    b. Drops, Ointment
  4. Ointment
  5. a. Polymyxin B, Neomycin, Gramicidin; (OINTMENT)
    b. Polymyxin B, Bacitracin (Ointment)
    c. Polymyxin B, Trimethoprim (DROPS)
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14
Q

Commonly Used Oral Antibacterials

  1. Penicillins
    a. What 2?
  2. Cephalosporins: What one?
  3. Macrolides: What one? (What’s the BLACK BOX WARNING for?)
  4. Tetracyclines: What 1?
  5. Fluoroquinolones: What one (generation 3)
A
  1. a. Augmentin (amoxicillin plus clauvanate) and Dicloxacillin
  2. Cephalexin
  3. on Z-pack for FATAL ARRYTHMIA
  4. Doxycycline
  5. Levofloxacin
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15
Q

General Rules for Antibacterials

  1. Don’t kill bugs you don’t need to kill
    a. so if infection has high probability of being gram positive but not too severe, use drug with what?
    b. What does this AVOID?
    c. You can always switch to what if necessary?
  2. Don’t use more powerful treatment than needed
    a. For mild infections: What may be acceptable?

b. Use what kind of Drugs when possible, to MINIMIZE SIDE EFFECTS?

  1. Don’t use a Newer generation than needed.
    a. Why?
    b. Older drugs are GOOD for what?
A
  1. a. with Gram + Coverage
    b. Avoids Superinfections
    c. to a more broad coverage if needed
  2. a. Cytostatic Drugs
    b. TOPICAL
  3. a. more often newer drugs are used, the sooner resistance to them will develop
    b. for COVER, mild infections (at least as a starting point), and unusual organisms
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16
Q

Antiviral Drugs

  1. Topical: 2 types
  2. Oral: FAV
  3. ALL of them are what ANALOGS?
A
  1. a. TRIFLURIDINE (VIROPTIC)
    b. GANCYCLOVIR (Zirgan)
  2. a. Famcyclovir
    b. Acyclovir
    c. Valacyclovir
  3. are Nucleoside analogs
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17
Q

Antifungal Drugs

  1. Topical: Only one is currently available.
    a. Amphoteracin is a better drug to use, but only approved to be used where?
  2. Oral: 2
A
  1. NATAMYCIN
    a. Off label: in Europe
  2. a. FLUCONAZOLE
    b. Voraconazole
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18
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

  1. ALL of them are caused by what type of infection?
  2. Name the 4 we talked about in class? (BC HD)
A
  1. Bacterial
  2. a. Blepharitis
    b. Cellulitis (Preseptal and Orbital)
    c. Hordeolum
    d. Dacrycystitis
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19
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Blepharitis

  1. What is it?
  2. Most common Pathogens?
    a. So mostly what type?
A
  1. Bacterial colonization of lid margin, lid glands, or cilia follicles
    (can cause lid changes, conjunctivitis, SPK, corneal infiltrates, and phlyctenules)
  2. Staph Aureus (by far), Strep epidermidis, Proprionibacterium Acnes, Moraxella spp.
    a. Mainly G + but minor contribution from Gram -
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20
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Blepharitis Treatment (BAD)

  1. Bacitracin: What is it?
    a. Good for coverage of what?
    b. Can put directly into what?
  2. Azythromycin 1% (DROP)
    a. How many drops per day?
    b. Works on what bacteria?
    c. May also help restore what?
  3. Doxycycline (100 mg, po, qd), Tetracycline (250 mg, po, qd)
    a. Static/Cidal
    b. Use this dosage for how long? Then taper to what?

c. Mainly used for what?
d. works on what?
e. Problem?
4. Older macrolides and Tetracyclines can be used, but they have limited effectiveness due to what?

A
  1. Ointment (1/2’’, qhs); CWI, CIDAL

a. Gram + and some -
b. onto lids

  1. Macrolide, PSI, Static
    a. 1 drop bid for first 2 days, then once DAILY for next 12 DAYS

b. Gram + and Negative; Covers all major bacterial causes!
c. Lipid in meibomian glands to more normal State (anti-lipase activity)
3. a. Static, PSI
b. 1-2 weeks; then taper to 1/4 dose for 6 MONTHS
c. Anti-Lipase Activity
d. Gram + and Negative Effects, but Significant resistance has developed
e. SEE d.
4. Resistance

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21
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Non-Drug Blepharitis Tx

  1. Lowers Bacterial Burden?
  2. Decreases VISCOSITY of meibum encouraging outflow and renewal
  3. Also encourages renewal of meibum
A
  1. LID SCRUBS
  2. WARM COMPRESSES
  3. EXPRESSION of MEIBOMIAN GLANDS
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22
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Hordeolum

  1. Infection of what?
    a. External: Associated with what?
    b. Internal: Associated with what?
  2. Most COMMON PATHOGENS? (2)
A
  1. Sebaceous glands
    a. associated w/Cilia
    b. w/Meibomian Glands
  2. Staph Aureus and Staph Epidermidis (GRAM POSITIVE)
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23
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Hordeolum Treatment

  1. Topically treated with 1 of 2 drugs?
    a. External Hordeolum: Apply ointment to Lid margin to do what?

b. Internal Hordeolum: Apply Antibiotic Ointment to Cul-De-Sac as what kind of Tx against CONJUNCTIVITIS in case of SPONTANEOUS RUPTURE
c. Older, less potent drugs are useful? If so, Why?
2. If you want to actually treat it, GIVE them ORAL what? (3 things possible)
a. For cases that don’t respond to what Tx?
b. Oral Route will get more drug to what locations?

c. Supply primarily G+ effects (extended for what oral drug)
a. Don’t want to necessarily kill what kind of bacteria in this case?

A
  1. Bacitracin (CWI, CIDAL) or Erythromycin (Macrolide, PSI, Static)
    a. REDUCE BACTERIAL LOAD
    b. PROPHYLAXIS against those things…
    c. Resistance is less important so yes…purpose of these is to reduce it…doesn’t actually treat the actual infection!
  2. ORAL DICLOXACILLIN (penicillin, CWI, CIDAL), CEPHALEXIN (Cephalosporin, CWI, CIDAL), or AUGMENTIN (PENICILLIN w/CLAUVANATE, CWI, CIDAL)
    a. to Topical Tx
    b. to deeper locations
    c. a. Gram Negative bacteria (Systemic)
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24
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Non-Drug Hordeolum Tx

  1. Main thing to do?
    a. How long?
    b. Purpose?
    c. If if persists, it may give rise to what 2 things that are harder to treat?
A
  1. Warm Compresses, 10 min, qid, w/light massage over hordeolum
    a. 10 m qid.
    b. get lesion to point and DRAIN
    c. Chalazion or Pyogenic Granuloma
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25
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Dacryocystitis

  1. Infection of what?
    a. usually secondary to what?
  2. Most common Infective Organisms (3)
    a. These are…
A
  1. Lacrimal Sac
    a. to Nasolacrimal Duct Obstruction
  2. a. Staph, Strep, Diptheroids (Corynebacterium)
    a. Gram +
26
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Dacryocystitis Treatment

  1. Oral what for ADULTS ONLY?
    a. Or what other 2 oral things?
    b. These all give what kind of COVERAGE?
    c. What types of drugs are they and are they cidal/static?
  2. If acutely ill or febrile, Hospitalize and treat with 1 of 2 things?
  3. Prophylaxis for Neonates: What do you give?
A
  1. Oral Cephalexin (Adults only)
    a. Augmentin (amoxacillin plus Clauvanate), or Cephaclor
    b. Good Gram + coverage
    c. CWI, CIDAL
  2. IV Cefaxolin (adults) or Cefuroxime
  3. Topical POLYTRIM (trimethoprim/Polymyxin B)
    * If someone looks like they’re really sick, have chills, not eating alot, in a lot of pain, send them to the ER!
27
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Preseptal Cellulitis

  1. What is seen?
  2. May have history of 1 of three things?
  3. May also have a MILD what?
  4. NO: THEY WILL NOT HAVE WHAT? (differentiation b/w Preseptal and Orbital)
  5. Infecting Organism is usually WHAT? (3 things)
    a. These are what?
A
  1. Tenderness, Redness, Swelling of Eyelid and Periorbital Area
  2. Abrasion, Insect Bites, Sinusitis
  3. Mild Fever
  4. NO Proptosis, Optic Neuropathy, restriction and/or pain of eye movement
  5. Staph Aureus, Strep, H. Influenzae
    a. Gram + and -
28
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Preseptal Cellulitis Treatment

  1. Mild
    a. 4 drugs that can be used (ACTM)
  2. Moderate or SEVERE
    a. So what 3 situations?
    b. Send them where?
    c. Give them what?
A
  1. a. Augmentin (20-40 mg/kg/day divided in 3 DOSES for KIDS!) or 400 mg po q8h for ADULTS
    b. CEFACLOR, po, similar dosing
    c. Trimethoprim/Sulfamethoxazole (Bactrim), po
    d. Moxifloxacin (CI in CHILDREN), po
  2. a. CHILD
29
Q

Lids, Lashes, Lacrimal, Adnexia, Orbit

Orbital Cellulitis

  1. Symptoms?
  2. What do we see?
  3. Infecting organisms Same as for what?
    a. What else could cause it in IMMUNOCOMPROMISED PATIENTS?
  4. TREATMENT?
A
  1. Red eye, Pain, blurred/double vision, nasal/sinus congestion/pain, tooth pain, orbital pain
  2. Eyelid edema, erythema, warmth, tenderness, conjunctival chemosis and injection, proptosis, pain on eye movement, restricted eye movements
  3. as for Preceptal Cellulitis
    a. Fungi
  4. Admit to Hospital for BROAD Spectrum IV Antibiotics
30
Q

Conjunctiva and Cornea

  1. Conjunctivitis: infection type(s)
  2. Keratitis: same question
  3. Abrasion: same…
A
  1. Bacterial, Viral
  2. Bacterial, viral, Fungal, Protozoan
  3. Bacterial, Fungal
31
Q

Bacterial Conjunctivitis

  1. Common as Viral Conj…?
  2. Progression: Rapid or slow?
  3. Injection is what?
  4. There’s usually what?
  5. What will patient say they feel?
  6. Main bacteria involved? (4)
A
  1. No.
  2. RAPID (person will say i saw it last night or i woke up this morning) :Viral: last 3 or 4 days
  3. MEATY RED (much greater in Bacterial)
  4. a Discharge: Mucopurulent; Eyes may be GLUED SHUT in the Morning? (viral will be more of a WATERY)
  5. FBS, Grittiness
  6. Staph Aureus, S. Pneumoniae, N. Gonorrhoeae (if hyperacute, report and refer), Haemophilus sp.
    a. Gram + and -.
32
Q

Bacterial Conjunctivitis Tx

  1. Fluoroquinolones (BMG)
    a. Number of times a day?
    b. Topical or Oral
    c. Length of use?
    d. May use what?
  2. Polytrim
    a. Amt?
    b. number of days?
  3. Azithromycin
    a. Amt?
    b. Number of days?
A
  1. B-Floxaxin, Moxi-Floxacin, Gatifloxacin

a. 3-4 times a day
b. Topical
c. 3-7 days
d. a Loading Dose (so you could tell them to take it every hour on day one, then switch to TID on the second day)

  1. 4 times a day (topical)
    b. 7 days
  2. a. BID to QID (topical)
    b. 7 days
33
Q

Viral Conjunctivitis (most conjunctivitis we see is VIRAL)

  1. What are the 3 main ones?
A
  1. HSV, HZV, Adenovirus
34
Q

Viral Conjunctivitis: HSV (not very common…he has only seen 2 cases of it since he has been here)

  1. What will patient complain of?
  2. Corneal Epithelium may show what kind of KERATITIS (2)?
    a. What else?
  3. Treatment
    a. VIROPTIC: How many times a day until what heals? Then what?
    b. ZIRGAN: Number of times a day until what heals? Then what?

c. Oral Acyclovir: Amt? Can be used in place of topicals
* *Good as a PROPHYLAXIS Tx (if this pt has been in with this infection for more than once) and you would give them 1/2 the dosage for when they actually have it.

d. Can you use Corticosteroids?

A
  1. Red eye, Pain, PHOTOPHOBIA, Tearing, DECREASED VISION, Vesicular rash in Eyelid, Conjunctival Injection w/Follicles
  2. Macropunctate Keratitis, or Dendritic Keratitis
    a. Geographical ULCER!!
  3. a. (Trifluridine 1% drops) 9x’s day until Ulcer heals! Then q4h while Awake for 7 DAYS
    b. 5x’s/day till ulcer heals. Then TID for 7 DAYS
    c. 400 mg, 5x/day, 10 days. (Doesn’t add an acute benefit when given in addition to topicals; May be beneficial in preventing recurrence (lower dose))
    d. NO! not until corneal epithelium ulcer is healed!
35
Q

Viral Conjunctivitis: HZV

  1. What will you see?
  2. Corneal Epithelium shows what?
  3. Tx? (4 things you could do)
    * If it’s raised, dye sits around it. (don’t mistake it for an exudate)
A
  1. Dermatomal PAIN, Skin rash, Blurred vision, red eye, eye pain, HUTCHINSON SIGN
  2. SPK, and may show Pseudodendrite (raised instead of Excavated, w/no end bulbs…reason why we use a dye)
  3. a. Acyclovir (800 mg, po, 5x’s/day), Famciclovir (500 mg, po, q8h), Valcyclovir (1000 mq, po, qid)

or Erythromycin ung bid as antibiotic Cover

36
Q

Viral Conjunctivits: ADENOVIRUS (EKC): (WE will see this ALL THE TIME!!)

  1. EKC is distinguished from a Bacterial Infections by what?
  2. Infection: Self-resolving?
  3. Treatment (off label)
    a. Betadine: what do you do? (Not standard of care)
    * Occurs more gradually.
A
  1. Signs and Natural history (by it’s Size. My eye has kind of been hurting me a week and my vision has gotten all blurry…so natural history will distinguish it)…
  2. YES!
  3. a. wash regimen: Anesthetize, Treat w/Betadine for 1 min; Wash w/Sterile Saline 1 min; Re-anesthetize

or

Gangiclovir Ophthalmic Gel 0.15% (ZIRGAN)

  • These may reduce length of conjunctivitis.
  • Normally: Lasts 3 Weeks.

1st Wk: SPK

2nd Wk: Corneal Infiltrates

3rd Wk: Corneal infiltrates as well…?? Generally disappears in 3 wks.

37
Q

Bacterial Keratitis

  1. What will we see on the Conj?
    a. What other symptoms are there?
  2. What will we see in the CORNEAL STROMA?
    a. There may also be an OVERLYING what?
  3. This is usually associated with the use of what?
  4. Common infecting organisms?
A
  1. Injection
    a. FBS, Pain, Decrease VA, Photophobia, Discharge (Purulent or mucopurulent)
  2. Focal, White Opacity
    a. ULCER
  3. of CL wear
  4. Staph Aureus, Staph Epidermidis, Staph Pneumoniae, Strep. Viridians, Moraxella, Propionibacterium Acnes, Klebsiella, Proteus, Serratia, Haemophilus, Nisseria, Pseudomonas Aeruginosa (In CL WEARERS!)
38
Q

Bacterial Keratitis Treatment

  1. Fortified Antibiotics:
    a. Oral or Topical?
    b. Alternating what 2 drugs?
    c. Are they more effective than Fluoroquinolones in this Tx?
  2. Fluoroquinolones
    a. Topical or Oral
    b. What ones are FDA approved?
    c. What are used Off Label?
    d. How many drops every what?
  3. What kind of coverage do you start w/until culture results are back?
  4. Use drugs with what kind of resistance?
A
  1. Topical
    b. Tobramycin (9.1 or 14 mg/ml) and Cefazolin (50 mg/dl), q30 to 60 m around the clock (need to have a good compounding pharmacy)

c. No
2. a. Topical
b. Ciprofloxacin, Ofloxacin, Levofloxacin
c. BGM (-Floxacin)
d. 2 drops q15 for 6 HOURS, then 2 drops q30 m for 18 HOURS, then taper depending on Pt Response
3. Broad Coverage
4. LOW Resistance. Don’t have time to try a couple of different Drugs

39
Q

Bacterial Keratitis: Other Considerations

  1. TREAT AGGRESSIVELY!
    a. Loading doses (how much for first day), esp if what is present?
    b. recheck when?
    c. What do you do w/the organism?
  2. What do you do if Infection is SIGHT THREATENING (centrally located)
A
  1. a. 15 min to hourly for first day; esp if Ulcer is present
    b. in 24 hrs
    c. culture it
  2. use Fortified antibiotics or NEWER Fluoroquinolones w/around the clock Tx. or REFER : Emergency. Start Tx if requested by doctor to whom u are referring, or if referral is delayed.
40
Q

Viral Keratitis

  1. HSV: AKA?
    a. Infective in nature?
    b. Treat with what, along with what?
  2. HZV: AKA?
    a. GIVE what cover?
    b. Consider using what?
A
  1. Disciform Keratitis
    a. No
    b. Steroid, as well as Antiviral Prophylaxis
    i. Topical: Trifluridine, Valacyclovir; TID to QID

ii. Oral: Acyclovir; 400 mg, bid
2. Neurotrophic Keratitis
a. Antibiotic Cover (Erythromycin ung)
b. Bandage CL

41
Q

Fungal Keratitis

  1. What does patient feel?
  2. Usually associated with 2 things?
  3. What do we see on the cornea?
    a. What may happen to the Epithelium of the cornea (2)?
  4. Infectious agent is usually 1 of 3 things?
A
  1. Pain, Photophobia, Tearing, Discharge, FBS
  2. CL wear or Trauma involving Vegetative Matter
  3. GREY-WHITE CORNEAL INFILTRATE w/FEATHERY BORDER
    a. Epi may be ELEVATED or ULCERATED
  4. Aspergillus, Candida, or Fusarium
42
Q

Tx of Fungal Keratitis

  1. Topical
    a. Main drugs we can give?
    b. How often do we give them?
    c. Taper over how many weeks?
  2. Oral
    a. This is given in ADDITION to what?
    b. Fluconazole
    c. Voraconazole
A
  1. a. Natamycin 5% (or Amphoteracin B 0.15%) drops
    b. q1-2 hrs around the clock
    c. over 4-6 wks
  2. a. to Topicals
    b. 200-40 mg loading dose, then 100-200 mg qd
    c. 200 mg BID, or Topical (1%: not yet commercially available)
43
Q

Acanthamoeba (Protozoan) Keratitis

  1. Pt will experience SEVERE what?
    a. What other symptoms will persist for weeks?
  2. Cornea shows what 3 things?
  3. Usually associated with IMPROPER what?
A
  1. Ocular pain (out of proportion to EARLY CLINICAL FINDINGS)
    a. Redness, Photophobia
  2. Pseudodendrites, Inflammation, Subepithelial Infiltrates
  3. Improper CL Wear (like in a hot tub)
44
Q

Tx of Acanthamoeba Keratitis

  1. Topical
    a. PHMB
    b. Chlorhexidine
    c. Propamide Isethionate (Brolene)
    d. Dibromopropamidine Isethionate (brolene Ointment)
  2. Oral
    a. K
    b. I
    c. V
A
  1. a. 0.02% drops q1h
    b. 0.02% as alternative to above
    c. 0.1% drops q1h
    d. 0.15% ointment
  2. a. Ketoconazole: 200 mg qd
    b. Itraconazole: 400mg loading dose, then 100 to 200 mg qd
    c. Voriconazole: 200 mg qd to BID
45
Q

Collagen Crosslinking (CXL)

  1. Used in Cases of TREATMENT RESISTANT what?
  2. What 2 things produce Enzymes that cause CORNEAL MELTING?
  3. So what does CXL do?
  4. Treatment Regiment
    a. First, what is done to the Cornea
    b. What is instilled over 30 m at intervals of 2-3 minutes?
    c. What is done to the cornea next?
    d. What else can be given topically?
  5. This treatment is EFFECTIVE against what strains?
A
  1. Microbial Keratitis
  2. Bacteria and Fungi
  3. Inhibits Enzymatic Digestion of the Cornea and Enhances Rigidity
  4. a. Anesthetized
    b. Riboflavin in Dextran (0.5-1%)

c. It is IRRADIATED w/UVA
d. Topical Antibiotics
5. Acanthamoeva, Candida, MRSA, Pseudomonas, Staph and Strep.

46
Q

Abrasion

  1. What does the patient feel?
    a. What is one main thing that would help you know that it’s just an abrasion?
  2. Treatment
    a. What Antibiotic Ointment? Given every what?

b. What Antibiotic Drop? Given when?
c. Secondary to VEGETABLE MATTER or FINGERNAILS?

d. CL wearer must have what coverage?
i. What are good drops for that?

A
  1. SHARP Pain, Photophobia, FBS, Tearing, Discomfort w/Blinking
    a. History of TRAUMA
  2. a. Bacitracin, Erythromycin, Polysporin (q2-4 hrs)
    b. Polytrim QID
    c. Floroquinolone Drop QID or ung q2-4 hrs

d. ANTIPSEUDOMONAL COVERAGE
i. UNG (tobramycin, Ciprofloxaxin) q2-4 hrs
ii. DROPS (tobramycin, Ciprofloxaxin, Gatifloxacin, Moxifloxacin, Besifloxacin) QID

47
Q

Retinitis

  1. What four did we talk about?
A

Neurosyphilis (Bacterial)

ARN (VIRAL)

CYTOMEGALOVIRUS Retinitis (VIRAL)

TOXOPLASMOSIS (Protozoan)

48
Q

Retinitis

  1. Neurosyphilis
    a. Bacterial/viral?
    b. Treat how?
A
  1. a. Bacterial

b. Systemically w/PARENTERAL PEN G

49
Q

Retinitis: ARN

  1. 4 symptoms?
  2. What do we see?
  3. Clinical Syndrome caused by what 3 things?
A
  1. Blurred Vision, Floaters, Pain, Photophobia
  2. AC RxN, Conj Injection, SCLERITIS, INCREASED IOP, Sheathed retinal vessels, Hemes, Disc Edema
  3. VZV, HSV, CMV (RARE)
50
Q

ARN Tx

  1. IV?
  2. ORAL?
  3. Can add what 2 things as needed?
A
  1. ACYCLOVIR, 1500 mg/m2/d i.v., 10-14 days
  2. Famciclovir 500 mg po TID

Acyclovir 400-600 mg po 5x’s day or Valcyclovir: 1g po TID for up to 6 wks to PROTECT FELLOW EYE

  1. Cycloplegics and Steroids as needed.
51
Q

Retinitis: CMV

  1. What is it?
  2. Most frequent Opportunistic Ocular infection in what?
  3. Treatment?
A
  1. Scotoma or Decreased VA in 1 or both eyes, usually no pain or photophobia. Can be ASYMPTOMATIC
  2. AIDS; Less common since there are better Anti-AIDS drugs
  3. IV GANCICLOVIR, Cidofovir, or FOSCARNET
    * people that respond can switch to ORAL Therapy (Ganciclovir or Valganciclovir)
52
Q

Toxoplasmosis

  1. Get it from what?
  2. What does the patient see/feel?
  3. What do we see?
  4. More severe in pts with what?
A
  1. Ingestion/inhalation of T. Gondii Cysts (CAT is common Vector)
  2. Increased Floaters, Decreased Vision, usually no pain.
  3. Fluffy, creamy-white, Necrotic Lesion w/Blurred margins, “Headlight in FOG” appearance; Recurrent disease may form SATELLITE LESIONS
  4. Immunocompromised Pts; Extensive, Deep, BILATERAL Lesions
53
Q

Toxoplasmosis Tx

  1. Oral Antitoxoplasmic Drugs: What are they (6)
  2. What else is added when LESIONS are near OPTIC NERVE or MACULA, but NOT in immunocompromised pts?
A
  1. PYREIMETHAMINE, Azithromycin, Clindamycin, Tetracycline, Trimethoprim, and Sulfadiazine
  2. STEROIDS
54
Q

4 Types of Endophthalmitis

A
  1. Postoperative, Endogenous Bacterial, Candida, Traumatic
55
Q

Postoperative Endophthalmitis

  1. When does it occur?
  2. What does the pt experience?
  3. What do we see?
  4. Common pathogens?
A
  1. days after surgery
  2. Sudden onset of DECREASED VISioN and Increased Eye Pain
  3. SEVERE AC RxN, Vitreous CElls and Haze, reduced Red Reflex
  4. Staph Epidermitis, Staph Aureus, Strep Sp.; Gram Negative (these are less common)
56
Q

Postoperative Endophthalmitis Tx

  1. 2 things?
  2. What is given topically?
    a. Name the drugs?
A
  1. Intravitreal Antibiotics, sometimes w/Intrevitreal Steroids
  2. Topical Fortified Antibiotics and Topical STEROIDS (q1h around the clock for 24-48 hrs…can be considered an alternative)
    a. Vancomycin: 50 mg/ml q1h; Alternate w/Ceftazidime, same dosing, q30m

or use Tobramycin

57
Q

Traumatic Endophthalmitis

  1. May be due to what?
  2. Usual infecting organisms?
A
  1. Occult or missed IOFB

2. Bacillus Sp, Staph Epidermidis, Strep. Sp., other Gram NEGATIVE Bacteria

58
Q

Tx for Traumatic Endophthalmitis

  1. Treat what if necessary?
  2. Topical Antibiotics: What ones?
  3. Systemic Antibiotics: What 3?
A
  1. Ruptured globe if necessary
  2. Fortified TOBRAMYCIN q1h and Alternate w/FORTIFIED CEFAZOLIN or VANCOMYCIN every HALF HOUR!
  3. a. Ciprofloxaxin: 400 mg, iv, q12h
    b. Moxifloxacin: 400 mg, po, qd
    c. Cephazolin: 1g, iv, q48h
59
Q

Enodgenous Bacterial Endophthalmitis

  1. This happens in what 4 pt types?
  2. What will we see?
  3. Tx?
A
  1. Acutely Ill pt, Recently Hospitalized, Immunocompromised, and IV Drug Abuser
  2. Vitreous Cells and Debris, AC RxN, Hypopion
  3. Broad Spectrum IV, Oral, or Intravitreal (Amakacin, Vancomycin, Clindamycin) Antibiotics
60
Q

Candida Endophthalmitis

  1. What 3 pts will we see this in?
  2. What 2 things will pts See? (is it uni/bi)?
  3. What wil we see on the RETINA?
    a. Where can it spread to?
  4. Tx
    a. What 3 drugs?

d. Also Consider what 3 drugs?

A
  1. Immunocompromised, IV drug abusers, Chronically Catheterized Pts
  2. Floaters, Decreased Vision and Pain. BILATERAL
  3. Discrete, Multifocal, Yellow-White, CHOROIDAL or DEEP RETINAL LESIONS
    a. into the VITREOUS and APPEAR as COTTON BALLS
  4. a. Caspofungin: 70 mg, iv loading followed by 50 mg qd.
    b. Fluconazole: 400-600 mg iv/po loading dose then 200-400 mg
    c. Voriconazole: 200 mg, iv/po, BID
    d. Liposomal Amphoteracin, Itraconazole, and Micafungin
61
Q

Other Anti-Infective Drugs on the National Board List

  1. Metronidazole
  2. Rifampin
  3. Ribavirin
  4. Efavrenz-Emtricitabine-Tnofovir
  5. Lopinavir
  6. Zidovudine
  7. Miconazole
  8. Nystatin
A
  1. Ocular ROSACEA (treats facial lesions, not used in EYE)
  2. TB
  3. Hep C
  4. HIV
  5. HIV
  6. AIDS
  7. Fungal Skin Infections (athlete’s foot)
  8. Fungal Infections of Skin, Intestinal Tract, Orifices

Ocular Pharm (13 decks)

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