Treatment of exogenous endophthalmitis

The Royal Victorian Eye and Ear Hospital (RVEEH), 2022

Urgently refer all cases of endophthalmitis to an ophthalmologist so that they can obtain a vitreous sample for culture and administer intravitreal antibiotics. Delayed treatment results in loss of vision.

Note: All cases of endophthalmitis require urgent same-day management by an ophthalmologist with intravitreal antibiotic injections.

Administration of intravitreal antibiotics by an ophthalmologist is the mainstay of treatment for all cases of exogenous endophthalmitis. A suitable regimen isPeyman, 2009:

ceftazidime 2 mg/0.1 mL or 2.25 mg/0.1 mL by intravitreal injection ceftazidime ceftazidime ceftazidime

PLUS

vancomycin 1 mg/0.1 mL by intravitreal injection. vancomycin vancomycin vancomycin

If transfer to an emergency department or specialised unit for intravitreal treatment is likely to be delayed, start empirical oral therapy in consultation with an ophthalmologist. Use:

1moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) orally, daily for up 5 days or until intravitreal antibiotics are available¹ ². For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment moxifloxacin moxifloxacin moxifloxacin

2ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, 12-hourly for up 5 days or until intravitreal antibiotics are available³ ⁴. For dosage adjustment in adults with kidney impairment, see ciprofloxacin oral dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin

Ciprofloxacin has poorer intraocular penetration than moxifloxacin; however, it can be used if moxifloxacin is not available. Urgent transfer for intravitreal treatment is the first priority; do not delay patient transfer to start oral antibiotics.

Modify treatment according to clinical response and the results of culture and susceptibility testing, if available.

¹ Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Moxifloxacin can be used in children when it is the drug of choice.Return

² An oral liquid formulation of moxifloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

³ Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Ciprofloxacin can be used in children when it is the drug of choice.Return

⁴ An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return