Treatment of endogenous 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.

In cases of endogenous endophthalmitis, identify and treat the primary infection with systemic antibiotics, which are used in addition to intravitreal therapy for endophthalmitis. Collect blood and other relevant samples for culture and susceptibility testing before starting treatment.

Note: In cases of endogenous endophthalmitis, identify and treat the primary infection with systemic antibiotics, which are used in addition to intravitreal therapy.

Choose initial systemic antibiotic therapy based on the likely source of infection (eg endocarditis). Consider whether systemic antifungal therapy is required (eg patient has signs of fungal infection on ophthalmological examination, a history of injecting drugs or has not responded to antibiotic therapy). Also consider the intraocular penetration of the drug(s), which is limited by the blood–retina barrier and blood–aqueous barrier, though inflammation can increase penetration. Seek advice from an infectious diseases physician or clinical microbiologist.

Note: Choose initial systemic antibiotic therapy for endogenous endophthalmitis based on the likely source of infection and the intraocular penetration of the drug(s) – seek expert advice.

If the source of infection is not apparent, and advice from an infectious diseases physician or clinical microbiologist is not immediately available, start empirical systemic therapy. Use:

ceftazidime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ceftazidime dosage adjustment ceftazidime ceftazidime ceftazidime

PLUS

vancomycin intravenously; see Intermittent vancomycin dosing in noncritically ill adults or Intermittent vancomycin dosing for children for initial dosing. vancomycin vancomycin vancomycin

If fungal infection is suspected, seek advice from an infectious diseases physician or clinical microbiologist regarding choice of systemic antifungal therapy.

Administration of intravitreal antibiotics by an ophthalmologist is the mainstay of treatment for all cases of endogenous 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

PLUS if fungal infection is suspected

voriconazole 0.05 mg/0.1 mL by intravitreal injection. voriconazole voriconazole voriconazole

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