11.2 Endophthalmitis
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| Acute postoperative endophthalmitis (within 6 weeks of surgery) | Intravitreal antibiotics: Vancomycin 1 mg/0.1 ml (0.1 ml) intravitreal with Ceftazidime 2.25 mg/0.1 mL (0.1 ml) /intravitreal Amikacin 0.4 mg/0.1 ml (0.1 ml); instead of Ceftazidime if Penicillin allergy. + Systemic antibiotics: Vancomycin (15-20 mg/kg every 12 hrly) 1g IV BD and Amikacin (15 mg/kg q24h) 240 mg IV TDS Or Vancomycin 1 g IV BD and Ceftazidime 2g IV q8h + Topical antibiotics: Fortified Tobramycin 1.3% with fortified Cefazolin 5% eye drop 1 hrly to be reduced according to response Duration: 2 weeks | Intravitreal Piperacillin- tazobactam (250 μg/0.1 ml) repeated in 48 hours with Amikacin 7.5 mg/kg initial dose followed by 6 mg/kg every 12 hrly Or Piperacillin- tazobactam; If creatinine clearance > 40 ml/min and is normal - 3.375 IV q6hr for 7 to 10 days Or Meropenem + Moxifloxacin eye drops 0.5% in hrly or two hrly frequency | Post Surgical: Staphylococcus epidermidis, (60-70%), Staphylococcus aureus, Streptococcus & Enterococcus (5-10%) Gram negative Bacilli (- 5%) Propionibacterium acnes (delayed disease) Post- traumatic: Staphylococcus species, Streptococcus species, Bacillus cereus. Vitreous tap/ Aqueous tap or vitreous biopsy to be sent for microbiological testing prior to administration of the first dose of intravitreal injection. Vitrectomy improves retinal oxygenation, reduces the inflammatory load within the eye, provides specimens for diagnostic evaluation, allows direct inspection of the retina, allows definitive treatment, reduces the load of infection, and reduces the severity of the disease, and accelerates visual rehabilitation. Corticosteroids topical maybe added based on response to treatment. Homatropine 2%/ atropine 1% are essential part of treatment to relieve ciliary spasms and preventing synechiae formation. |
| Chronic post-cataract surgery endophthalmitis (after 6-week of surgery) | Intravitreal ceftazidime (2.25 mg/0.1 ml) And Intravitreal vancomycin (1 mg/0.1 ml) + Topical Vancomycin (50 mg/ml) and Amikacin (20 mg/ml) every 4 hrly /Ceftazidime or Cefazolin) Duration: few weeks depending on resolution of signs and symptoms | Intravitreal Piperacillin- tazobactam (250 μg/0.1 ml) repeated in 48 hours + Intracameral Moxifloxacin 500 mcg/0.1 ml- in select cases | The decision for systemic treatment may be taken in consultation with the ophthalmologist. Vitreous humor sample to be sent for microbiological testing: Gram stain/ cultures with prolonged incubation for slow growing organisms. PCR to be done if cultures are negative. |
| Endogenous/ Hematogenous (bacteraemia any source) | Intravitreal antibiotics: (Inj Vancomycin + Inj Ceftazidime) along with Systemic antibiotics Systemic antibiotics: Inj Ceftazidime 2 g IV q8h + Inj Vancomycin 1 g IV q12h Duration: Systemic antibiotics given for 7 to 10 days or more depending on culture reports and based on resolution of clinical signs. | Streptococcus pneumoniae, Staphylococcus aureus, Group B Streptococcus, Klebsiella pneumoniae, Neisseria meningitidis Endocarditis is the source in 40% of cases. Systemic antibiotics are mandatory in treatment of endogenous/hematog enous endophthalmitis. Appropriate cultures (Blood culture/urine culture etc) to be sent for microbiological testing before initiation of antibiotics. | |
| Fungal Endophthalmitis (Usually endogenous) | Intravitreal antifungal therapy: Amphotericin B (5 micrograms/0.1 ml (0.1 ml) Or Voriconazole 100 micrograms/0.1 ml (0.1 ml) Empiric systemic antifungal therapy- Candida suspected/confirmed: Fluconazole- Loading dose of 800 mg (12mg/kg) then 400-800 mg (6-12 mg/kg) daily Or Voriconazole – 400 mg loading dose (6 mg/kg) PO/IV q12h for 2 doses, then 200 mg (4 mg/kg) PO/IV q12h Duration: IV 10 days (range 2-90 days); PO 76 days (range 2-232 days). Systemic antifungal treatment typically lasts 4 to 6 weeks or longer, depending on the clinical response and presence of other organ involvement, with serial examinations to assess treatment response. | Duration is dependent on resolution of eye lesions. Candida spp.: 4-6 weeks. Mucorales: if spreads to eye- needs systemic treatment. Refer to ROCM. Appropriate cultures (Blood culture/urine culture etc) to be sent for microbiological testing before initiation of antifungals. |
For common etiological agents of Endophthalmitis, see Annexure B.11.2
Additional Information
- Viruses usually do not cause suppurative inflammation of the eye or endophthalmitis.
References
1. Endophthalmitis Durand, M.L.Clinical Microbiology and Infection, Volume 19, Issue 3, 227 – 234. Available from: https://theretinainstitute.org/endophthalmitis
2. Sharma Aditya; Madan, Siddharth; Beri, Nitika. An Approach to Endophthalmitis. Delhi Journal of Ophthalmology 33(3): p 180-185, Jul–Sep 2023. | DOI: 10.4103/DLJO.DLJO_146_23
3. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO. Available from: https://www.who.int/publications/i/item/9789240062382