ICO International Clinical Guidelines:

Bacterial Keratitis (Management Recommendations)

(You can also download this Guideline as a PDF file - 103 KB)

Follow-up Evaluation

• Frequency depends on extent of disease, but follow severe cases initially at least daily until clinical improvement or stabilization is documented. [A:III]
  
  

Patient Education

• Educate about the destructive nature of bacterial keratitis and need for strict compliance with therapy. [A:III]
  
  
• Discuss possibility of permanent visual loss and need for future visual rehabilitation. [A:III]
  
  
• Educate patients with contact lenses about increased risk of infection associated with contact lens, overnight wear, and importance of adherance to techniques to promote contact lens hygiene. [A:III]
  
  
• Refer patients with significant visual impairment or blindness for vision rehabilitation if they are not surgical candidates. [A:III]

Antibiotic Therapy of Bacterial Keratitis [A:III]

Organism	Antibiotic	Topical Concentration	Subconjunctival Dose
No organism identified or multiple types of organisms	Cefazolin with Tobramycin / Gentamicin or Fluoroquinolones	50 mg/ml 9-14 mg/ml 3 or 5 mg/ml	100 mg in 0.5 ml 20 mg in 0.5 ml
Gram-positive Cocci	Cefazolin Vancomycin* Bacitracin* Moxifloxacin or Gatifloxacin	50 mg/ml 15-50 mg/ml 10,000 IU 3 or 5 mg/ml	100 mg in 0.5 ml 25 mg in 0.5 ml
Gram-negative Rods	Tobramycin /Gentamicin Ceftazidime Fluoroquinolones	9-14 mg/ml 50 mg/ml 3 or 5 mg/ml	20 mg in 0.5 ml 100 mg in 0.5 ml
Gram-negative Cocci**	Ceftriaxone Ceftazidime Fluoroquinolones	50 mg/ml 50 mg/ml 3 or 5 mg/ml	100 mg in 0.5 ml 100 mg in 0.5 ml
Non-tuberculous Mycobacteria	Amikacin Clarithromycin*** Fluoroquinolones	20-40 mg/ml 3 or 5 mg/ml	20 mg in 0.5 ml
Nocardia	Amikacin Trimethoprim/Sulfa methoxazole: Trimethoprim Sulfamethoxazole	20-40 mg/ml 16 mg/ml 80mg/ml	20 mg in 0.5 ml

* For resistant Enterococcus and Staphylococcus species and penicillin allergy.
Vancomycin and Bacitracin have no gram-negative activity and should not be used as a single agent empirically in treating bacterial keratitis.

** Systemic therapy is necessary for suspected gonococcal infection.

*** Dosage for oral systemic therapy in adults is 500 mg every 12 hours. Topical therapy has had some success but the medication is irritating and clinical experience is limited.

Adapted from the American Academy of Ophthalmology Summary Benchmarks, November 2006 (www.aao.org)

(You can also download this Guideline as a PDF file - 103 KB)

Next: Blepharitis (Initial and follow-up evaluation)

Also see:

• International Clinical Guidelines (Preface)
  
  
• Introduction to the Guidelines
  
  
• List of Guidelines