Oral anti-infectives expedite resolution of ocular infections
Oral anti-infectives can be quite useful in treating external infections, particularly those affecting the eyelids. For these types of infections, oral agents expedite recovery and decrease the chance of relapse.
“Eyelid-based problems are often self-limiting but can be very symptomatic during the course of the disease process,” said James L. Fanelli, OD, FAAO, a practitioner based in Carolina Beach, N.C. “Oral anti-infectives help facilitate quicker resolution as well as decrease the likelihood of recurrence.”
When are orals warranted?
According to Dennis L. Smith, OD, MS, FAAO, a professor at Pacific University, Forest Grove, Ore., the most common situations in which he will prescribe oral anti-infectives are soft tissue infection, meibomian gland dysfunction, chlamydial conjunctivitis and herpes infection.
Dr. Fanelli said he most commonly prescribes oral anti-infectives for chronic blepharitis and acute hordeolum.
He added, however, that oral antibiotics are not always the first line of treatment in eyelid infections. “Blepharitis is a good example. Initial treatment should consist of lid hygiene and topical antibiotic ointments in conjunction with warm compresses,” he said. “This should be continued for at least a week or two in most cases, as the clinical picture will look better in a few days, but recurrence is likely with shortened treatment.”
Dr. Fanelli said that more often than not, topical therapy will eradicate the problem for the short term. He said orals would be called for in cases where the patient has a clearly documented pattern of recurrence.
In the case of acute hordeolum, however, Dr. Fanelli explained that while hot compresses are an integral part of the therapy, oral therapy is required as a first-line treatment most of the time. “Some clinicians recommend an initial course of hot compresses and topical antibiotic ointments, but I have found this method moderately successful, at best,” he said. “In fact, I believe that the hot compresses alone are just as effective as the hot compresses plus antibiotic therapy, simply because very little of the antibiotic will actually make its way into the infected gland.
“My typical oral antibiotic of choice in these patients is Keflex (cephalexin, Dista) 250 mg four times daily for 7 to 14 days,” he continued. “Keflex is generally effective against common eyelid pathogens, which are generally gram-positive. The dosage can be modified easily, depending on the severity of the condition and the age and weight of the patient.”
Dr. Fanelli said oral therapy delivers a clinically significant dose of antibiotic directly into the affected eyelid and is more effective in resolving the situation much faster.
Most common oral anti-infectives
Dr. Smith referred to the Rxlist Top 200 Prescriptions (www.Rxlist.com/ top200.htm) in citing the most commonly prescribed anti-infective agents in 2002. “These agents were azithromycin, amoxicillin, cephalexin, amoxicillin clavulanate, ciprofloxacin, doxycycline, clindamycin, acyclovir, clarithromycin, cefprozil, penicillin VK and tetracycline,” he said.
For skin infections, Dr. Smith told Primary Care Optometry News that he has used the following medications: dicloxacillin, because it is an effective, penicillinase-resistant penicillin; cephalexin, because it seemed to cause fewer problems than penicillin and is inexpensive; doxycycline for Chlamydia, rosacea and sebaceous blepharitis; erythromycin when the patient could not take any other antibiotic; azithromycin for chlamydial conjunctivitis due to its single-dose therapy; and acyclovir for herpes zoster.
Dr. Fanelli said for chronic blepharitis, he traditionally used vibramycin 100 mg twice daily. He said therapy must continue for a minimum of 30 days and often proceeds for 60 days. “Vibramycin is very effective in reducing the recurrence rate in these patients,” he said. “Notice I said ‘reduce’ the recurrence rate, not ‘eliminate’ recurrence. The problem typically recurs, but much less frequently.”
Dr. Fanelli said although he has successfully used vibramycin for years, he has recently switched to minocycline 50 mg twice daily for 30 days. “Recent literature has shown that minocycline is very effective in reducing recurrence of chronic blepharitis, primarily because significant clinical effects are seen physiologically within the eyelid glands more than 30 days after the antibiotic has been discontinued. This is very beneficial in the elderly, as they often need reduced dosages of antibiotics,” he said.
Oral antibiotics are also very useful in conditions such as acute dacryocystitis and inclusion conjunctivitis, continued Dr. Fanelli. “While Keflex is effective in most cases of acute dacryocystitis, acute dacryocystitis in the elderly is often obstructive in nature,” he said. “This would require somewhat more aggressive therapy in the form of Augmentin (amoxicillin/clavulanate, SK Beecham), ciprofloxacin, Biaxin (clarithromycin, Abbott) or azithromycin. Adult inclusion conjunctivitis is most appropriately treated with azithromycin — 1 g on day 1, followed by 500 mg on day 2.”
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Complications of oral anti-infectives
According to Dr. Smith, the most common complications he has seen with oral anti-infectives are upset stomach and light sensitivity in fair-skinned patients using doxycycline. “There is also some discussion that antibiotics might interfere with oral contraceptives, so I caution patients of that possibility,” he said.
Dr. Fanelli said the most common complication he has observed has been gastrointestinal toxicity, which may manifest as upper gastrointestinal disturbances such as nausea and vomiting or lower gastrointestinal problems such as diarrhea.
“Of course, prior to prescribing any oral antibiotic, a proper history must be taken to rule out true antibiotic allergenicity,” he said. “Once a proper history excludes antibiotics that the patient is sensitive to, there will be few reactions other than the gastrointestinal disturbances.”
One of these, Dr. Fanelli noted, is the incidence of vaginal yeast infections once antibiotic therapy is initiated. “These patients usually are well aware of their propensity to develop yeast infections and will often inform you of that when you discuss with them the need for oral antibiotics,” he said. “In these situations, the patient should also be medicated with an appropriate antifungal to prevent secondary infection.”
Dr. Fanelli added that vibramycin is known to produce photosensitivity, especially in prolonged dosages of 30 to 60 days. “You need to warn your patients to wear sunscreen and a wide-brimmed hat when outside, especially in the summer,” he said. “I see this complication regularly in the summer, partly because I practice in a beach community.”
Minocycline has been known to cause inner ear vertigo and tinnitus, Dr. Fanelli said. The dizziness can be pronounced in some patients, he said, so practitioners should warn patients to take the first day’s dose at home to avoid hazardous driving situations.
Oral antivirals and the HEDS
Antivirals also may play a role in the primary care armamentarium, Dr. Fanelli said, for the treatment of herpes simplex as well as herpes zoster. “This does not mean that all patients with ocular HSV should be treated with antivirals,” he said. “For the most part, I follow the protocols that have been gleaned from the Herpetic Eye Disease Study (HEDS), but with some modifications. It is important to first look at what HEDS has shown us.”
Dr. Fanelli said, essentially, HEDS looked at the role of antivirals in managing HSV epithelial keratitis, HSV stromal keratitis, uveitis associated with HSV and the recurrences of stromal and epithelial disease. “Personally, the decision as to whether or not to prescribe an oral antiviral in no way depends on the presence or absence of anterior uveitis,” he said. “I have seen numerous cases of what I would consider ‘mild’ HSV epithelial keratitis that resulted in a rather significant anterior uveitis.”
Dr. Fanelli said the development of an anterior chamber reaction is a given in just about all cases of HSV keratitis at some point in the disease process. Furthermore, he said, the longer the case lingers on or the more severe the epithelial and stromal disease, the more significant the uveitis will become. “This is where appropriate aggressive management of the uveitis comes into play,” he said. “I do not think that cyclopentolate or homatropine are appropriate in managing the uveitis that will occur in HSV patients.”
Instead, Dr. Fanelli said he recommends 0.25% scopolamine up to four times daily, or 1% atropine. This must be administered from day 1 of HSV onset, he said, even if there is no clinical sign of uveitis. This aids significantly in keeping the uveitis under control.
He added that topical steroids should be avoided in the early management of HSV keratitis, even though the steroids play a significant role in quieting down the uveitis.
Dr. Fanelli said, in his clinical practice, he does not prescribe oral antivirals for simple, straightforward cases of HSV keratitis. “HEDS showed that oral antivirals had little effect on epithelial disease,” he said. “In these ‘simple’ cases, I use Viroptic (trifluridine, Monarch) up to every 2 hours while awake, along with scopolamine.”
If, however, the epithelial disease is progressing despite aggressive topical therapy, or if there are extenuating circumstances such as resistant HSV in a monocular patient, Dr. Fanelli said he would initiate therapy with oral antivirals.
Dr. Smith said, in his practice, he has used oral antiviral agents only for herpes zoster infections, and then only in conjunction with a dermatologist.
“The HEDS group recommendations suggest that oral acyclovir prophylaxis can be considered for recurrent herpes simplex stromal disease and uveitis,” he said. “However, the costs and undiscovered side effects make it difficult for me to use oral medications for epithelial disease that can be successfully managed with topical meds alone.”
Dr. Smith said if a patient has a history of recurrent HSV eye disease that involves the stroma, he would consider treating with oral acyclovir to try to prevent vision loss from corneal scarring. “While acyclovir was the only oral antiviral used by the HEDS group, I suspect valacyclovir and famciclovir would show the same results,” he said.
Dr. Fanelli said he would prescribe 400 mg of oral acyclovir per day.
For Your Information:
- James L. Fanelli, OD, FAAO, practices in Carolina Beach, N.C. He can be reached at 1300-C Dow Rd., Carolina Beach, NC 28428; (919) 458-8600; fax: (910) 458-8601; e-mail: email@example.com.
- Dennis L. Smith, OD, MS, FAAO, is a professor at Pacific University College of Optometry. He can be reached at 2043 College Way, Forest Grove, OR 97116; (503) 352-2791; fax: (503) 352-2929; e-mail: firstname.lastname@example.org.
- Neither Dr. Fanelli nor Dr. Smith has a direct financial interest in the products mentioned in this article, nor are they paid consultants for the companies mentioned.