You are in: eMedicine Specialties > Ophthalmology > INFECTIOUS DISEASE Escherichia ColiArticle Last Updated: Jan 10, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Donny W Suh, MD, FAAP, Clinical Assistant Professor, Pediatric Ophthalmology Service, University of Nebraska Medical Center; Pediatric Ophthalmologist, Adult Strabismus Specialist, Wolfe Eye Clinic, PC; Consulting Staff, Blank Children's Hospital, Mercy Medical Center of Des Moines, Iowa Methodist Hospital of Des Moines, and Marshalltown Medical Center Donny W Suh is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Medical Association, and Iowa Medical Society Editors: Kilbourn Gordon III, MD, FACEP, Urgent Care Physician, Primary Medical, Huntington Walk-In and Greenwich Convenient Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Author and Editor Disclosure Synonyms and related keywords: E coli, ocular infections, corneal ulcers, endophthalmitis INTRODUCTIONSection 2 of 11
  BackgroundThe genus Escherichia is named after Theodor Escherich who isolated the type species of the genus in 1885. Escherichia coli is a gram-negative rod that is found as a normal commensal in the GI tract, which can produce ocular infection including corneal ulcer and endophthalmitis, which can result in a devastating outcome. Early recognition and appropriate treatment is crucial. These infections most commonly occur in patients who are debilitated, immunocompromised, or diabetic or in corneas with an underlying pathologic condition. PathophysiologyE coli is rarely found in the normal flora of the conjunctiva. It most commonly is seen as a source of infection in ophthalmia neonatorum. E coli endophthalmitis is a rare complication of E coli septicemia. Antimicrobial resistance occurs through plasmid-mediated determinants. These multiresistant plasmids can be transferred by conjugation. It has a poor prognosis, and early diagnosis and treatment are essential to retain useful vision. These infections most commonly occur in patients who are debilitated, immunocompromised, or diabetic or in corneas with an underlying pathologic condition. Exogenous endophthalmitis usually is associated with trauma or intraocular surgery. In endogenous endophthalmitis, urinary track infection was the most common primary site of infection and nearly all patients are diabetic. Early recognition and appropriate treatment is crucial, since E coli endophthalmitis has an extremely poor prognosis. Depending on the severity, most patients need aggressive management and early medical and surgical intervention. FrequencyUnited StatesApproximately 5-10% of endogenous bacterial endophthalmitis is due to E coli. Exogenous endophthalmitis associated with intraocular surgery is 0.1-0.5%. Of these infections, E coli is rare a cause. Endophthalmitis occurs following 2-7% of penetrating injuries. Incidence is higher in association with intraocular foreign body. Of these infections, E coli is a rare cause. InternationalInternational frequency is unknown. Mortality/MorbidityIn endophthalmitis, the course of illness is very rapid, and complete destruction of intraocular tissues occurs. Corneal infection due to E coli produce indolent corneal ulcers with poor prognosis because most of these patients of have an underlying immunocompromised disorder or have abnormal corneal surface with compromised protective barrier. SexMen are 4 times more likely to have ocular trauma than women, which may lead to bacterial endophthalmitis. For corneal ulcer due to E coli, no difference exists in frequency between the sexes. AgeE coli may be seen as a source of infection in ophthalmia neonatorum in neonates. Also, endophthalmitis may occur in neonates following meningitis. However, almost all cases of E coli endophthalmitis have been in adults with an immunocompromised state or with diabetes. CLINICALSection 3 of 11
History
Physical
Causes
DIFFERENTIALSSection 4 of 11
Corneal Edema, Postoperative Corneal Foreign Body Corneal Melt, Postoperative Endophthalmitis, Bacterial Endophthalmitis, Fungal Endophthalmitis, Postoperative
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| Drug Name | Ciprofloxacin (Ciloxan) |
|---|---|
| Description | Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ciprofloxacin. |
| Adult Dose | 1 gtt q5min for 5-7 doses, then repeat q2h |
| Pediatric Dose | <1 year: Not recommended >1 year: Administer as in adults |
| Contraindications | Documented hypersensitivity; viral, mycobacterial, and fungal eye infections; avoid coadministration with steroid combinations after uncomplicated removal of a foreign body from cornea |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | A white crystalline precipitate located in superficial portion of corneal defect may occur (onset starts in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy |
| Drug Name | Ofloxacin (Ocuflox) |
|---|---|
| Description | Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ofloxacin. |
| Adult Dose | 1 gtt q5min for 5-7 doses, then repeat q2h |
| Pediatric Dose | <1 year: Not recommended >1 year: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent |
| Drug Name | Tobramycin (Tobrex, AKTob) |
|---|---|
| Description | Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Available as a solution, ointment, and lotion. |
| Adult Dose | 1 gtt q5min for 5-7 doses, then repeat q2h |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; steroid combinations after uncomplicated removal of a foreign body from cornea also should avoid using this product |
| Interactions | Anesthetics potentiate effects; effects decrease when used concurrently with gentamicin |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics, may result in bacterial or fungal overgrowth of nonsusceptible organisms |
| Drug Name | Gentamicin (Ocumycin, Genoptic) |
|---|---|
| Description | Aminoglycoside antibiotic used for gram-negative bacterial coverage. |
| Adult Dose | 1 gtt q5min for 5-7 doses, then repeat q2h 100 mcg/0.1 cc for intravitreal injection, 20 mg/0.5 cc for subconjunctival injection |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; mycobacterial, viral, and fungal infections of the eye; steroid combinations after uncomplicated removal of a foreign body from cornea also should avoid using this product |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infections |
| Drug Name | Cefazolin (Kefzol, Zolicef) |
|---|---|
| Description | First-generation cephalosporin antibiotic for gram-positive bacterial coverage. Commonly used in combination with an aminoglycoside to achieve broad spectrum. This 50-133 mg/mL solution must be compounded. |
| Adult Dose | 1 gtt q5min for 5-7 doses, then repeat q2h |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; use of steroid combinations after uncomplicated removal of corneal foreign body |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Not for use in ocular infections likely to become systemic; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy |
| Drug Name | Vancomycin (Lyphocin, Vancoled, Vancocin) |
|---|---|
| Description | Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures. |
| Adult Dose | 500 mg to 2 g/d IV divided tid/qid 7-10 d 1 mg/0.1 cc for intravitreal injection 25 mg/0.5 cc for subconjunctival injection, or 25 mg/mL 1 gtt q5min for 1-7 doses depending on severity, repeat q1h |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced, when coadministered with nondepolarizing muscle relaxants |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in renal failure, neutropenia; Red Man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given as 2-h administration or as PO or IP administration; Red Man syndrome is not an allergic reaction |
| Drug Name | Gatifloxacin (Zymar) |
|---|---|
| Description | Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. Elicits a dual mechanism of action by possessing an 8-methoxy group, thereby inhibiting the enzymes DNA gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division. |
| Adult Dose | Days 1-2: Instill 1 gtt into affected eye(s) q2h while awake; not to exceed 8 administrations/d Days 3-7: Instill 1 gtt into affected eye(s) up to 4 times/d while awake |
| Pediatric Dose | <1 year: Not established >1 year: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | For ophthalmic use only; commonly causes conjunctival irritation, increased lacrimation, corneal inflammation, or papillary conjunctivitis; less common adverse effects include conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid swelling, headache, red eye, reduced visual acuity, or taste disturbance |
| Drug Name | Levofloxacin (Quixin) |
|---|---|
| Description | S-enantiomer of ofloxacin. Inhibits DNA gyrase in susceptible organisms, thereby inhibiting relaxation of supercoiled DNA and promoting breakage of DNA strands. |
| Adult Dose | Instill 1-2 gtt in affected eye(s) qid for 1 wk |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Failure to respond after treating for 2-3 d may indicate presence of resistant organism or another causative agent; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy |
| Drug Name | Moxifloxacin (Vigamox) |
|---|---|
| Description | Indicated to treat bacterial conjunctivitis. Elicits antimicrobial effects. Inhibits topoisomerase II (DNA gyrase) and IV enzymes. DNA gyrase is essential in bacterial DNA replication, transcription, and repair. Topoisomerase IV plays a key role in chromosomal DNA portioning during bacterial cell division. |
| Adult Dose | Instill 1 gtt in affected eye(s) tid for 7 d |
| Pediatric Dose | <1 year: Not established >1 year: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Prolonged use may cause organism overgrowth and result in superinfection; do not wear contact lenses until infection clears and eye drops discontinued |
Instillation of a long-acting cycloplegic agent can relax any ciliary muscle spasm that can cause a deep aching pain and photophobia.
| Drug Name | Scopolamine (Isopto, Isopto Hyoscine Ophthalmic) |
|---|---|
| Description | Blocks the action of acetylcholine at parasympathetic sites in the smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia). |
| Adult Dose | 1-2 gtt into eye(s) up to bid |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; narrow-angle glaucoma |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Avoid excessive systemic absorption by compressing lacrimal sac, using digital pressure for 1-3 min after instillation; may produce drowsiness, blurred vision, or sensitivity to light (due to dilated pupils); observe caution while driving or performing other tasks requiring alertness, coordination, or physical dexterity |
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
| Drug Name | Prednisolone ophthalmic (Pred Forte) |
|---|---|
| Description | Treats acute inflammations following eye surgery or other types of insults to eye. Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability. In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely. |
| Adult Dose | Solution: 1-2 gtt into conjunctival sac q1h during day and q2h noct; once desired response is obtained, use 1 gtt q4h; may reduce to 1 gtt tid/qid to control symptoms Suspension: Shake well before using and instill 1-2 gtt into conjunctival sac 2-4 times/d; if necessary, may increase dosing frequency during initial 24-48 h |
| Pediatric Dose | Administer as in adults |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (take fungal cultures when appropriate) |
| Media file 1: Bacterial corneal ulcer with hypopyon. | |
 | View Full Size Image | Media type: Photo |
Article Last Updated: Jan 10, 2007
