What Is the First-Line Treatment for Bacterial Keratitis?
Clinical scenario
Bacterial keratitis is a sight-threatening infection of the cornea requiring prompt antibiotic treatment. Early initiation of topical therapy and close follow-up are essential to prevent corneal scarring and vision loss.
Treatment approach (partial overview)
Topical antibiotic eye drops are the preferred initial treatment. A fluoroquinolone-based single-drug approach is the recommended starting point, with dosing intensity adjusted according to severity — the full regimen and algorithm are available in the protocol below.
Treatment goals
- Reduced pain and discharge
- Reduced eyelid edema and conjunctival injection
- Consolidation and sharper demarcation of the stromal infiltrate
- Decreased stromal infiltrate density
- Reduced anterior chamber cells, fibrin, or hypopyon
- Initial re-epithelialization
- Cessation of progressive corneal thinning
Improvement or stabilization is expected within 48 hours of starting therapy.
References
- Topical antibiotic eye drops are capable of achieving high tissue levels and are the preferred method of treatment in most cases of bacterial keratitis.
- Single-drug therapy using a fluoroquinolone has been shown to be as effective as combination therapy utilizing antibiotics that are fortified by increasing their concentration over commercially available topical antibiotics.
- Ciprofloxacin 0.3%, ofloxacin 0.3%, and levofloxacin 1.5% have been approved by the FDA for the treatment of bacterial keratitis.
- For central or severe keratitis (e.g., deep stromal involvement or an infiltrate larger than 2 mm with extensive suppuration), a loading dose such as every 5 to 15 minutes followed by frequent applications, such as every hour, is recommended.
- Cycloplegic agents may be used to decrease synechiae formation and decrease pain from anterior segment inflammation associated with bacterial keratitis.
- In general, the initial therapeutic regimen should be modified when the eye shows a lack of improvement or stabilization within 48 hours.
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