Eyelid hygiene/scrubs is the mainstay of therapy. 

Topical antibiotics are not indicated as an initial therapy.

Chloramphenicol ointment 1% applied q12h to the lid margin for 1-2 weeks

OR

Oxytetracycline with Polymyxin B eye ointment applied q12h to the lid margin

OR

Fusidic Acid 1% eye ointment applied q12h to the lid margin

--

Warm compresses and massage.

Systemic therapy is not indicated as an initial therapy. 

*Doxycycline 100mg PO daily or q12h for 4-6 weeks

OR

**Azithromycin 500mg PO q24h  for 3 days weekly intervals with a minimum of 3 cycles 

*Tetracyclines are contraindicated in children < 8 years.

**Off-label use. 

Warm compresses.

Systemic antibiotics are indicated in the presence of superficial cellulitis or abscess.

Mild Infections:

Cloxacillin 500mg IV/PO q6h

Severe Infections:

Cloxacillin 1-2g IV/PO q6h

Amoxicillin/clavulanate 625mg PO q8h

--

Epilation of affected eye lash and warm compresses.

Systemic antibiotics are indicated in the presence of superficial cellulitis or abscess

Mild Infections:

Cloxacillin 500mg IV/PO q6h

Severe Infections:

Cloxacillin 1-2g IV/PO q6h

Mild Infections:

Amoxicillin/clavulanate 625mg PO q8h

Severe Infections:

Cefazolin 1-2g IV q8h

OR

Cephalexin 500mg PO q6h

MRSA or penicillin allergy:

Trimethoprim/sulfamethoxazole 5-10mg/kg/day of TMP component q12h 

--

Chloramphenicol 0.5% eye drop q6h

MAY ADD

Chloramphenicol eye ointment at night

Moxifloxacin 0.5% eye drop q6h

OR

Ciprofloxacin 0.3% eye drop q6h

OR

Levofloxacin 0.5% eye drop q6h 

--

Azithromycin PO 1g STAT

MAY ADD

Topical tetracycline eye ointment 1% q12h for 6 weeks

Doxycycline PO 100mg q12h for 7 days 

Requires systemic therapy.

Doxycycline not recommended for pregnancy.

Azithromycin PO 1g STAT

Doxycycline PO 100mg q12h for minimum of 21 days 

--

Ceftriaxone IM/IV 1g STAT

--

Frequent eye toileting of the infected eye with topical saline eye drops until discharge reduces.

Topical antibiotics may be considered as ancillary therapy. 

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h

OR

Moxifloxacin 0 .5% eye drop q1-2h 

OR

Levofloxacin 0.5% eye drop q1-2h

Combination therapy of two:

Moxifloxacin 0.5% q1-2h

OR

Ciprofloxacin 0.3% eye drop q1-2h

OR

Levofloxacin 0.5% eye drop q1-2h

PLUS

*Gentamicin 0.9% eye drop q1-2h

MRSA:

*Vancomycin 5% eye drop q1-2h

Monotherapy is indicated for mild bacterial keratitis.

Combination therapy is indicated for severe bacterial keratitis.

*Prepared extemporaneously using injectable forms.

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h 

OR

Levofloxacin 0.5/1.5% eye drop q1-2h

Combination therapy of two:

*Ceftazidime 5% eye drop q1-2h

OR

Ciprofloxacin 0.3% eye drop q1-2h 

OR

Levofloxacin 0.5/1.5% eye drop q1-2h

PLUS

 *Gentamicin 0.9% eye drop q1-2h

*Prepare extemporaneously using injectable forms

Moxifloxacin 0 .5% eye drop q1-2h 

*Cefuroxime 5% eye drop q1-2h 

MRSA:

*Vancomycin 5% eye drop q1-2h

*Prepare extemporaneously using injectable forms.

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h

OR

Levofloxacin 0.5/1.5% eye drop q1-2h

Combination therapy of two:

*Ceftazidime 5% eye drop q1-2h

OR

Ciprofloxacin 0.3% eye drop q1-2h

OR

Levofloxacin 0.5% eye drop q1-2h

PLUS

*Gentamicin 0.9% eye drop q1-2h 

Monotherapy is indicated for mild bacterial keratitis.

Combination therapy is indicated for severe bacterial keratitis.

*Prepare extemporaneously using injectable forms.

*Chlorhexidine 0.02% eye drop q1-2h

PLUS

**Propamidine isethionate 0.1% eye drop q1-2h

--

*Prepare extemporaneously using injectable forms.

**Requires DG’s approval.

Polyenes:

**Natamycin 5% eye drop q1-2h

OR

*Amphotericin B 0.05-0.15% eye drop q1-2h

Azoles:

*/**Voriconazole 1% eye drop q1-2h

OR

*Fluconozole 0.2% eye drop q1-2h

Oral Therapy:

May be considered in the absence of contraindications.

Fluconazole 200mg PO q24h

OR

Itraconazole 200mg PO q24h

--

Dual combination therapy of polyene and azole antifungal may be used.

Natamycin is the choice of therapy for Fusarium sp.

Amphotericin B is the choice of therapy for yeasts.

*Prepare extemporaneously using injectable forms.

**Requires DG’s approval.

Minimum: 3 weeks duration

Acyclovir 3% eye ointment 5 times/day for 10 – 14 days or for at least 3 days after healing, whichever shorter.

In the presence of stromal or endothelial disease:

Acyclovir 400mg PO 5 times/day for 7-10days

Prophylaxis for recurrent cases:

Acyclovir 400mg PO q12h for 12 months

--

 --

Acyclovir 10-12mg/kg/dose IV q8h (not more than 800mg) for 7-10 days until disease stabilize, then oral therapy for a minimum 6 weeks as below:

Acyclovir 800mg PO 5 times/day

PLUS (if retinitis is threatening the macular/ optic disc)

Intravitreal therapy:

*Intravitreal foscarnet 1.2-2.4mg/0.1ml

OR

Intravitreal ganciclovir 0.2-2mg/0.1ml biweekly

*Valacyclovir 1g PO q8H for 6 weeks

*Requires DG’s approval

Recommended to switch to definitive treatment once microbiology results available.

Systemic therapy:

Ganciclovir 5mg/kg IV q12h for 2-3 weeks

Intravitreal therapy:

Intravitreal ganciclovir 2mg/0.1ml biweekly 

Systemic therapy:

*Valganciclovir 900mg PO q12h for 2-3 weeks (induction) followed by 900mg PO q24h (maintenance)

OR

*Foscarnet IV 60mg/kg q8H or 90mg/kg q12h for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance

Intravitreal therapy:

*Intravitreal foscarnet 2.4mg/0.1ml (1-2weekly) 

Systemic therapy is indicated in all cases.

Maintenance therapy may need to be continued until CD4 count is > 100 cells/mm3 for 3 consecutive months.

Intravitreal therapy is indicated in zone 1 and 2 lesions.

Intravitreal therapy to be tapered according to clinical response.

Ganciclovir implant 4.5g is an option for prolonged usage of intravitreal ganciclovir.

*Requires DG’s approval

Intravitreal antibiotic injections:

*Vancomycin 1-2mg/0.1ml 

PLUS

*Ceftazidime 2mg/0.1ml 

Systemic therapy:

Vancomycin 15 – 20mg/kg IV q8-12h; not to exceed 2g/dose

PLUS

Ceftazidime 1-2g IV q8h

Deescalate to,

Ciprofloxacin 750mg PO q12h after 72 hours / evidence of clinical improvement

For culture negative,

ADD

Clarithromycin 500mg PO q12h for 2 weeks

If suspicious of fungal endopthalmitis, refer section fungal endopthalmitis. 

Topical therapy:

Moxifloxacin 5% eye drop

Intravitreal antibiotic injections:

*Vancomycin 1-2mg/0.1ml 

PLUS

*Amikacin 0.4mg/0.1ml

Systemic therapy:

Ciprofloxacin 750mg PO q12h for 10 days 

OR

Moxifloxacin 400mg PO q24h for 10 days

Topical therapy:

Ceftazidime 5% eye drop 

Systemic antibiotics are indicated in severe, virulent endophthalmitis.

Repeat intravitreal antibiotics after 48 to 72 hours if indicated.

*Prepare extemporaneously using injectable forms

Systemic treatment only indicated in cases of delay of transfer to ophthalmology centre.

Intravitreal therapy:

Amphotericin B 0.005mg/0.1ml

PLUS

Systemic therapy:

Fluconazole IV 800mg (12mg/kg) loading dose then 400-800mg (6-12mg/kg daily)

For severe condition:

Amphotericin B 0.5-1mg/kg IV q24h; MAY ADD

**Flucytosine 25mg/kg q6h

Step down therapy:

Fluconazole 200mg PO q24h for total 4-6 weeks (minimum)

Intravitreal therapy:

*Voriconazole 50ug-100ug/0.1ml

PLUS

Systemic therapy:

*Voriconazole 400mg (6mg/kg) IV/PO q12h for 2 doses, followed by 200mg (4mg/kg) PO q12h

Intravitreal and systemic therapy are indicated in all cases.

Refer to microbiological sensitivity.

Systemic therapy is typically continued for at least 4-6 weeks depending on observed ophthalmologic improvement.

*Requires DG’s approval

**Flucytosine is recommended for less susceptible azole isolates.

Systemic therapy:

Vancomycin 15-20mg/kg IV q8-12h; not to exceed 2g/dose

PLUS

Ceftazidime 1-2g IV q8h

Deescalate to,

Ciprofloxacin 750mg PO q12h after 72 hours / evidence of clinical improvement

For culture negative cases,

ADD

Clarithromycin 500mg PO q12h for 7-14 days

AND

Intravitreal antibiotic injections: 

Vancomycin 1-2mg/0.1ml

PLUS

Ceftazidime 2mg/0.1ml

If suspicious of fungal endopthalmitis, refer section fungal endopthalmitis. 

Topical treatment:

Moxifloxacin 5% eye drop 

Systemic therapy:

Ciprofloxacin 750mg PO q12h for 10 days

OR

Moxifloxacin 400mg PO q24h for 10 days

Intravitreal antibiotic injections: 

Vancomycin 1-2mg/0.1ml

PLUS

Amikacin 0.4mg/0.1ml 

Topical treatment:

Ceftazidime 5% eye drop

Treatment is based on primary infection (bacterial/fungal) and culture and sensitivity results.

All cases require systemic therapy. Intravitreal injection is indicated in cases with vitreous involvement and sight threatening choroidal lesions.

Topical therapy may supplement therapy. Not to use systemic steroids in these cases.

Review antibiotic regimen after microbiology results. Repeat intravitreal antibiotics after 48 to 72 hours if indicated.

Trimethoprim/sulfamethoxazole 160/800mg PO q12h for at least 6 weeks

Prophylaxis for recurrent lesions:

Trimethoprim/sulfamethoxazole 80/400mg q12h PO for 3 times a week

*Pyrimethamine 100mg PO on Day 1

Followed by:

*Pyrimethamine 25-50mg PO q24h

PLUS
Folinic acid 10-25mg PO q24h

PLUS

*Sulfadiazine 1g PO q6h for at least 6 weeks

OR

Azithromycin 500mg PO q24h for 3 weeks

OR

Clindamycin 300mg PO q6h for 3 weeks

Pregnancy: May consider intravitreal clindamycin 1.0mg/0.1ml.

Systemic steroids are usually indicated in immunocompromised patients.

*Requires DG’s approval.

Doxycycline 100mg PO q12h

OR

Azithromycin 500mg PO on Day 1, then 250mg PO q24h

--

Duration: 2 – 6 weeks

Amoxicillin/clavulanate 625mg PO q8h 

Ampicillin/sulbactam PO 375mg q12h 

Consider intravenous antibiotics in severe infections.

Duration: 7 days 

Cloxacillin 500-1000mg PO q6h for 5-7 days

OR

Cephalexin PO 500mg q6H for 7 days

OR

Cefuroxime 500mg q12h for 7 days

Oral Therapy:

Clindamycin PO 300mg-600mg q8h (if penicillin allergy) for 7 days

OR

Amoxicillin/clavulanate 625mg PO q8h for 7 days (for concurrent sinusitis)

IV Therapy:

Cloxacillin IV 2g q6h for 7 days

OR

Clindamycin IV 600mg q8h for 7 days (if penicillin allergy)

OR

Ceftriaxone IV 2g q24h for 7 days (for concurrent sinusitis)

Consider intravenous antibiotics in severe infections. 

Cefotaxime IV 2g q8h

OR

Ceftriaxone IV 2g q24h

OR

Amoxicillin/clavulanate 1.2g IV q8h for 7-10days

If anaerobes suspected,

ADD

Metronidazole 500mg IV q8h 

Penicillin/cephalosporin allergy:

Vancomycin 15-20mg/kg IV q8-12h

PLUS

Ciproflxacin 400mg IV q12h 

Duration: 7-14 days depending on clinical response