Anti-Infectives

Anti-infectives: A Primer

Keeping abreast of these important medications will add value to your skill set, especially in the coming healthcare environment.

By Frank Celia, contributing editor

The Association of American Medical Colleges estimates that, by 2015, the nation will have 62,900 fewer physicians than is necessary to treat the millions of new patients covered by President Obama's healthcare law. Even without the law, eyecare industry forecasters have been warning for years that ophthalmologist shortfalls are imminent. In such a workplace environment, the value of, and pressure on, support staff will only continue to grow.

Practices and surgery centers will need ophthalmic technicians who can manage the workaday tasks associated with prescribing medications like educating patients, tracking compliance, and fielding questions. Anti-infective drugs present special challenges because, unlike other therapeutic agents, they can lose their effectiveness over time. As disease causing pathogens evolve and develop resistance, the drug that worked last year might fail today. So, the field is always changing.

Additionally, the pharmaceutical industry's new, more stringent policy on drug samples puts even greater emphasis on financial issues. Which means increased time spent dealing with insurance coverage red tape.

Surgeons rely on support staff to handle many of these ancillary details, says Mitchell Shultz, MD, of Northridge, CA. “Whether it's for LASIK, cataract surgery, glaucoma surgery or a corneal transplant, before I ever enter an exam room pre- or post-operatively, my staff instructs our patients and tells them how many times a day to use each medication and for how long,” he says, adding that it's helpful when staff maintain a general knowledge of prescribing trends.

In most ophthalmic practices, surgical patients require prophylactic antibiotics before, during, and after surgery to decrease potentially pathogenic, bacterial flora. Because these patients will likely be elderly and suffering no acute symptoms, explaining to them the vital importance of compliance is paramount. Sporadic administration of topical antibiotics is a common cause of bacterial antibiotic resistance. Furthermore, because the drops often sting or irritate the eye, surgical staff members must make sure patients comply with the full regimen. One way to accomplish this is to ask patients to bring their drops on the day of their surgery and to the office for follow up visits, according to Teresa L. Cartwright, COT, and the Clinical Operations Officer for Virginia Eye Consultants. “When we see them on the first day of postop care, we double check that they have followed the instructions, that they have plenty of drops, haven't deviated from the prescribed medication, left them at home, lost them, or never filled them,” she explains.

Another big challenge with the use of antibiotics is spotting allergic patients when collecting the medical history before the ophthalmologist prescribes the drug.

In the coming years, ophthalmic technicians who can master the kind of tacit knowledge that doesn't require recurrent physician instruction will be in high demand at eyecare practices and ASCs.

Moxifloxacin (Alcon)

Brand names: Moxeza, Vigamox

Label indication: Bacterial conjunctivitis

Dosage: Twice a day for Moxeza; three times a day for Vigamox

Contraindications: Patients with a history of allergy to moxifloxacin, other quinolones, or to components of the ophthalmic solution.

Adverse side effects: Approximately 1-6% of Vigamox patients experienced conjunctivitis, decreased visual acuity, dry eye, keratitis, ocular discomfort, hyperemia, ocular pain, ocular itching, subconjunctival hemorrhage, and tearing; 1-2% of Moxeza patients experienced eye irritation, ocular itching, and conjunctivitis.

Typical uses: Though this popular fourth-generation fluoroquinolone works well on conjunctivitis, it is probably most often prescribed for perioperative prophylaxis. Moxeza, the newer formulation, is slightly stronger, thus requiring fewer doses.

Gatifloxacin (Allergan)

Brand names: Zymaxid, Zymar

Label indication: Bacterial conjunctivitis

Dosage: For conjunctivitis, on day one, up to eight times a day for both drugs; thereafter up to four times a day. For prophylaxis, many surgeons prescribe Zymaxid twice a day.

Contraindications: Patients with a history of allergy to gatifloxacin, other quinolones, or to components of the ophthalmic solution.

Adverse side effects: Approximately 5-10% of Zymar patients experienced conjunctival irritation, increased lacrimation, keratitis, and papillary conjunctivitis; 1-4% experienced chemosis, conjunctival hemorrhage, dry eye, eye discharge, eye irritation, eye pain, eyelid edema, headache, red eye, reduced visual acuity and taste disturbance.

Less than 1% of Zymaxid patients experienced worsening of conjunctivitis, eye irritation, taste disturbance, and eye pain.

Typical uses: Another popular fourth-generation fluoroquinolone often prescribed for perioperative prophylaxis, gatifloxacin, in its newer, stronger form of Zymaxid, has fewer side effects and allows for less frequent dosage.

Besifloxacin (Bausch + Lomb)

Brand name: Besivance

Label indication: Bacterial conjunctivitis

Dosage: Three times a day

Contraindications: None

Adverse side effects: Approximately 2% of patients experienced conjunctival redness.

Typical uses: The latest member of the fourth-generation fluoroquinolone family, (sometimes referred to as a “fifth-generation”) besifloxacin was specially designed for use in the eye. It has no systemic oral equivalent. Surgeons often use it for prophylaxis and conjunctivitis.

Levofloxacin (Vistakon)

Brand names: Iquix, Quixin

Label indications: Bacterial conjunctivitis, corneal ulcers

Iquix Dosage: Day 1-3: one or two drops every 30 minutes to two hours while awake and every four to six hours while sleeping; Day 4 and thereafter: one or two drops every four hours while awake.

Quixin Dosage: Day 1-2: one to two drops every two hours up to eight times a day; Day 3-7: one or two drops every four hours up to four times a day.

Contraindications: Patients with a history of allergy to levofloxacin, other quinolones, or to components of the ophthalmic solution.

Adverse side effects: Approximately 8-10% of Iquix patients experienced headache and taste disturbance; Approximately 1-3% of Quixin patients experienced transient decreased vision, fever, foreign body sensation, headache, transient ocular burning, ocular pain or discomfort, sore throat and photophobia.

Typical uses: An older, third-generation fluoroquinolone, levofloxacin still has great clinical value because it kills so broad a spectrum of bacteria. For this reason it is often prescribed for the more serious infections involved in conditions like corneal ulcers.

Azithromycin (Inspire)

Brand name: AzaSite

Label indication: Bacterial conjunctivitis

Dosage: Day 1-2: twice daily, eight to twelve hours apart; Day 3 and thereafter: once a day.

Contraindications: Hypersensitivity

Adverse side effects: Approximately 1-2% of patients experienced eye irritation

Typical uses: A relatively new formulation, AzaSite is most often prescribed to treat blepharitis

Ciprofloxacin (Alcon)

Brand name: Ciloxan (ointment and solution)

Label indication: Bacterial conjunctivitis, corneal ulcers

Solution Dosage: For corneal ulcers, day 1: two drops every 15 minutes for the first six hours and then two drops every 30 minutes for the remainder of the day; Day 2: two drops every hour; Day 3 and thereafter: two drops every four hours.

For bacterial conjunctivitis, day 1-2: one or two drops every two hours; day 3 and thereafter: one to two drops every four hours.

Ointment dosage: For bacterial conjunctivitis, day 1-2: apply a halfinch ribbon into the conjunctival sac three times a day; day 3 and thereafter: apply ribbon two times a day. (Ointment is not FDA approved for treating corneal ulcers.)

Contraindications: Patients with a history of allergy to ciprofloxacin, other quinolones, or to components of the ophthalmic solution.

Adverse side effects: Approximately 2% of ointment patients experienced discomfort and keratopathy. Less than 1% experienced dermatitis, nausea and taste perversion.

When the solution was used in corneal ulcer patients 17% developed white crystalline precipitates. Fewer than 1% of patients experienced corneal staining, keratopathy/keratitis, allergic reactions, lid edema, tearing, photophobia, corneal infiltrates, nausea and decreased vision.

Typical uses: Although the second-generation fluoroquinolone ointment is not FDA approved for corneal ulcers doctors often prescribe it off-label for this indication. The solution version, because it is generic, is often prescribed for patients who cannot afford or whose insurance doesn't cover the more expensive drug.

Ofloxacin (generic)

Brand name: Ocuflox

Label indication: Bacterial conjunctivitis, corneal ulcers

Dosage: For conjunctivitis, days 1-2: one or two drops every two to four hours; days 3-7: one to two drops four times a day.

For corneal ulcer, days 1-2: one to two drops every thirty minutes; one to two drops every six hours while asleep; days 3-7: one to two drops every hour; days 7-8: one to two drops four times a day.

Contraindications: Patients with a history of allergy to ofloxacin, other quinolones, or to components of the ophthalmic solution.

Adverse side effects: The most frequently reported drug-related adverse reaction was transient ocular burning or discomfort.

Typical uses: This second-generation fluoroquinolone is often prescribe for corneal ulcers. Its generic status means it's often prescribed in cases where patients cannot afford or insurance doesn't cover the more expensive drug.

Tobramycin (Alcon)

Brand names: Tobradex ST, Tobraflex, Tobrex

Label indication: For external infections of the eye and its adjacent structures.

Dosage: Tobradex ointment: three or four times a day

Tobradex suspension: One or two drops every four to six hours. In the first two days dosage may be increased to one or two drops every two hours.

Contraindications: The latest formulation is contraindicated in most viral corneal and conjunctival diseases, including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures.

Adverse Side effects: Because the ST version includes a steroid there is risk of IOP spikes.

Typical uses: Because many formulations of tobramycin are generic, there are a wide variety of uses and products. The latest version, Tobradex ST, is often prescribed for blepharitis.

Ganciclovir (Bausch + Lomb)

Brand name: Zirgan Label indication: Acute herpetic keratitis (dendritic ulcers)

Dosage: Five times a day until the cornea heals, then three times a day for seven days.

Contraindications: None Adverse Side effects: Blurred vision (60%), eye irritation (20%), punctate keratitis (5%), and conjunctival hyperemia (5%).

Typical uses: Approved in 2009, the anti-viral Zirgan is the latest weapon against herpetic keratitis.

Explaining the importance of compliance is paramount.

Trifluridine (Monarch)

Brand name: Viroptic

Label indication: Primary keratoconjunctivitis and recurrent epithelial keratitis due to herpes simplex virus, types 1 and 2.

Dosage: Every two hours while awake up to nine times a day, until the ulcer completely re-epithelializes. Then once every four hours with a minimum of five times a day.

Contraindications: Hypersensitivity or chemical intolerance to trifluridine.

Adverse Side effects: Mild, transient burning or stinging upon instillation (4.6%) and eyelid swelling (2.8%).

Typical uses: Prescribed for herpetic keratitis. OP