Bệnh nhân điều trị viêm kết mạc- với đỏ, chảy ghèn - chỉ định điều trị

kháng sinh nhỏ tại chỗ (Moxi

4l/ngày). 3-5 ngày sau bệnh nhân quay lại mắt đỏ hơn, NHÌN MỜ 2 mắt, đau, chói sáng

 Khác biệt hiện tại: BN xuất hiện thương tổn ở giác mạc – nghĩ đến: đầu tiên bn nhiễm trùng di ổ
thương tổn kết mạc lân cận hay bội nhiễm thêm các tác nhân khác (như nấm) . sau khi đã loại
trừ (nhờ cấy…) – khả năng thương tổn do độc tố thuốc???

corneal toxicity with corneal edema and superficial punctate keratitis following topical
moxifloxacin use

 LUÔN LUÔN ĐẶT CÂU HỎI: TRIỆU CHỨNG BN KHAI CÓ PHÙ HỢP VỚI TRIỆU CHỨNG
THỰC THỂ THĂM KHÁM HAY KHÔNG???

Experimental studies have suggested the mechanism of toxicity of moxifloxacin to be due to

corneal epithelial degradation, inhibition of collagen IV synthesis, damage to Descemet's
membrane [5] and breakdown of tight junctions of corneal epithelium [6].

https://insights.ovid.com/article/00003226-200610002-00003 tác động của fluorquinolon thế hệ 4 lên

về mặt nhãn cầu

KHÁNG SINH DÙNG TRONG NHÃN KHOA

Commonly Used Ophthalmic Antibiotics

See Table 1 for a detailed description of each antibiotic class and Table 2 for dosage
information.
Sulfonamides
Sulfonamides are broad-spectrum compounds with good corneal penetration, but the
development of resistance during treatment due to chromosomal or plasmid DNA transference is
common. Sulfonamides have a synergistic effect when combined with trimethoprim, effective in
MRSA or Nocardia keratitis and in B henselae conjunctivitis.
Macrolides
Macrolides are active against gram-positive cocci and bacilli, and a few gram-negative
organisms such as Neisseria; resistance is rising due to esterases in Enterobacteriaceae, 50S
ribosome mutations, enzyme modification of the binding site, and active pumping to extrude the
drug. Corneal penetration and penetration of the ocular-blood barrier is generally poor because of
poor solubility.
Erythromycin ointment is well tolerated and commonly used for blepharitis for its gram-positive
coverage. Newer macrolides can reach higher tissue levels, adding efficacy against intracellular
pathogens such as Mycobacteria and Chlamydia. Topical ophthalmic azithromycin is
commercially available for the treatment of conjunctivitis. Clarithromycin has been used for the
treatment of nontuberculous mycobacterial keratitis.
Systemic erythromycin is an alternative to tetracyclines for phlyctenular keratoconjunctivitis,
especially in children. Azithromycin is commonly used for treatment and suppression of
trachoma and treatment of adult chlamydial conjunctivitis. Gastric upset is common.
Chloramphenicol
Chloramphenicol is a broad-spectrum agent that inhibits bacterial protein synthesis. It penetrates
the corneal epithelium and the blood–ocular barrier well. Resistance is low. Concern over the
potential for idiosyncratic aplastic anemia has limited its use in the United States, but it has been
used safely elsewhere.
Aminoglycosides
Aminoglycosides enter the pathogen in an energy-dependent process, which is reduced in
anaerobic conditions (eg, abscesses). Synergy is achieved when combined with drugs that alter
the cell wall, such as cephalosporins, enhancing penetration. They are primarily narrow-spectrum
antibiotics, very effective against gram-negative organisms, with good activity
against Pseudomonas.However, there is emerging resistance. Amikacin has good activity
against Nocardia and Mycobacteria. Gentamicin and tobramycin are also active against S
aureus and epidermidis. Commercially available formulations are used for conjunctivitis but
fortified preparations are preferred for severe corneal infections. Amikacin is the drug of choice
because it is particularly resistant to enzymatic changes leading to aminoglycoside resistance.
Fluoroquinolones
Fluoroquinolones are currently the most popular broad-spectrum antibiotics for treatment and
prophylaxis of eye infections because of their safety, excellent penetration into the aqueous and
vitreous, long duration of tear concentration, and broad spectrum of antimicrobial activity
including gram-positive, gram-negative, and intracellular organisms (Chlamydia,
Mycoplasma,and some Mycobacteria). Although newer fluoroquinolones are more efficacious
against gram-positive organisms, rising laboratory resistance of 80% for MRSA and 40%
for Pseudomonas aeruginosa has been noted in recent ocular isolates. The development of
resistance is secondary to alteration or mutation of DNA gyrase and topoisomerase, decreased
outer membrane permeability, or the development of efflux pumps. Their effect is concentration
dependent; the higher the concentration at the infection site the faster the killing rate, and if the
peak concentration achieved is high enough (10 times above the MIC or MBC), the drug levels
during dosing intervals become less important (Figure 2). Therefore, these antibiotics can be
dosed less frequently but they must not be tapered to avoid generating resistance.
Systemic fluoroquinolones penetrate well into ocular tissues, achieving higher therapeutic
intravitreal levels than topical use and, therefore, they may have a role as adjunctive treatment
for bacterial keratitis, endophthalmitis, and as prophylactic agents in trauma. Serious adverse
reactions are rare; however, all quinolones should be avoided, if possible, in patients with
prolongation of the QT interval, hypokalemia, or those using class III antiarrhythmic agents
(amiodarone, sotalol). Central nervous system symptoms (headache, confusion, hallucinations,
and seizures) are seen especially in patients using theophylline, nonsteroidal anti-inflammatory
agents, or caffeine, or in patients with a history of seizures. These drugs should be used with
caution in children and nursing mothers due to the possibility of damage to growing cartilage.
Vancomycin
Vancomycin is derived from cultures of Nocardia orientalis and is highly narrow-spectrum,
active only against gram-positive organisms. It is the drug of choice for the treatment of MRSA
and penicillin-resistant streptococci, although vancomycin-resistant Enterococcus (VRE) is a
rapidly emerging organism. Poor tissue penetration necessitates topical or intraocular
administration for the treatment of bacterial keratitis and endophthalmitis, respectively. As a
time-dependent agent, vancomycin has a critical concentration (2 to 4 times above the MIC or
MBC) at which the killing rate is at its maximum and will not increase with higher
concentrations (Figure 2). Therefore, the time the drug remains above the MIC during dosing
intervals becomes the main predictor of efficacy, and frequent dosing is needed for adequate
contact time. Topical and intraocular administration is generally well tolerated, although corneal
epithelial toxicity is common. When the drug is used topically in a 5% concentration, patients
generally complain of severe burning on administration; this can be alleviated by reducing the
concentration to 1.5% and 2.5%.
Tetracyclines
Tetracyclines are a broad-spectrum group of antibiotics that concentrate in oil glands, a property
especially useful in meibomian gland disease including blepharitis and rosacea, but usually
taking several weeks for effect and requiring maintenance dosing. They are better tolerated when
taken with food; however, calcium, found in dairy foods and calcium-containing antacids,
chelates the drug and reduce its absorption. Bone deposition in young children (<8 years of age),
extensive drug interactions (eg, warfarin, oral contraceptives), and dosing in renal failure must be
considered when prescribing the drug.