What are the next steps for a patient with bacterial conjunctivitis who has failed therapy to Vigamox (moxifloxacin) eye drops?

From the Guidelines

For a patient with bacterial conjunctivitis who has failed therapy with Vigamox (moxifloxacin) eye drops, the next step would be to switch to a different antibiotic with a broader spectrum of activity. Consider prescribing tobramycin 0.3% ophthalmic solution, applied 1-2 drops every 4 hours while awake for 7-10 days. Alternatively, polymyxin B-trimethoprim (Polytrim) drops, applied 1 drop every 3 hours while awake for 7-10 days, can be effective against resistant organisms. If the infection appears severe or is not responding to these alternatives, obtaining a conjunctival culture before changing antibiotics would be prudent to identify the specific pathogen and its antibiotic sensitivities, as suggested by the bacterial keratitis preferred practice pattern 1. Treatment failure with moxifloxacin may indicate fluoroquinolone resistance, which has been increasing in ocular pathogens such as Staphylococcus aureus and certain streptococcal species 1. Patients should be advised to complete the full course of the new antibiotic, avoid sharing towels or pillows, practice good hand hygiene, and return for follow-up if symptoms persist beyond 3-5 days of the new treatment. In cases with persistent symptoms despite appropriate antibiotic changes, consider other diagnoses such as viral conjunctivitis, allergic conjunctivitis, or a more serious ocular condition requiring specialist evaluation, as outlined in the conjunctivitis preferred practice pattern 1. It is also important to note that the management of bacterial keratitis requires the clinical training and experience of an ophthalmologist, especially in the setting of concomitant pathology, as stated in the bacterial keratitis preferred practice pattern 1. Therefore, if the diagnosis or treatment is in question, or if the condition is severe or refractory to treatment, consultation with or referral to an ophthalmologist who has expertise and experience in the management of bacterial keratitis is desirable.

Some key points to consider:

• The increasing frequency of methicillin-resistant S. aureus (MRSA) in the general population, and the importance of conjunctival cultures before starting treatment to guide the appropriate choice of antibiotic 1.
• The potential for fluoroquinolone resistance in ocular pathogens, and the need for alternative treatment options 1.
• The importance of proper hand hygiene and avoidance of sharing personal items to prevent the spread of infection 1.
• The need for careful follow-up evaluation by an ophthalmologist to detect and treat possible late onset complications, such as scarring and immune reactions 1.

Overall, the management of bacterial conjunctivitis requires a comprehensive approach that takes into account the increasing frequency of antibiotic resistance, the importance of proper diagnosis and treatment, and the need for careful follow-up evaluation to prevent long-term complications.

From the Research

Next Steps for Failed Therapy to Vigamox Eye Drops

For a patient with bacterial conjunctivitis who has failed therapy to Vigamox (moxifloxacin) eye drops, the following steps can be considered:

• Re-evaluation of the diagnosis to confirm the presence of bacterial conjunctivitis and to rule out other causes of conjunctivitis, such as viral or allergic conjunctivitis 2
• Consideration of alternative antibiotic therapies, such as fortified tobramycin-cefazolin or other fluoroquinolones, such as gatifloxacin or besifloxacin 3, 4
• Evaluation of the patient's symptoms and medical history to determine the best course of treatment, including the use of antihistamines and mast cell stabilizers for allergic conjunctivitis 2
• Consideration of the potential for antibiotic resistance and the need for susceptibility testing to guide antibiotic selection 5, 3

Factors to Consider in Selecting Alternative Therapies

When selecting alternative therapies for a patient who has failed Vigamox eye drops, the following factors should be considered:

• The severity of the infection and the patient's symptoms
• The patient's medical history and any underlying conditions that may affect treatment
• The potential for antibiotic resistance and the need for susceptibility testing
• The efficacy and safety of alternative antibiotic therapies, including their potential for side effects and interactions with other medications 5, 3, 6, 4

Potential Alternative Therapies

Some potential alternative therapies for a patient who has failed Vigamox eye drops include:

• Fortified tobramycin-cefazolin 4
• Gatifloxacin or besifloxacin 3
• Other fluoroquinolones, such as ciprofloxacin or ofloxacin 3, 4
• Antihistamines and mast cell stabilizers for allergic conjunctivitis 2