What antibiotic is recommended for a metal corneal abrasion?

Antibiotic Treatment for Metal Corneal Abrasion

A broad-spectrum topical antibiotic is recommended for any patient presenting with a corneal abrasion following trauma, including metal corneal abrasions, to prevent bacterial infection. 1

First-Line Treatment Options

• Fluoroquinolones are effective first-line agents for metal corneal abrasions due to their broad-spectrum coverage and ability to achieve high tissue levels 1

  • Moxifloxacin or gatifloxacin (fourth-generation fluoroquinolones) have better coverage of gram-positive pathogens than earlier generation fluoroquinolones 1, 2
  • These antibiotics should be started within 24 hours of the abrasion to prevent ulceration 1

• Topical antibiotic eye drops are preferred over ointments for most cases as they achieve higher tissue levels 1

  • However, antibiotic ointments may be useful at bedtime or for adjunctive therapy in less severe cases 1

Treatment Algorithm

For Standard Metal Corneal Abrasions:

• Apply a fourth-generation fluoroquinolone (moxifloxacin or gatifloxacin) four times daily 1, 2
• Continue treatment until complete re-epithelialization occurs 1
• Do not patch the eye or use a therapeutic contact lens as this may increase the risk of secondary bacterial keratitis 1

For High-Risk or Severe Cases:

• Consider combination therapy with fortified antibiotics for severe cases or deep stromal involvement 1
• For suspected MRSA infection (history of previous MRSA, healthcare worker, etc.), consider vancomycin as fluoroquinolones are generally poorly effective against MRSA ocular isolates 1, 3
• For suspected Pseudomonas infection, consider an aminoglycoside (tobramycin) or colistin 0.19% for resistant strains 1

Important Considerations

• Prophylactic topical antibiotics have been shown to prevent ulceration when started within 24 hours of corneal abrasion 1
• Increasing resistance to fluoroquinolones has been observed, particularly with MRSA and Pseudomonas aeruginosa 1, 2
• For metal corneal abrasions specifically, ensure complete removal of any metal foreign body before initiating antibiotic therapy 4
• Avoid using topical corticosteroids until infection has been ruled out, as they can mask signs of infection 1

Follow-up Recommendations

• Patients with small (≤4 mm), uncomplicated abrasions with normal vision and resolving symptoms may not require follow-up 5
• All other patients should be reevaluated within 24 hours 5
• If no improvement is seen after 7 days of treatment, reevaluation of diagnosis and treatment should be considered 3

Adjunctive Therapy

• Consider topical NSAIDs (ketorolac) for pain management, which has been shown to decrease pain, photophobia, and foreign body sensation 6
• Cycloplegic agents may be used to decrease pain from anterior segment inflammation 1

Common Pitfalls to Avoid

• Do not patch the eye as it does not improve pain and may delay healing 5
• Do not use therapeutic contact lenses for contact lens-associated abrasions due to increased risk of bacterial keratitis 1
• Do not miss the opportunity to provide prophylactic antibiotics within the first 24 hours after abrasion 1
• Be vigilant for signs of infection such as increasing pain, worsening vision, or corneal infiltrate, which require immediate referral 5