What antibiotics are used to treat corneal abrasions?

Antibiotic Selection for Corneal Abrasion

For uncomplicated corneal abrasions, prescribe a topical fluoroquinolone (moxifloxacin 0.5%, gatifloxacin 0.5%, or levofloxacin 1.5%) four times daily until complete epithelial healing is confirmed, with treatment initiated within 24 hours of injury to prevent progression to bacterial keratitis. 1, 2

Standard Treatment Protocol

First-Line Antibiotic Selection

• Fluoroquinolones are the preferred prophylactic antibiotics for corneal abrasions due to their broad-spectrum coverage and ability to achieve high tissue levels in the cornea 2

• Specific recommended agents include:

  • Moxifloxacin 0.5% four times daily 2
  • Gatifloxacin 0.5% (FDA-approved for bacterial conjunctivitis, with demonstrated efficacy against common ocular pathogens including Staphylococcus aureus, S. epidermidis, Streptococcus pneumoniae, and Haemophilus influenzae) 3
  • Levofloxacin 1.5% (provides equivalent efficacy to ofloxacin with higher concentration advantage) 2

• The American Academy of Ophthalmology recommends prophylactic topical antibiotics to prevent progression to bacterial keratitis, with treatment initiated promptly within 24 hours of injury 1

Contact Lens-Related Abrasions: Critical Exception

• For contact lens wearers, antipseudomonal coverage is mandatory due to increased risk of Pseudomonas aeruginosa keratitis 4

• Fluoroquinolones remain appropriate as they provide antipseudomonal activity 2

• Never patch the eye or use bandage contact lenses in contact lens wearers due to significantly increased risk of secondary bacterial keratitis 1, 2

Alternative Antibiotic Options

Chloramphenicol

• Chloramphenicol ointment is an alternative broad-spectrum option, though evidence comparing it to fluoroquinolones shows no clear superiority 5, 6

• One study found chloramphenicol had a 4.1% rate of slight reactions versus 0% with fusidic acid, though this difference was not statistically significant 5

Role of Ointments vs. Drops

• Topical antibiotic drops are preferred over ointments as the primary treatment because ointments lack solubility and cannot penetrate the cornea significantly for optimal therapeutic benefit 2

• Tetracycline or other antibiotic ointments may be useful at bedtime as adjunctive therapy to antibiotic drops in less severe cases, but should not be used as monotherapy 2

Treatment Duration and Monitoring

• Apply antibiotic drops four times daily until complete epithelial healing is confirmed 2

• Small uncomplicated abrasions (≤4 mm) with normal vision and resolving symptoms may not require follow-up 4

• All other patients should be reevaluated within 24 hours to monitor healing and detect early signs of infection 2, 4

• Patients must return immediately if symptoms worsen, as this could indicate secondary bacterial infection 1

When to Escalate Treatment

Signs Requiring Aggressive Management

• Immediately escalate treatment if the abrasion progresses to bacterial keratitis with any of the following features 2:

  • Central location or infiltrate >2 mm
  • Deep stromal involvement
  • Presence of hypopyon
  • Corneal stromal loss

• For severe keratitis, initiate loading dose every 5-15 minutes, then hourly dosing 2

• Consider fortified antibiotics (tobramycin 1.5% + cefazolin 10%) for severe cases, which should be prepared by an FDA-designated 503A/503B compounding pharmacy 7, 2

• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) have demonstrated at least equivalent efficacy to fortified cefazolin/tobramycin combination therapy in bacterial keratitis 7

Critical Pitfalls to Avoid

• Never use combination steroid-antibiotic drops as initial therapy for corneal abrasions; steroids should only be added after 2-3 days of antibiotic-only therapy if needed 2

• Avoid eye patching in all cases, as it does not improve pain and may delay healing or increase infection risk 1, 4

• Be aware that chronic prophylactic antibiotic use may promote growth of resistant organisms 2

• The distinction between simple corneal abrasion and bacterial keratitis is critical: bacterial keratitis typically presents with unilateral infiltrate and suppuration, whereas uncomplicated abrasion shows epithelial defect without infiltrate 1

Evidence Quality Considerations

While the American Academy of Ophthalmology strongly recommends prophylactic antibiotics to prevent ulceration when started within 24 hours 1, 2, a 2025 Cochrane review found very low certainty evidence regarding antibiotic prophylaxis benefits 6. However, given the potentially sight-threatening consequences of bacterial keratitis and the low risk of short-term topical antibiotic use, prophylactic treatment remains the standard of care in clinical practice 1, 2, 4.