What is the best course of treatment for a 15-month-old patient presenting with Keratitis (inflammation of the cornea)?

Treatment of Keratitis in a 15-Month-Old Child

Immediate empiric treatment with topical broad-spectrum antibiotics is essential, using fortified antibiotic drops (fortified vancomycin 25-50 mg/mL plus fortified ceftazidime 50 mg/mL or fortified tobramycin 14 mg/mL) given every 30-60 minutes initially around the clock, with urgent ophthalmology consultation required within 24 hours. 1

Initial Assessment and Diagnosis

Critical History Elements

• Duration and onset of symptoms including pain, redness, discharge, photophobia, and vision changes 1
• Trauma history including any corneal foreign body, chemical exposure, or ocular injury 1
• Systemic conditions including immune status, recent viral illness (HSV, VZV), atopy, or other predisposing factors 1
• Environmental exposures that could contaminate the eye 1

Immediate Diagnostic Steps

• Visual acuity measurement appropriate for age (fixation patterns, preferential looking) 1
• Slit-lamp examination to assess epithelial defect size, stromal infiltrate depth and location, anterior chamber reaction 1
• Corneal cultures and smears are mandatory for sight-threatening keratitis (central location, deep infiltrate, severe presentation) before starting antibiotics 1, 2

Empiric Antibiotic Therapy

First-Line Treatment Options

Fortified antibiotic combination therapy is preferred over fluoroquinolone monotherapy for severe or central keratitis in young children: 1

• Fortified vancomycin 25-50 mg/mL (covers gram-positive organisms including MRSA) PLUS
• Fortified ceftazidime 50 mg/mL (covers gram-negative organisms including Pseudomonas) 1, 3

Alternative combination:

• Fortified cefazolin 50 mg/mL PLUS fortified tobramycin 14 mg/mL 1, 3

Dosing Schedule

• Every 30-60 minutes initially for severe cases, continuing around the clock 1
• After 24-48 hours of improvement, frequency can be reduced to every 1-2 hours while awake 1
• Avoid ocular ointments as they lack adequate corneal penetration for active infection 1

Why Fortified Antibiotics Over Fluoroquinolones in Children

Fluoroquinolone monotherapy (moxifloxacin, gatifloxacin) may be considered only for small, non-central, non-severe ulcers, but resistance rates exceed 30% for common organisms like Staphylococcus aureus. 2, 3 The 2025 Cochrane network meta-analysis found that while moxifloxacin showed faster healing than ciprofloxacin, vancomycin + ceftazidime combination ranked highest for efficacy (SUCRA 83.8) and lowest for adverse effects (SUCRA 93.1). 3

Monitoring and Follow-Up

Initial Phase (First 48-72 Hours)

• Daily examination is mandatory until stabilization or improvement is confirmed 1, 4, 5
• Expect increased inflammation during the first 24-48 hours despite appropriate therapy—this is NOT treatment failure 4, 5
• Modify therapy only if no improvement or stabilization within 48 hours 1, 4, 5

Clinical Indicators of Treatment Response

Monitor for these signs of improvement: 4, 5

• Reduced pain and discharge
• Decreased eyelid edema and conjunctival injection
• Consolidation and sharper demarcation of stromal infiltrate
• Decreased density of infiltrate without progressive stromal loss
• Reduced anterior chamber inflammation (cells, fibrin, hypopyon)
• Initial re-epithelialization
• Cessation of progressive corneal thinning

Special Considerations for Pediatric Patients

Compliance Challenges

• Frequent dosing in young children requires parental education and close supervision 1
• Consider brief hospitalization for severe cases to ensure proper medication administration 1
• Avoid patching the eye as this increases risk of worsening infection 1

Organism-Specific Concerns

• Pseudomonas aeruginosa causes rapid tissue destruction and requires prolonged therapy even after clinical improvement 1, 5
• Staphylococcus species have high resistance rates (>30%) to fluoroquinolones and methicillin 2
• If Nocardia or fungal infection suspected, corticosteroids are contraindicated 1

Adjunctive Therapy Considerations

Corticosteroid Use

Corticosteroids should NOT be used initially in pediatric bacterial keratitis. 1 If considered after pathogen identification:

• Wait at least 2-3 days of progressive improvement on antibiotics 1
• Only after fungal infection ruled out and organism identified 1
• Monitor IOP closely due to risk of steroid-induced glaucoma 1
• Examine within 1-2 days after starting corticosteroids 1

Systemic Antibiotics

IV antibiotics are indicated if: 4

• Scleral extension is present
• Impending or frank corneal perforation
• Continue IV therapy for 7-14 days until clinical resolution 4

Tapering Strategy

When to Reduce Frequency

• After sustained clinical improvement with all response indicators showing progress 4, 5
• Epithelial defect is healing and infection is controlled 4, 5
• Never taper below 3-4 times daily as lower doses are subtherapeutic and promote resistance 4, 5

Duration of Treatment

• Standard bacterial keratitis: Continue until complete epithelial healing plus additional days based on severity 1
• Pseudomonas keratitis: Requires more prolonged therapy due to organism virulence 5
• With scleral involvement: Continue topical therapy longer than standard keratitis 4

Critical Pitfalls to Avoid

• Premature discontinuation is the major risk in bacterial keratitis treatment 4, 5
• Do not reduce corticosteroids in patients already on them until infection is controlled, as this may temporarily worsen inflammation 1
• Medication toxicity from prolonged antibiotic use can mimic treatment failure—distinguish this from worsening infection 5
• Do not use therapeutic contact lenses during active infection as this increases microbial keratitis risk 1
• Failure to eliminate predisposing factors is a common cause of treatment resistance 2

When to Escalate Care

Urgent ophthalmology consultation is required for all cases of suspected bacterial keratitis in children. 1 Consider tertiary referral if:

• No improvement within 48 hours of appropriate therapy 1, 4
• Central or large infiltrates threatening vision 1
• Corneal perforation or impending perforation 4
• Multidrug-resistant organisms identified 2