Antibiotic Prophylaxis for Globe Rupture
For globe rupture, administer intravenous vancomycin 30 mg/kg over 120 minutes plus intravenous cefepime 2g every 8-12 hours (or cefazolin 2g IV followed by 1g every 6-8 hours) for 48 hours, starting immediately upon diagnosis. 1, 2
Primary Antibiotic Regimen
The standard prophylactic regimen consists of:
- Vancomycin 30 mg/kg IV over 120 minutes (single dose or continued for 48 hours) 1
- Plus cefepime 2g IV every 8-12 hours for 48 hours 2
This combination provides comprehensive coverage against the most critical pathogens in post-traumatic endophthalmitis: Staphylococcus aureus (including MRSA), Streptococcus species, and gram-negative organisms including Pseudomonas aeruginosa. 2
Alternative Regimens
If cefepime is unavailable, use cefazolin:
- Cefazolin 2g IV slow injection initially, then 1g IV every 6-8 hours for 48 hours 1
- This provides adequate gram-positive and some gram-negative coverage when combined with vancomycin 1
For patients with beta-lactam allergy:
- Continue vancomycin 30 mg/kg IV over 120 minutes 1
- Add ciprofloxacin 400mg IV every 8-12 hours for gram-negative coverage 3
Critical Timing Considerations
Antibiotics must be administered immediately upon diagnosis of globe rupture, ideally before surgical repair. 4, 2 The evidence demonstrates that delayed presentation from time of injury significantly increases endophthalmitis risk (p=0.0002). 2 Every hour of delay matters for preventing this vision-threatening complication.
Duration of Therapy
Continue prophylactic antibiotics for 48 hours post-presentation. 2, 5 This duration is supported by the highest quality evidence showing endophthalmitis rates of only 0.9-2.0% when this protocol is followed. 2, 5
Oral Antibiotic Alternative (Selected Cases Only)
For patients without high-risk features (no intraocular foreign body, no delayed presentation >24 hours, no gross contamination), oral prophylaxis may be considered:
- Oral ciprofloxacin 500mg twice daily plus oral cefuroxime 500mg twice daily for 3 days 5
- This regimen showed non-inferiority with 2.7% endophthalmitis rate versus 2.0% with IV therapy 5
However, IV therapy remains the gold standard for most globe ruptures given the severity of potential complications. 2
Essential Adjunctive Management
Tetanus prophylaxis is mandatory:
- Administer 0.5 mL tetanus toxoid IM if not current within 10 years 4
- Prefer Tdap over Td if patient has not previously received Tdap 6
Immediate protective measures:
- Place rigid eye shield (never pressure patch) to prevent further injury 4, 7
- Keep patient NPO for urgent surgical repair 4
- Obtain immediate ophthalmology consultation 4
High-Risk Features Requiring Enhanced Vigilance
The following factors significantly increase endophthalmitis risk and warrant strict adherence to IV prophylaxis:
- Intraocular foreign body present (approaching significance, p=0.064) 2
- Delayed presentation >24 hours from injury 2
- Gross contamination with soil or organic matter 4
- Extensive tissue damage or tissue loss 7
Common Pitfalls to Avoid
Do not use topical antibiotics alone - they provide inadequate intraocular penetration for prophylaxis after globe rupture. 1 Systemic therapy is essential.
Do not delay antibiotics waiting for surgical repair - start prophylaxis immediately upon diagnosis, as the window for preventing endophthalmitis is narrow. 4, 2
Do not use oral antibiotics as first-line in severe injuries - reserve oral regimens only for selected low-risk cases without the features listed above. 5
Do not manipulate or explore the globe in the emergency department - this risks expulsive hemorrhage and should only be performed in the operating room. 7
Antifungal Considerations
Add antifungal prophylaxis if there is history of organic matter contamination (soil, vegetable matter, wood). 4 While specific regimens are not detailed in the ophthalmology guidelines, this follows general principles for contaminated traumatic wounds.