Treatment-Resistant Bacterial Keratitis: Challenges and Solutions

Authors: Sait Egrilmez , Şeyda Yildirim-Theveny

Journal: Clinical Ophthalmology
Enero - 2020
Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996220/

Duvan Alexis Linares Arenas

Objective
This article has as objective understand the different causes that generates resistant
Bacteria to ophthalmic antibiotic, in cases of bacterial keratitis and as give solution to this
problem, thinking many aspects.

Thematic Analysis
It is necessary to understand the problems worldwide to take it to each of the specific
cases. In developed countries, the causes of bacterial keratitis are related to the excessive
use and overuse of contact lenses, causing corneal damage.
On the other hand, developing countries encompass causes such as poor access to health
services and agricultural practices, which, due to experience in my practice, generate
bacterial keratitis and corneal damage since there are no compulsory policies on
occupational health or education for the workers.
Among these cases, a large percentage of bacterial origin, for this reason it is important to
address the bacterial resistance of topical antibiotics, and how to prevent it from
developing rapidly. Among these cases, a large percentage of bacterial origin, for this
reason it is important to address the bacterial resistance of topical antibiotics, and how to
prevent it from developing rapidly.
The inability to eliminate predisposing risk factors, the wrong diagnosis and the same
resistance or toxicity of the drugs due to the misuse and self-medication are the main
factors that must be managed.
Currently, there are many factors that can cause a bacterial infection in the eyeball. These
factors must be clear to the eye and eye health professional, starting with exogenous
factors, which do not come from our own body. Contact lenses are the first fact to
consider, educating the patient for its correct and proper handling. There are also anti-
inflammatory or anti-glaucomatous eyedrops, when they contaminate the droppers or
through their conversant.
If we talk about endogenous factors, which depends on our organism, we can highlight all
the infectious disorders that can be generated in the ocular annexes, such as in the eyelids
(blepharitis, ectropion, entropion), conjunctiva (allergic conjunctivitis, chemical burns,
wounds) cornea (keratopathies, foreign bodies, herpetic disorders), all of which can be
superinfected and generate a keratitis of bacterial origin.
In many occasions, eye and eye health professionals do not take into account the systemic
factors that predispose an eye infection. Some are diabetes, immunosuppression, mucosal
disorders, grafts. This is part of a good questioning carried out by the professional, to
understand the causes and predisposition that caused the infection, as well as the severity
of this.
An important element that prevents antibiotic resistance, if used properly, is accurate
diagnosis and differential diagnosis. It is clear to professionals that the key signs and
symptoms in bacterial keratitis are photophobia, eye pain, blurred vision, discharge,
redness, and generalized inflammation. All these symptoms must be characterized very
well and anchored with the predisposing factors that have already been mentioned.
In specific cases of intense pain related to the presence of corneal thinning, almost
reaching perforation, the presence of pseudomonas can be inferred. If the keratitis
pattern is round and delimited, with epithelial defect and related edema, the involved
microorganism may be staphylococcal.
To all this there is a report that many corneal specialists can very well distinguish and
differences between bacterial and fungal keratitis, all through appearance and semiology.
however, despite expertise, the best method of diagnosis is still staining, if available,
which does not mean that we should deny treatment without having stained or cultured.
For this reason, differential diagnosis is a challenge for eye and eye health professionals,
since there are signs that are very similar among the different types of keratitis and it is
the professional's ability to assess and understand each case from the history to the
signs. , and in which case to hesitate you can resort to culture tests through corneal
scraping samples that he can take.
As preventive actions to prevent the increase of antibiotic resistance in cases of bacterial
keratitis, it is first of all to protect the injured corneal epithelium through the use of
contact lenses, suspend toxic topical eyedrops and replace with eye drops without
preservatives and with less risk of toxicity, as well as treating persistent injuries with
ocular lubricants with high viscosity and the ability to regenerate tissue.
Mentioning the appropriate treatment for these cases is relevant to understand why
emphasis is placed on bacterial resistance. Due to the avascular characteristic of the
cornea, ocular topical antibiotics are the main treatment, so much so that for central and
serious injuries, loading doses are started every 5 minutes for the first half hour, gradually
decreasing the dosage within the first 48 hours of use. If there is pain and danger of
synechia formation, administering a cyclic will help to avoid these consequences. This is
the conventional management used by many eye health professionals.
Several topical antibiotics have been approved by the FDA for the treatment of bacterial
keratitis, specifically the group of fluoroquinolones are the most widely used and studied
as treatment. Ciprofloxacin, levofloxacin and ofloxacin to the presented good and very
similar results, moxifloxacin which is one of the most widely used at present has not been
approved by the FDA, but works for many cases. But studies between prolonged 6 years
showed a high resistance of moxifloxacin for S. aureus, one of the most causative agents
of the pathology.
In these same studies it is highlighted that despite the resistance of these widely used
antibiotics, there are others that maintain a high susceptibility against many bacteria.
Vancomycin has been noted for its low resistance, and in the attempt to analyze
fluoroquinolones Besifloxacin comes out at 0.6%, newer and updated fluoroquinolone, it
reports a very aggressive susceptibility against S. aureus and S. epidermidis, with no
resistance eye topic. Therefore, it is recommended to implement new antibiotics and
manage those that are already in the most careful and discreet way, taking into account
all the aforementioned fatigue.
So as health professionals we must manage the different therapeutic options that we have
available, emphasizing a treatment with a maximum load dose for the first 48 hours and
then observe if the treatment has improved or not, if the improvement is null and void,
we must change treatment and drug, in addition to carrying the corneal shaving process
for bacterial identification culture.
Conclusion
In conclusion the main factors to take into account to avoid bacterial resistance are the
predisposing factors that must be eliminated, among these previously mentioned local
and systemic exogens and the erroneous diagnosis with erroneous treatment that incurs a
series of resistances and worsening clinical symptoms.
 It should be noted that non-pharmacological treatment issues must be addressed in a
more extensive and practical way for health professionals, meeting the needs of the
patient but avoiding antibiotic resistance as a pillar.
Contribution to Professional Practice
For my professional practice it is very important to understand the proper management of
topical antibiotics, it is a big responsibility since antibiotic resistance is a reality and it is in
our hands to combat and reduce it so that cases of preventable blindness caused by
infectious keratitis decrease in a high percentage. In addition to educating patients that
self-medication is the biggest mistake on their part and that eye and eye health
professionals come to any eye condition before applying anything.
Contribute to The Practice Scenario
For my practice scenario it is important to manage the concepts of microbial resistance,
since the incidence of bacterial keratitis is very high and of ocular infection, for this reason
I must handle in the most appropriate and effective way the treatment that does not
generate damage but allows an improvement fast, avoiding permanent problems such as
corneal perforation or blindness.