Emily Peterson's Policy Papaer

Emily Peterson
Dr. Rachel Robson
23 September 2008

Policy on Prescribing Correct Medications for Ocular Infections

Many people fail to think of antibiotic resistance and its effect on ocular health. However, most people have experienced an ocular infection, whether it was conjunctivitis (commonly known as pink eye) or a more serious contact lens infection, keratitis. Many types of bacteria and other microbes cause ocular infections, making it more difficult for optometrists and ophthalmologists to know what antimicrobial medications to use to treat infections. Conjunctivitis can be caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Chlamydia trachomatis (1). Common causes of bacterial keratitis are S. aureus, S. pneumoniae, or Staphylococcus epidermidis (1). Many of these organisms have become resistant to several antibiotics (1). In a study of S. epidermidis, 19 strains were tested using the Kirby-Bauer method and the following results were discovered: seventeen were penicillin resistant, four were resistant to methicillin, six were resistant to gentamicin, seven to erythoromycin, two were resistant to ciprofloxacin, one to vancomycin, and one to teicoplanin; nine were resistant to tetracycline, and only two strains were susceptible to all antibiotics tested, while seven were resistant to three or more antibiotics (4). Yet another cause of several ocular infections, most commonly conjunctivitis, is methicillin-resistant S. aureus (MRSA), a term used to describe S. aureus that is resistant to β-lactam antibiotics (2). The number of ocular infections caused by MRSA is rapidly increasing (2).
The development of fluoroquinolones for treating ocular infections seemed to improve treatment of these diseases. However, reports of resistance to ciprofloxacin and ofloxacin began to occur (1). The introduction of new fluoroquinolones, called third and fourth-generation fluoroquinolones is currently thought to evade resistance (1). These antibiotics are the most effective in treating bacterial keratitis and conjunctivitis (1).
The increasing threat of antibiotic resistance is especially difficult for optometrists and ophthalmologists to deal with because of the high risk of vision loss (1). Appropriate treatment of these infections must begin immediately, especially in the case of contact lens wear (3). Because of the need to treat immediately, antibiotics are often used when they are not needed. Unfortunately, approximately 80 percent of all conjunctivitis cases are treated with antibiotics, but less than half of these cases are actually caused by bacteria (1). In most cases, it takes too much time and is too expensive to culture and test the infection before prescribing an antibiotic (1). However, because of the many varieties of organisms that cause ocular infections, it has become increasingly important to culture bacteria, even after treatment has begun (5). Because they have more than one target in the bacterial cell, initial use of fourth generation fluoroquinolones is effective in treating many bacterial infections while still preventing resistance (1). Yet another reason that fourth generation fluoroquinolones may slow the development of resistant strains of bacteria is their ability to treat infections quickly, because prolonged exposure to antibiotics is a significant factor in causing antibiotic resistance. Another method of reducing antibiotic resistance is to educate patients on the issue of compliance (1). Appropriate treatment dosage and duration is equally important in slowing antibiotic resistance (2). Prolonged treatment is suspected to be one cause of the multiple resistances of S. epidermidis (4).

A. Ophthalmologists and optometrists will be required to test and culture microbes causing eye infections before making a diagnosis and prescription whenever possible. When vision loss is a significant threat, ophthalmologists and optometrists will begin treatment for the likely type of infection, while simultaneously testing and culturing the infection to make a complete diagnosis. This testing will include the Kirby-Bauer test of antibiotic resistance.
B. When vision loss is a significant threat and treatment is required before a complete diagnosis can be made, only fourth generation fluoroquinolones will be used to treat infections. Fourth-generation fluoroquinolones are least likely to cause resistance and they are the most effective at treating the multitude of bacteria that can cause eye infections. They also work quickly, which should reduce the time bacteria are exposed to the antibiotic, ideally preventing, or at least slowing, resistance.
C. Educational pamphlets urging patients to comply with their prescription will be provided to all patients treated with an ocular antibiotic. These pamphlets will provide information on the reasons appropriate dosage and duration slow antibiotic resistance. Ophthalmologists and optometrists will go over the pamphlet with the patient. Patients will be required to sign a document stating that they were provided with educational information about how antibiotic compliance slows the development of resistant strains of bacteria.
D. Ophthalmologists and optometrists will be required to document every case to show their compliance. Compliance with this policy will be monitored by the Iowa Board of Healing Arts and the Iowa Health Department. The process of monitoring will be random office checks and annual audits of paperwork. Failure to comply will result in fines of up to $100,000 and possible revocation of licensure. Funds for completing the tests and cultures will be provided by the Iowa Health Department.

Opponents of this policy may argue that it will make treatment of infections much more difficult. However, this is a short-term complaint. This policy will slow antibiotic resistance, allowing the antibiotics we have now to be effective longer, and making treatment of bacterial infections easier in the future. Another argument is that patients expect something to be done to treat their infection immediately. Ophthalmologists and optometrists will have to explain to patients that sometimes in order to treat an infection correctly, it is not possible to treat it immediately.
Antibiotic resistance in ocular infections is becoming increasing common. By prescribing antibiotics without knowing exactly what is causing the disease, optometrists and ophthalmologists are causing antibiotic resistance to happen more quickly. This new policy, with the help of the Iowa Health Department and the Iowa Board of Healing Arts, will require optometrists and ophthalmologists to treat the causes of ocular infections correctly. With the implementation of this policy, antibiotic resistance should slow tremendously.

Works Cited
1. Abelson, Mark B. and Annie Plumer. “Bacterial Resistance: The Ubiquitous Menace”. Review of Ophthalmology. November 2004. Volume 11. Issue 11. 80-83. 23 September 2008.
2. Blomquist, Preston Howard. “Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (An American Ophthalmological Society Thesis)”. Transactions of the American Ophthalmological Society. December 2006 Volume 104. 322-345. 23 September 2008.
3. Pascucci, Stephen E. “Antibiotics and Contact Lens Wear”. Review of Optometry. October 2003 Supplement. 25-26. 23 September 2008.
4. Sechi, Leonardo A., et.al. “Molecular Characterization and Antibiotic Susceptibilities of Ocular Isolates of Staphylococcus epidermidis.” Journal of Clinical Microbiology. September 1999. 3031-3033. 23 September 2008.
5. McGhee, Charles NJ and Rachael Niederer. “Resisting susceptibility: Bacterial keratitis and generations of antibiotics”. Clinical and Experimental Ophthalmology. Jan/Feb 2006. Volume 34. Issue 1. 3-5. 23 September 2008.

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