TERRY KIM, MD
Fortunately, the incidence of a true allergic reaction to systemic ciprofloxacin is rare (approximately 1.2 per 100,000 prescriptions)1 and is even more uncommon with topical formulations.2 Patients who claim an allergic reaction to oral or intravenous ciprofloxacin often refer to side effects of the medication, most commonly gastrointestinal upset, nausea, vomiting, and diarrhea. In those individuals or for a patient who has a history of mild reaction (ie, skin rash), topical fluoroquinolone therapy should not cause any harm, especially considering the extremely low systemic absorption with topical dosing.
In the setting of a true anaphylactic or severe hypersensitivity reaction to ciprofloxacin (ie, hives, dyspnea, pharyngeal edema, cardiovascular collapse, etc.), any topical fluoroquinolone antibiotic should be avoided. If the patient's history of reaction is vague and/or uncertain, preoperative testing could easily be performed in the clinic. With Benadryl (Pfizer Inc., New York, NY) and Epipen (Dey, Napa, CA) available, one can administer a test dose of a topical fluoroquinolone to the eye and monitor the patient for any allergic reaction.
If a history or demonstration of true anaphylactic reaction exists, one could combine a topical polypeptide antibiotic (ie, bacitracin) for gram-positive coverage with a topical aminoglycoside (ie, tobramycin) for gram-negative coverage. Because using a povidone-iodine sterile preparation preoperatively has been shown to reduce the risk of infection, it should also be instituted prior to cataract surgery.3
ERIC D. DONNENFELD, MD
The first step when dealing with a patient who states that he has a ciprofloxacin allergy is to establish exactly what he means by the word allergy. Diarrhea and gastrointestinal upset are normal complications of the medication, not allergic reactions.
The allergic response that merits concern would be a skin rash or certainly an anaphylactic reaction with any problems breathing. A patient who presented with a history of a true allergy to ciprofloxacin certainly should not receive a ciprofloxacin antibiotic prophylactically before cataract surgery, and the ophthalmologist should explore alternatives.
The broad-spectrum antibiotics that are currently available are the aminoglycosides tobramycin and gentamicin and the sulfonamides, represented by sulfacetamide, chloramphenicol, polymyxin B and trimethoprim, and Neosporin (Pfizer Inc.). Of these, chloramphenicol is seldom used in the US because of the rare risk of aplastic anemia, although it is the most common antibiotic in Europe. Because it is associated with a high degree of allergic response, Neosporin is rarely used but does provide effective broad-spectrum coverage. The entire class of ciprofloxacin analogs (including levofloxacin, ofloxacin, ciprofloxacin, moxifloxacin, and gatifloxacin) would clearly not be considered. I would lean toward tobramycin due to its fairly broad-spectrum activity and its good activity against Staphylococcus aureus (although the antibiotic is particularly weak against Staphylococcus epidermidis), followed by polymyxin B and trimethoprim.
In a patient truly allergic to ciprofloxacin, I would be more concerned about preoperative lid scrubbing to reduce the risk of contaminating lid flora, and I would probably use hot compresses with bacitracin if the patient had preexisting blepharitis. At the time of cataract surgery, I would certainly pursue aggressive antiseptic prophylaxis by means of a Betadine lid preparation3 (The Purdue Frederick Company, Stamford, CT). One could also consider administering an intracameral antibiotic, in which case I would use vancomycin intracamerally to provide additional gram-positive coverage.
MICHAEL L. NORDLUND, MD, PhD
For most ophthalmologists in the US, a patient with a true allergy to fluoroquinolones requires a deviation in protocol, because standard cataract surgery includes the use of a topical fluoroquinolone to prevent endophthalmitis. Fortunately, allergies to common fluoroquinolones are extremely rare. A review of the literature in 2000 failed to identify a single report of a severe adverse reaction to older fluoroquinolones such as ofloxacin, ciprofloxacin, and levofloxacin.4 Although the newer flouroquinolones moxifloxacin and gatifloxacin appear to have similar safety profiles, the use of these medications has not been widespread until recently, and further surveillance data are required. Three fluoroquinolones—temafloxacin, grepafloxacin, and trovafloxacin—have been associated with severe adverse reactions and therefore have been withdrawn from the market or restricted in their use.
With any reported allergy to medication, it is important to establish the nature of the reaction. True allergic responses to antibiotics are typically urticaria (hives), asthma or respiratory difficulties, and anaphylaxis. I would not use a topical fluoroquinolone in a patient with a history of one of these reactions. Nausea and gastrointestinal upset, for example, are side effects and not true allergies, and fluoroquinolones may be used safely in patients with these reactions.
When evaluating the alternatives to the fluoroquinolones, it is useful to consider the reasons for their current popularity. First, these agents (particularly fourth-generation fluoroquinolones) have excellent broad-spectrum activity against both gram-positive and gram-negative bacteria. Equally important, they penetrate well through the cornea and achieve therapeutic levels in the anterior chamber. Finally, these drugs possess minimal epithelial toxicity. Because no individual, commercially available, alternative topical antibiotic possesses all of these same characteristics, choosing an alternative antibiotic is complicated.
My approach is to use topical trimethoprim/polymyxin B and tobramycin preoperatively to reduce both gram-positive and gram-negative ocular-surface flora, respectively. Together, these medications offer broad-spectrum coverage, but they do not achieve therapeutic levels in the anterior chamber.5,6 I therefore supplement their use with an intraoperative subconjunctival injection of 50mg cefazolin to cover gram-positive organisms and 25mg of gentamicin to cover gram-negative organisms. My goal with these injections is to achieve therapeutic antibiotic levels in the aqueous for at least a few hours following surgery to minimize the growth of any bacteria that may have seeded the anterior chamber.
Finally, patients are instructed to continue their preoperative topical antibiotics for 5 days postoperatively to minimize bacterial colonization while the corneal incision heals. This approach maximizes the spectrum of coverage as well as the eradication of bacteria on the ocular surface and in the aqueous with minimally increased potential toxicity.
Section Editors Robert J. Cionni, MD; Michael Snyder, MD; and Robert H. Osher, MD, are cataract specialists at the Cincinnati Eye Institute in Ohio. They may be reached at (513) 984-5133; firstname.lastname@example.org.
Eric D. Donnenfeld, MD, is Co-Chairman of Cornea and External Disease at the Manhattan Eye, Ear, and Throat Hospital, and he is Partner in Ophthalmic Consultants of Long Island in Rockville Centre, New York. He is a consultant for Allergan, Inc., Alcon Laboratories, Inc., and Bausch & Lomb. Dr. Donnenfeld may be reached at (516) 766-2519; email@example.com.
Terry Kim, MD, is Associate Professor of Ophthalmology, Cornea and Refractive Surgery Services, at Duke University Eye Center in Durham, North Carolina. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Kim may be reached at (919) 681-3568; firstname.lastname@example.org. Michael L. Nordlund, MD, PhD, is Assistant Professor, Department of Ophthalmology, University of Cincinnati College of Medicine and Cincinnati Eye Institute. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Nordlund may be reached at (513) 984-5133; email@example.com.
1. Davis H, McGoodwin E, Reed TG. Anaphylactoid reactions reported after treatment with ciprofloxacin. Ann Intern Med. 1989;111:1041.
2. Leibowitz HM. Antibacterial effectiveness of ciprofloxacin 0.3% ophthalmic solution in the treatment of bacterial conjunctivitis. Am J Ophthalmol. 1991;112(suppl):29S-33S.
3. Speaker MG, Menikoff JA. Prophylaxis of endophthalmitis with topical povidone-iodine. Ophthalmology. 1991:98;1769-1775.
4. Bertino J, Fish D. The safety profile of the fluoroquinolones. Clin Ther. 2000;22:798-817.
5. Kirsch LS, Jackson WB, Goldstein DA, Discepola MJ. Perioperative ofloxacin vs. tobramycyin: efficacy in external ocular adnexal sterilization and anterior chamber penetration. Can J Ophthalmol. 1995;30:11-20.
6. Osher RH, Amdahl LD, Cheetham JK. Antimicrobial efficacy and aqueous humor concentration of preoperative and postoperative topical trimethoprim/polymyxin B sulfate versus tobramycin. J Cataract Refract Surg. 1994;20:3-8.