MANAGING ANTERIOR SEGMENT INFECTIONS IN CHILDREN Rachel A. Stacey Coulter, OD, MSEd, FAAO, Diplomate BVPPO Julie A. Tyler, OD, FAAO Nova Southeastern University College of Optometry, Fort Lauderdale, FL Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.
Disclosure Statement: Rachel'A.' 'Stacey 'Coulter,'OD,' MSEd,'FAAO,'Diplomate'BVPPO None Julie'A.'Tyler,'OD,'FAAO Virtual'advisory'board' optometric'educators,'shire
Considerations+in+managing+children+as+patients The$ever'changing$pediatric$patient Developmental$differences$among$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ pediatric$age$groups Infants$ birth$to$one$year Toddlers$ one$to$three$years Preschool$ three$to$five$years School$age$ five$to$twelve$years Adolescents$ thirteen$to$eighteen$years
Differences)in)pharmacokinetic)responses)to) medications) Differences greatest in infants Differences in. Drug absorption Distribution Metabolism and excretion
Prescribing*challenges* Pediatric)Use)section Manufacturer s)drug)insert Age)for)which)the)drug)is)approved,)any) associated)side)effects)and)outcomes Off<label)prescribing) Pediatric)Use)section)states, Safety)and)effectiveness)in)children) have)not)been)established HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use AUGMENTIN safely and effectively. See full prescribing information for AUGMENTIN. AUGMENTIN (amoxicillin/clavulanate potassium) Tablets, Powder for Oral Suspension, and Chewable Tablets Initial U.S. Approval: 1984 To reduce the development of drug-resistant bacteria and maintain the effectiveness of AUGMENTIN and other antibacterial drugs, AUGMENTIN should be used only to treat infections that are proven or strongly suspected to be caused by bacteria. ----------------------------INDICATIONS AND USAGE -------------------- AUGMENTIN is a combination penicillin-class antibacterial and beta-lactamase inhibitor indicated for treatment of the following: Lower respiratory tract infections (1.1) Acute bacterial otitis media (1.2) Sinusitis (1.3) Skin and skin structure infections (1.4) Urinary tract infections (1.5) -----------------------DOSAGE AND ADMINISTRATION---------------- Adults and Pediatric Patients > 40 kg: 500 or 875 mg every 12 hours or 250 or 500 mg every 8 hours. (2.1, 2.2) Pediatric patients aged 12 weeks (3 months) and older: 25 to 45 mg/kg/day every 12 hours or 20 to 40 mg/kg/day every 8 hours, up to the adult dose. (2.2) Neonates and infants < 12 weeks of age: 30 mg/kg/day divided every 12 hours, based on the amoxicillin component. Use of the 125 mg/5 ml oral suspension is recommended. (2.2) ----------------------DOSAGE FORMS AND STRENGTHS -------------- Formulations and amoxicillin/clavulanate content are: Tablets: 250 mg/125 mg, 500 mg/125 mg, 875 mg/125 mg; 875 mg/125 mg tablets are scored. (3) Powder for Oral Suspension: 125 mg/31.25 mg per 5 ml, 200 mg/28.5 mg per 5 ml, 250 mg/62.5 mg per 5 ml, 400 mg/57 mg per 5 ml (3) Chewable Tablets: 125 mg/31.25 mg, 200 mg/28.5 mg, 250 mg/62.5 mg, 400 mg/57 mg (3) FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 1.1 Lower Respiratory Tract Infections 1.2 Acute Bacterial Otitis Media 1.3 Sinusitis 1.4 Skin and Skin Structure Infections 1.5 Urinary Tract Infections 1.6 Limitations of Use 2 DOSAGE AND ADMINISTRATION 2.1 Adults 2.2 Pediatric Patients 2.3 Patients with Renal Impairment 2.4 Directions for Mixing Oral Suspension 3 DOSAGE FORMS AND STRENGTHS 4 CONTRAINDICATIONS 4.1 Serious Hypersensitivity Reactions 4.2 Cholestatic Jaundice/Hepatic Dysfunction 5 WARNINGS AND PRECAUTIONS 5.1 Hypersensitivity Reactions 5.2 Hepatic Dysfunction 5.3 Clostridium difficile-associated Diarrhea 5.4 Skin Rash in Patients with Mononucleosis 5.5 Potential for Microbial Overgrowth 5.6 Phenylketonurics 5.7 Development of Drug-Resistant Bacteria Reference ID: 3248650 ------------------------------ CONTRAINDICATIONS ----------------------- History of a serious hypersensitivity reaction (e.g., anaphylaxis or Stevens-Johnson syndrome) to AUGMENTIN or to other beta-lactams (e.g., penicillins or cephalosporins) (4) History of cholestatic jaundice/hepatic dysfunction associated with AUGMENTIN. (4) ----------------------- WARNINGS AND PRECAUTIONS ---------------- Serious (including fatal) hypersensitivity reactions: Discontinue AUGMENTIN if a reaction occurs. (5.1) Hepatic dysfunction and cholestatic jaundice: Discontinue if signs/symptoms of hepatitis occur. Monitor liver function tests in patients with hepatic impairment. (5.2) Clostridium difficile-associated diarrhea (CDAD): Evaluate patients if diarrhea occurs. (5.3) Patients with mononucleosis who receive AUGMENTIN develop skin rash. Avoid AUGMENTIN use in these patients. (5.4) Overgrowth: The possibility of superinfections with fungal or bacterial pathogens should be considered during therapy. (5.5) ------------------------------ ADVERSE REACTIONS ----------------------- The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%), vomiting (1%) and vaginitis (1%) (6.1) To report SUSPECTED ADVERSE REACTIONS, contact GlaxoSmithKline at 1-888-825-5249 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. ------------------------------ DRUG INTERACTIONS------------------------ Co-administration with probenecid is not recommended. (7.1) Concomitant use of AUGMENTIN and oral anticoagulants may increase the prolongation of prothrombin time. (7.2) Coadministration with allopurinol increases the risk of rash. (7.3) AUGMENTIN may reduce efficacy of oral contraceptives. (7.4) ----------------------- USE IN SPECIFIC POPULATIONS ---------------- Pediatric Use: Modify dose in patients 12 weeks or younger. (8.4) Renal impairment; Dosage adjustment is recommended for severe renal impairment (GFR< 30mL/min). (2.3, 8.6) See 17 for PATIENT COUNSELING INFORMATION and FDAapproved patient labeling. Revised: 01/2013 XXXXXXXXX 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience 6.2 Postmarketing Experience 7 DRUG INTERACTIONS 7.1 Probenecid 7.2 Oral Anticoagulants 7.3 Allopurinol 7.4 Oral Contraceptives 7.5 Effects on Laboratory Tests 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Labor and Delivery 8.3 Nursing Mothers 8.4 Pediatric Use 8.5 Geriatric Use 8.6 Dosing in Renal Impairment 10 OVERDOSAGE 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 12.3 Pharmacokinetics 12.4 Microbiology 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Prescribing*challenges:*Off1label* considerations Eye$drops$and$dermatologic$preparations$are$the$most$likely$ prescribed$off6label$medications Off6label$education$and$prescribing$considerations Check$package$insert$and$FDA$website$for$warnings$or$contraindications!Example:$$Doxycycline$and$other$tetracycline$analogues$cause$ abnormalities$in$children$younger$than$eight Discuss$whether$or$not$the$drug$has$been$approved$for$pediatric$use Document$the$decision6making$process$and$the$parent s/guardian s$consent$ in$the$medical$record.
Prescribing*challenges:*Off1label*considerations Best*source*! Dosage(and(Administration(section(of(package(insert If(not(available( other(common(adaptations(for(topical( pharmaceuticals Cut(Dose 1/2(adult(dose(for(children(<(2(yrs 2/3(adult(dose(for(children(ages(2( 3(yrs Decrease(frequency(of(dosing( When(available,(use(lower(percentage(of(mediation((eg,(olapatadine)
Determining&dosage ORAL%medications%adjusted%according%to%body%weight%(mg/kg/day)%and%many% medications%for%children%are prescribed)as)mg/kg,)mcg/kg)or)units/kg Weigh&patient&in&office;&don t&rely&on&reported&weight Four%Step%Approach: (1)%convert%pounds%to%kg%(1kg%=%2.2lb) (2)%calculate%the%dose%in%mg (3)%divide%dose%by%frequency%needed%for%oral%solutions/suspensions (4)%convert%mg/dose%to%mL Image:%https://www.quickmedical.com/detecto/physician/437.html?gclid=EAIaIQobChMIw562vZqW3gIVQhV GCh1blQPDEAQYAyABEgK9MfD_BwE&sku=477&utm_campaign=google_shopping&utm_medium=shopping&utm_source=google
Differences)in)diagnosis:))History Pediatric)patients)may)be)unable)or)unlikely)to)report)their)symptoms Diagnosis)often)made)by: Findings) History)reported)by)parent)or)caregiver)including: Duration Laterality Discharge Presence)of)pain)and)photophobia History)of)trauma)or)exposure)to)someone)else)with)red)eye
Common%Anterior%Segment%Infections%
Pediatric)Red)Eyes 1"%"primary"care"office"visits"="conjunctivitis Causes"of" red"eyes " infection,"allergy,"trauma,"dryness,"systemic" inflammation History Duration"symptoms Pain"present Photophobia Hx of"traumac high"or"low"velocity Prior"red"eyes/Previous"treatment
Blepharitis Pediatric)presentation Most)commonly)presents)in)children)age)6)5 10)yrs Symptoms)and)signs Injection)and/or)vessel)telangiectasia)along)lid) margin Hard,)fibrinous)crusts)and)scales) Occasional)misdirected)or)missing)lashes Staphylococcus overgrowth)5major)causative) factor)
Blepharitis Treatment(agents Lid(hygiene( Lid(scrubs( diluted(baby(shampoo(applied(to(lid(margins Commercial(wipes Systane lid(wipes((alcon)( Ocusoft lid(scrubs(available(in(a( baby (formulations Dandruff(ShampoosCseborrheic(blepharitis
Topical(agents Topical(antibiotic(options(when(indicated Erythromycin+ointment+ 1/2x+daily+x+2+weeks When+using+ointments,+apply+close+to+bedtime+to+decrease+ blur+ Azasite Conjunctivitis+dosing:+2x+daily+x+2+days,+then+1x+for+5+days Targets+Staphylococcus,AND+MGD+via+immunomodulatory+response Approved+>12+mos Expensive Fluoroquinolones Besivance (besifloxacin)+0.6%+ophthalmic+suspension Ciloxan (ciprofloxacin)+0.3%+solution Others/ ofloxacin,+moxifloxacin+and+gatifloxacin
Topical(Agents Topical(antibiotic/steroid(combinations Warranted(in(severe(cases,(to(eliminate(inflammation/(complications(of( bacteria((eg,(exotoxins)(with(concurrent(bacterial(overgrowth Ointments(may(be(easier(to(administer Options(include( Tobradex (tobramycin+and+dexamethasone+ophthalmic+suspension,+ Alcon)( Neomycin/polymyxin B/dexamethasone Considerations(in(Steroid(Use Side(effects( elevated(iop(and(cataract(formation If(HSV(is(culprit,(cornea(at(increased(risk(of(complications Clinicians(should(weigh(dosing(frequency(and(risks/benefits(
Blepharitis&? Oral Prescribing*oral*medications Azithromycin*(macrolide6type*antibiotic) Both*anti6inflammatory*and*antibacterial*properties Studies*in*adults*=*1*gram*for*3*weeks Approved*for*children*> age*six*months Example:*Treatment*options:* SINUSITIS&Dosing:&Child&dosage&(ages&6&months&to&17&years) Typical*dosage*is*10*mg/kg*of*body*weight*once*per*day*for*three*days.
Blepharitis+ Additional+considerations Additional)considerations:)Hypochlorous acid)treatments) (eg,%rx:%avenova [30%day%shelf%life%open],%Non;Rx:%HypoChlor Gel%0.02%%and%OcuSoft HypoChlor Spray%.02%[18month%shelf%life%open%or%closed) Manages)bacterial)overpopulation,)penetrates)biofilm,)inactivates) lipase)! Approved)for)blepharitis Spray)application!) Tea)tree)oil)treatments Nutrition
Hordeola Symptoms(and(signs Focal(infections(of(eyelid(glands Signs:( Localized(swelling,(pain(and(redness Pediatric(presentation Usually(caused(by(Staphylococcus,aureus
Hordeola Treatment)agents Warm)compress) apply)10>15)min Considerations: Topical)antibiotic)agents)> prevent) infection)spread)when) drainage/expression)is)significant,) especially)with)external)hordeolum Oral)antibiotics)may)be)needed)if) progresses)to)preseptal cellulitis Strategies)for)pediatric) compliance Freeze /music)game
Viral&conjunctivitis Symptoms(and(signs Usually(bilateral symptoms(starting(in(one(eye( and(progress(to(other(eye Red,(watery(eyes;(sometimes(small( (sub)conjunctival(hemorrhages Swollen(pre?auricular(nodes(in(children(with( developed(immune(systems Hx exposure(to(sick(people? Causes( usually(adenovirus,(although(hsv(&(varicella( zoster(possible
Viral&conjunctivitis Some&adenoviral&conjunctivitis&sub4types& (EKC)&! possible(delayed(corneal(response( with(sub3epithelial(infiltrates( (keratoconjunctivitis) Clinicians(should(emphasize(to(patient( and(parent(with(patient(education( regarding(expected(outcomes(and(the( importance(of(follow3up
Viral&conjunctivitis Pediatric)presentation Self1limiting)condition symptoms)usually)decrease)within)first)week Contagious)for)10121)days Palliative)measures)such)as)cool)compresses)and)artificial)tears)(PF) No)current)ophthalmic)agents)are)approved)for)adenoviral)infections
Prevent'spread'of'infection Educate(the(patient(and(caregiver(on(proper(hygiene(practices: Avoid(touching(the(eyes(or(eye(area. Use(disposable(tissues(and(wipes(instead(of(towels. Wash(hands(immediately(after(touching(the(eyes(or(eye(area. Don t(share(towels,(washcloths,(dishes,(cups(or(eating(utensils. Play(with(hard(surface(toys(that(can(be(thoroughly(cleaned. Discuss(the(need(to(keep(children(out(of(daycare(or(school( Complete(notes(or(documentation(required(for(absences(or(reentry
Microbial)conjunctivitis Presentation Generally,.sticky.mucopurulent.discharge. Eyelids. stick.together Bacterial.Causes: Staphylococcus,aureus,,Staphylococcus,epidermis,,Streptococcus, pneumoniae,,moraxella,catarrhalis,,pseudomonas,and,haemophilus
Bacterial)conjunctivitis Topical(antibiotics(- broad-spectrum(antibiotic(effective(against( Gram((+),(Gram((-) Erythromycin(0.5%( Antibiotic(combination(options: polymyxin B(sulfate(and(trimethoprim(sulfate(ophthalmic(solution polymyxin B/bacitracin(ophthalmic(ointment(and(erythromycin(0.5%( Aminoglycosides: Pro:((Often(inexpensive Con:(Less(desirable(due(to(corneal(epithelial(toxicity(reaction( Azithromycin,(AzaSite Multiple( pros(and(cons
Specific'notes'on'topical'azithromycin,-AzaSite Effectivity:''Beneficial'for'acute'bacterial'conjunctivitis Unique'dosing'regimen:' Dosed'one'drop'twice'daily,'eight'to'12'hours'apart'x'two'days;' then'once'daily'for'next'five'days Total'='9'drops Viscous'vehicle'enhances'contact'with'the'eye'and'enables'rubbing' excess 'drop'along'lid'margins'to'target'concurrent'eyelid'infection Cons:'Cost'and'availability Oral'antibiotics Bacterial-conjunctivitis
Viral&(HSV)&keratitis&with&a& primary&corneal&defect Symptoms(and(signs( conjunctival(injection,( follicles,(corneal(staining(with(rose(bengal or( discrete(punctuate(defects,(classic(dendrite Pediatric(presentation
Viral&keratitis&with&a&primary&corneal&defect Antivirals Trifluridine 1%1 Dosed1up1to1nine1times1per1day1 Disadvantage18 corneal1toxicity1over1time Zirgan (ganciclovir)1ophthalmic1gel10.15% Less1corneal1toxicity1than1trifluridine,1less1frequent1dosing,1 gel1formulation1that1may1be1preferable Approved1age1> 21years1 Oral1consideration Co8management
Fungal'keratitis History( Contact(lens(wearer?(Trauma? Thickened,(feathery,(poorly(defined(corneal(lesion Not(responsive(to(antibiotic Pediatric(presentation Most(common(risk(factor(=(trauma(with(plants( material Also(associated(with(trauma(from(metal,( pieces,(firecrackers,(pencils Treatment(antifungals Topical Systemic(
Preseptal cellulitis Symptoms(and(signs Lid(swelling(and(redness Fever Discharge R/O(!orbital(cellulitis( Proptosis,(decreased(ocular(motility,(severe(pain,(APD,(optic( nerve(head(edema,(decreased(va Pediatric(presentation Caused(by(BSinusitis,(hordolea,(dacryocystitis,(trauma(and(insect(bite
Preseptal cellulitis Treatment Oral%antibiotics Augmentin%(amoxicillin%+clauvanate) Monitor%for%progression
Preseptal cellulitis
Additional)management)considerations
Preventing)spread)of)infection Educate(the(patient(and(caregiver(on(proper(hygiene(practices: Avoid(touching(the(eyes(or(eye(area. Use(disposable(tissues(and(wipes(instead(of(towels. Wash(hands(immediately(after(touching(the(eyes(or(eye(area. Don t(share(towels,(washcloths,(dishes,(cups(or(eating(utensils. Play(with(hard(surface(toys(that(can(be(thoroughly(cleaned. Discuss(the(need(to(keep(children(out(of(daycare(or(school( Complete(notes(or(documentation(required(for(absences(or(reentry
Scheduling+treatment Set$family$up$for$success Consider$family$schedules$ Coordinate$with$regular$family$activities$to$improve$compliance Recommend$caregiver$administer$the$medication$at$regular$family$ activities$(breakfast,$after$school,$bedtime$may$improve$compliance)
Communication Touching)base)with)patient s)family)and)other)providers When)prescribing)an)oral)medication,)follow)up)with)a)phone)call)to)check)on) the)patient s)status)and)review)any)concerns. Document)these)phone)calls)in)the)patient s)record.) Call)or)write)to)the)child s)pediatrician)regarding)the)condition)and)any) prescribed)medication.) Be)sure)to)document)this)communication)in)the)medical)record.)
Case%Studies
5"year'old'female'presents'with'itchy'eyelids,'reddened'lid' margins;'no'discharge Other'findings7 inferior'corneal'staining History' third'episode'in'five'months Most'likely'diagnosis? Management'options?
12#year(old(male(who$has$Spina$Bifida$presents$with$swollen$lids,$ itchy$red$eyes $and$watery$discharge Other$symptoms$: pain$and$severe$foreign:body$sensation History: His$mother$noted$started$a$few$days$earlier,$when$he$felt$ itchiness$in$his$right$eye$that$appeared$inflamed Most(likely(diagnosis? Management(options?
7"year'old'female'presents'painful,'swollen'left'eyelid'x'two'days' Other'findings'6 low6grade'fever;'swollen'left'preauricular node VA'20/20'OD'and'OS' Most'likely'Diagnosis? Management'options?
4"year'old'male'presents'with'a'red'eye,'that'is'not'resolving History'4 Being'treated'with'Polytrim (dosed'appropriately)' Findings4 Appears'to'be'keratoconjunctivitis with'significant' corneal'staining'(pek),'papillae,'and'mucopurulent'discharge.' What'is'your'next'step?
13#year(old(male(complains*of*intense*itching*x*several*weeks Other*findings7 swollen*eyelids,*injection,*chemosis,*large* papillae,*mucus*strings*and*strands*ou; OD*cornea*has*2*x*3* mm*area*of*excavation,*3+*anterior*chamber*reaction* Most(likely(diagnosis?( Management(options?
Thank you for your interest and attention! Have questions? Please feel free to contact us Rachel'A.' 'Stacey 'Coulter,'OD,' MSEd,'FAAO,'Diplomate'BVPPO staceyco@nova.edu Julie A. Tyler, OD, FAAO jtyler@nova.edu
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