Opinions of the Fourth-Generation Fluroroquinolones in

the Management of Bacterial Keratitis: A Survey of

Ophthalmologists from Four States

This study was supported in part by Research to Prevent Blindness (RPB), Inc.

Financial Disclosures:

Hugo Y. Hsu None

Heidi A. Israel None

Randall Nacke None

Jonathan C. Song None

Sonia H. Yoo Alcon, AMO, Carl Zeiss Meditect

Eduardo C. Alfonso None

Background

• Over the past 20 years, empiric therapy with commercially-available antibiotics has come to replace fortified antibiotics as the drugs of choice in the treatment of the majority of bacterial keratitis.

• The 1990’s saw the introduction of the fluoroquinolones for ophthalmic use with studies suggesting equal efficacy when compared to fortified antibiotics.

• The newest “generation” of fluoroquinolones– moxifloxacine & gatifloxacine–were introduced in 2003 for ophthalmic use.

• While officially approved for the treatment of bacterial keratitis, the newer fluoroquinolones have become popular replacements for their older cousins in the treatment of bacterial keratitis.

Purpose• To evaluate ophthalmologists’ opinions

of the newer fluoroquinolone antibiotics in the management of bacterial keratitis.

• 6100 anonymous practice-pattern questionnaires were sent to ophthalmologists in California, Florida, Illinois, & Missouri

• The questionnaires were grouped and filtered by the type and setting of the respondents’ practices

• Descriptive statistics, chi-square, & non-parametric analysis techniques were employed.

Methods

Methods: Questions asked

Results

• 629 surveys were returned (10.3%)

Comprehensive 475 (75.5%)Cornea 100 (15.9%)Retina 45 (7.2%)Refractive 58 (9.2%)Glaucoma 52 (8.3%)Peds/Strabismus

40 (6.4%)

Others 31 (4.9%)Total 629*

* Respondents were allowed to indicate more than one choice to describe the nature of their practice

“Overall, has the introduction of the 4th generation fluoroquinoones (Vigamox® & Zymar®) impacted your practice and your usage of antibiotics?”

Comprehensive practices

Cornea practices

P-value

“not really” 35 (8.5%) 9 (9.2%)

0.334

“a little bit” 107 (25.8%) 30 (30.6%)

“definitely” 272 (65.7%) 59 (60.2%)

Total 414 98

“4th generation fluoroquinolones make me < fill in the blank > to culture a patient with a corneal ulcer.”

Comprehensive practices

Cornea practices

P-value

“more likely”

9 (2.2%) 3 (3.0%)

< 0.001

“no change”

195 (47.3%) 67 (67.7%)

“less likely” 208 (50.5%) 29 (29.3%)

Total 412 99

“4th generation fluoroquinolones make me < fill in the blank > to refer a patient with a corneal ulcer.”

Comprehensive practices

Cornea practices

P-value

“more likely”

3 (0.7%) 0

< 0.001

“no change”

219 (53.0%) 78 (79.6%)

“less likely” 191 (46.2%) 20 (20.4%)

Total 413 98

“4th generation fluoroquinolones represent a significant improvement over prior fluoroquinolons in the treatment of corneal ulcers.”

Comprehensive practices

Cornea practices

P-value

“don’t agree” 35 (8.5%) 13 (13.1%)

0.122

“somewhat agree”

138 (33.3%) 37 (37.4%)

“mostly agree”

141 (34.1%) 28 (28.3%)

“strongly agree”

100 (24.2%) 21 (21.2%)

Total 414 99

Is there a difference between cornea specialists in private vs. academic

practices?

P-value

“…has the 4th generation fluoroquinolones impacted your practice and usage of antibiotics?”

0.55

“4th generation…make me < fill in > culture a patient”

0.08

“4th generation…make me < fill in > refer a patient”

0.22

“4th generation…represent a significant improvement…” (degrees of agreement)

0.90

Conclusion

• The newer fluoroquinolones have impacted the practices of and the usage of antibiotics among ophthalmologists.

• Slightly over half of ophthalmologists surveyed indicate that the newer fluoroquinolones are an improvement over their older cousins in the management of corneal ulcers.

• These impacts and impression are more strongly felt by comprehensive ophthalmologists than cornea specialists.

Conclusion

• Specifically, while having similar opinions, fewer cornea specialists have changed their management of corneal ulcers compared to their comprehensive colleagues due to the newer fluoroquinolones.

• No difference(s) were found in the answers between private cornea specialists and academic cornea specialists.