This week my daughter called and texted me pictures to say my four-year-old granddaughter had “pink eye.” Not getting a call back immediately from me prompted a quick visit to the local urgent care center. I had trouble reaching her, so I decided to phone in a prescription for Polytrim (trimethoprim/polymyxin B, Allergan) to their local pharmacy. When I finally got to speak to my daughter, the urgent care had already phoned in a topical antibiotic—Polytrim. So, now she has two bottles, which is good because half the first bottle’s contents ended up on my granddaughter’s cheek. It would be easier applying drops into a squirrel’s eye. 

Should I have prescribed an antibiotic without first seeing her? The short answer is probably not, but we’re two hours away, and the photo surely showed a red, inflamed eye. Second, and most important, were either one of us (the center and me) good stewards for prescribing? Again, probably not. I doubt that I’m alone in sending along an antibiotic when it might not be needed. Of course, my daughter felt both the urgent care provider and I were geniuses since my granddaughter was clearly better in just a few days. Was it a bacterial conjunctivitis? Likely not, very few are.

Avoiding Resistance

Within the last two decades, bacterial resistance has become a crisis—one that is outpacing the development of new antibiotics.^1,2 The CDC estimates that antibiotic resistant infections cost the US more than $20 billion each year—not to mention lost productivity.¹ Ocular concerns differ somewhat from systemic ones, but the risks and consequences are comparable in many respects.

However, the ophthalmic community is not immune to treatment-resistant organisms. Just this month a multi-state cluster of carbapenem-resistant Pseudomonas aeruginosa was associated with multiple different infections including the eye.³ A review of common exposures among patients identified that the majority of patients used artificial tears prior to the infection. The most common brand identified was EzriCare Artificial Tears (Global Pharma Healthcare). Further CDC testing is ongoing to assess if they match the outbreak strain.³ The agency is investigating a cluster of 56 isolates from 50 patients in 11 states.⁴

In doing our part to minimize and avoid antimicrobial resistance, addressing ongoing threats requires aggressive actions.¹

• Prevent infections with healthy habits (get recommended vaccines, keep hands and wounds clean and take care of chronic conditions such as diabetes).
• Improve antimicrobial (antibiotic and antifungal) use to slow the development of resistance.
• Stop the spread of resistance when it does develop with surveillance of antibiotic resistance and antibiotic use (report when such events as described occur).

Recent strategies encouraged by CDC include pathogen reduction (decreasing the number of bacterial and fungal pathogens that might lead to infection) and decolonization (goal would be to remove pathogens from our skin, gut, nose, etc.). Future options to reduce pathogens and colonization may involve bacteriophages and other live biotherapeutic products.¹ Understanding the microbial ecology and ecological pressures, as well as looking at the relationship of microbes that allow some germs to survive and multiply in a competitive environment and why others do not, will be a key component to the fight.

Better Judgment

I doubt that my indiscretion in prescribing Polytrim for my granddaughter has contributed significantly to the resistance patterns in her local community, but nevertheless I feel guilty for not doing my part in being a good steward of antibiotic use. Overall, rational use of antibiotics, even when used in a topical fashion, is needed to help minimize antimicrobial resistance in your community.

Before prescribing a broad-spectrum antibiotic, examine the conjunctiva carefully for follicles and papillae. Are there any lid or skin findings such as molluscum, vesicles or adenopathy? Is there any significant discharge? And, what involvement—if any—is found on the cornea, especially in contact lens wearers? So, the next time a patient—or relative—calls with what is likely a self-limiting acute red eye often seen in contact lens wearers, consider holding the antibiotic at least until you see them. Simply ordering an NSAID, antihistamine/mast cell stabilizer or just the topical steroid for more severe cases of conjunctivitis will often suffice.

1. Actions to fight antimicrobial resistance. CDC. www.cdc.gov/drugresistance/actions-to-fight.html. Last updated December 14, 2021. Accessed February 1, 2023. 2. Office of the Press Secretary. Executive order-combatting antibiotic-resistant bacteria. obamawhitehouse.archives.gov/the-press-office/2014/09/18/executive-order-combating-antibiotic-resistant-bacteria. The Obama White House Archives. September 18, 2014. Accessed February 1, 2023.  3. State-based HAI prevention activities. CDC. www.cdc.gov/hai/state-based/index.html. Accessed February 1, 2023. 4. CDC urges discontinued use of EzriCare artificial tears. American Academy of Ophthalmology. www.aao.org/headline/cdc-urges-discontinue-use-ezricare-artificialtears. January 20, 2023. Accessed February 1, 2023.