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September 2013 over several years (January 2002 through December 2009) of patients seen at Kaiser Permanente. There was a total of 399 culture-positive MRSA isolates in all ages, increasing upward each year but peaking at 2006. Pediatric cases made up about one third of the total number of cases; 58% of the pediatric cases had been community acquired. The most common presentations were conjunctivitis, stye/chalazion, orbital cellulitis and abscess, dacryocystitis, and brow abscess. Children with MRSA were more likely to be male, neonatal, and have multiple infection sites on their body. "Genetic typing was not performed in our study, but, if performed, it may have revealed a higher incidence of communityacquired MRSA in neonates than reported," said lead investigator Malena Amato, MD, now with Texas Oculoplastics Consultants, Austin. "With the presence of CA MRSA in hospitals, genetic typing may be essential to adequately identify and treat ocular and periocular MRSA." The children tracked in the study had high resistance to bacitracin and ofloxacin but lower resistance to trimethoprim/ sulfamethoxazole. Nearly 30% of cases used topical therapy, and 47% used oral antibiotics. However, 12% of cases needed IV therapy, and 19% required incision or drainage. No patients had permanent ocular sequelae, Dr. Amato said. Resistance to antibiotics increased during the study timeframe, particularly by the final two years. Early recognition of infection, proper antibiotic use, and obtaining cultures and sensitivities when resistant or severe infections occur can help clinicians better manage MRSA infections, the investigators concluded. Considering implications The results from studies like the ones here can help give clinicians a global view of ocular infection, especially with MRSA. However, they also help track regional differences in microbiologic isolates and their resistant patterns, Dr. Lichtinger said. "It's important to have up-todate local data available to guide initial empirical treatment," he said. Clinicians need to consider ways to diminish the risk of antibiotic resistance, Dr. Lichtinger added. For example, he does not recommend tapering antibiotics as one might do with corticosteroids, but he will decrease the frequency of the drops. "I usually start the drops every hour but then stay at a lower but still effective dose of four times a day for about a week after we consider the ulcer healed and sterile and then discontinue the medication," he said. Clinicians should also consider the increasing resistance that MRSA has to specific ophthalmic antibiotics such as topical bacitracin, erythromycin, and fluoroquinolones, Dr. Amato said. "In the face of ocular and periocular infection failing to respond to first-line antibiotic therapy, the possibility of MRSA should be considered and appropriate steps taken," she said. EW References 1. Hsiao CH, Chuang CC, Tan HY, et al. Methicillin-resistant Staphylococcus aureus ocular infection: A 10-year hospital based study. Ophthalmology. 2012;119:522-527. 2. Lichtinger A, Yeung SN, Kim PK, et al. Shifting trends in bacterial keratitis in Toronto: An 11-year review. Ophthalmology. 2012. 119:1785-1790. 3. Amato M, Pershing S, Walvick M, Tanaka S. Trends in ophthalmic manifestations of methicillin-resistant Staphylococcus aureus in a northern California pediatric population. J AAPOS. 2013:17:243-247. Find us on social media Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine Editors' note: Dr. Lichtinger has financial interests with Bausch + Lomb (Rochester, N.Y.). Dr. Amato has no financial interests related to this article. EW CORNEA Contact information Amato: 512-458-2141, malena_amato@hotmail.com Lichtinger: drlichtinger@yahoo.com Visit us at AAO Booth 2201 59