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Vancomycine and amikacine fortified drop preparation

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bacterial keratitis AND fortified antibiotics

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fortified vancomycin amikacin ophthalmic drops preparation 50 mg/mL 25 mg/mL sterile compounding

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https://www.aao.org/Assets/6dd86c3a-c71f-44c8-aec1-fd833faca…

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For fortified ophthalmic drops used in severe bacterial keratitis, prepare them as separate sterile bottles. Do not mix vancomycin and amikacin in the same bottle unless your hospital pharmacy has a validated compatibility protocol.

1. Vancomycin fortified eye drops

Common concentration: 50 mg/mL (5%)
  • Vancomycin powder for injection: 500 mg vial
  • Add 10 mL preservative-free 0.9% sodium chloride for injection or preservative-free artificial tears.
  • This yields 500 mg / 10 mL = 50 mg/mL (5%).
  • Mix gently until fully dissolved.
  • Dispense into a sterile ophthalmic dropper bottle.
  • Label: Vancomycin 50 mg/mL (5%), ophthalmic use only, shake well, refrigerate.
Other commonly prescribed concentrations:
  • 25 mg/mL (2.5%): 500 mg + 20 mL diluent
  • 15 mg/mL (1.5%): 500 mg + 33 mL diluent
The AAO lists 15, 25, and 50 mg/mL formulations, prepared with preservative-free normal saline or artificial tears and refrigerated with shaking before instillation. AAO bacterial keratitis guidance

2. Amikacin fortified eye drops

Common concentration: 40 mg/mL (4%)
  • Amikacin injection 80 mg/2 mL, which is already 40 mg/mL
  • Use the injectable solution undiluted in a sterile ophthalmic dropper bottle.
  • Label: Amikacin 40 mg/mL (4%), ophthalmic use only, shake well, refrigerate.
Some corneal services prescribe amikacin 20 mg/mL (2%), especially for Nocardia keratitis. To make this from 40 mg/mL stock, dilute 1 part amikacin 40 mg/mL with 1 part preservative-free normal saline.

Practical safety points

  • Prepare only using aseptic technique in an appropriate pharmacy/sterile-compounding setting.
  • Use preservative-free diluent.
  • Send corneal scraping/culture before treatment where this does not delay urgent therapy.
  • Severe ulcers are often treated initially hourly, including overnight for the first 24-48 hours, then adjusted by the ophthalmologist and culture results. Kanski notes that intensive topical therapy is initially hourly and later tapered according to clinical response. Kanski's Clinical Ophthalmology, 10th ed., Local therapy.
  • Refrigerate and discard according to your local pharmacy’s validated beyond-use date. Do not assume a universal expiry for compounded drops.
  • Vancomycin targets resistant Gram-positive organisms. Amikacin is particularly useful for organisms such as Nocardia and atypical mycobacteria, rather than being the standard empiric Gram-negative companion in every ulcer. The AAO lists amikacin at 20-40 mg/mL for these indications. AAO cornea benchmarks
A recent meta-analysis found fortified-antibiotic regimens and fluoroquinolones both remain used for bacterial keratitis, but the regimen should be based on ulcer severity, microscopy, and culture where possible (2024 meta-analysis, PMID 37741755).
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