On-site Fortisite™ takes on serious infections quickly
The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.
By Joshua Davidson, OD, FAAO, FSLS
Stocking a broad-spectrum fortified antibiotic in the clinic is like having a powerful weapon on standby.
The vast majority of ocular infections that we treat here at the Williamson Eye Center (WEC) in Baton Rouge, Louisiana, can be managed successfully with broad-spectrum antibiotics or fourth-generation fluoroquinolones. Then there are the outliers—the ones that keep us up at night. These potentially sight-threatening infectious keratitis cases and severe corneal ulcers require something even stronger—a fortified compounded antibiotic.
While these serious cases typically respond well to compounded fortified antibiotics, connecting the patient with a compounding pharmacy can sometimes seem like an exercise in futility. Issues such as obtaining prior authorization, determining whether the patient lives near the compounding pharmacy, or finding out how quickly the drug can be delivered wastes precious time. In these cases, the outcome often hinges on how quickly appropriate treatment begins. This scenario doesn’t often happen at WEC, but it occurs frequently enough that when the opportunity emerged to stock Fortisite™ (Harrow, ImprimisRx) on-site, we welcomed it.
Fortisite is a topical antibiotic compounded combination of tobramycin 1.5% and vancomycin 5% that is distributed through an ImprimisRx 503B outsourcing facility. Since it became possible to stock Fortisite in WEC’s 8 clinics, we are now able to prescribe and distribute a stronger topical antibiotic with half the preservative load of compound pharmacy-fortified eye drops—and without the delay associated with compounding pharmacies.
Previously, when a patient presented with a potentially sight-threatening ulcer, our options were limited to commercially available drops or waiting for drops from a compounding pharmacy, which could take up to 36 hours to be delivered to the patient. The ability to circumvent the obstacles of that inefficient process provides a valuable option for managing the most challenging corneal infections in the optometry clinic.
Immediate Access
In the United States, most corneal ulcers are associated with contact lens use and poor hygiene. When patients present with this type of infection and it appears like a calm or “normal” ulcer or abrasion, I start with a broad-spectrum antibiotic. When the patient returns for follow-up in 1 to 2 days, if there hasn’t been any improvement, I culture it to determine next steps. In more serious cases, if an ulcer appears “concerning” at presentation, a culture is taken from the infiltrate and the patient is treated with fortified antibiotics. Having Fortisite on hand means I can go ahead and treat with a broad-spectrum aggressive fortified antibiotic before the culture comes back. There’s no delay, and therefore, no potential for the infection to worsen while waiting for delivery from a compounding pharmacy.
Having immediate access to the tobramycin/vancomycin compound provides peace of mind—like an insurance policy—for those rare, but inevitable, severe infections that need prompt treatment. When describing on-site access to Fortisite, I like to use this analogy: While it’s not something we need frequently, having Fortisite in our clinic is like having a fire extinguisher—it’s rarely necessary, but when faced with an urgent situation, we’re prepared.
Lower Resistance
An important benefit to having Fortisite in the clinic is that, unlike most other antibiotics, we can expect significantly lower resistance to it. Because Fortisite is a relatively young antibiotic that has not been widely prescribed by the general medical community, we can expect that patients will not be immune to it. Having this formula on hand is great for the treatment of the angriest, most resistant corneal infections, but I also feel confident that I could use it on any infection, knowing resistance won’t be a problem and it will get the job done.
Administrative Concerns
For some eye care providers, the concept of stocking a fortified antibiotic on-site might inspire concerns about drug potency, sterility, and financial ramifications if the drug expires. Those concerns are easily alleviated. First, because Fortisite is available for in-office use from an FDA-registered 503B outsourcing facility, each bottle must strictly adhere to rigorous analytical testing protocols that are not required for locally regulated 503A compounding pharmacies. Next, it is tested for both potency and sterility before it is dispensed, and it is stable at refrigerated temperatures (5° C) for up to 180 days. Finally, ImprimisRx addresses concerns about the product going unused before it expires by offering a 100% replacement guarantee on a product that has expired. That’s a huge benefit because busy practices like WEC can keep Fortisite on hand—even if it is not used frequently—with no worries about expiration. If the drug expires, ImprimisRx will send a refund or replace the expired bottle.
Practice and Patient Benefits
Ultimately, stocking a fortified compounded antibiotic on-site is a win-win for the practice and our patients. My patients have the benefit of immediate treatment that, in some cases, is desperately needed by the time they see me, and I benefit from having a powerful “weapon” ready and waiting to eradicate stubborn and sometimes treatment-resistant corneal infections and ulcers. Having immediate access to a fortified compounded antibiotic inspires a high level of confidence; I know that, if for some reason, treatment with a broad-spectrum antibiotic isn’t sufficient, I have the ultimate game-changer on hand.
Joshua Davidson, OD, FAAO, FSLS, is an optometrist and director of the Dry Eye and Specialty Lens Center at Williamson Eye Center in Louisiana. He can be reached at jdavidson@weceye.com. He has no financial interests to report.
