Azithromycin is a great antibiotic to use when the patient is allergic to penicillin. There is, however, a downside: It is moderately expensive ($50).

Azithromycin is indicated for soft tissue infection which makes it a great drug for treatment of infection around the eyelid. It is known for treatment of Chlamydia infection. It also penetrates the sinus cavity and is approved for sinusitis, so it is a good drug to prescribe for prophyllactic treatment of a blow-out fracture.

Because this drug treats sinusitis, it can be utilized for referred periorbital pain secondary to sinusitis. A typical patient scenario is one that presents with orbital pain of an unclear etiology. If you have ruled out the typical things--corneal related issues, uveitis, lid issues, intraocular pressure elevation, optic neuritis--then treat for a sinus infection around the orbit. Patients may give a history of recently having an upper respiratory infection and they may report that the pain increases when they bend over. Remember, the orbit is lined by sinus cavities and it is a closed-off system, so a sinus infection can radiate pain to the orbit, upper teeth, or cheek. If you treat the patient with Azithromycin for sinusitis along with a decongestant, most of the time you will be successful.

Azithromycin is moderately expensive ($50).

	Prescription writing Zpak (trade name of Azithromycin) is a simple prescription to write because it comes in a self-explanatory packet. (It is also available as a tri-pack; the patient takes 1 pill per day for 3 days.) Be sure to caution the patient to take the pill at the same time each day; otherwise, the patient can develop stomach cramping and diarrhea.) LEFT: Sample prescriptions for Zpak.

Chlamydia Cases of chlamydia can be easily missed. The typical scenario is a "red eye" that does not respond to conventional treatment. The case initially looks like viral conjunctivitis, but doesn't get any better. Then 3 weeks into it, the light bulb turns on and you say, "Oh yeah . . . chlamydia." Don't let bilaterality fool you. About 90% of the chlamydia cases Dr. Grogg treats are bilateral rather than the classical unilateral. One eye is usually involved more than the other. Discharge is very sticky and stringy. Although a follicular response is notarious in chlamydia, you see significant follicles in EKC (epidemic keratoconjunctivitis) cases, which explains why chlamydia cases are routinely missed initially. In chlamydia cases, the upper lid becomes involved. If you're dealing with a red eye 3-4 weeks in and you flip the upper lid and it is NOT red, the case is probably NOT chlamydia. Case example:   A patient presented with a red eye recently to Dr. Grogg. When she everted the lid on Day 1, it looked fine. The patient was so uncomfortable with lid evertion, she didn't attempt lid evertion until 3 weeks later when the conjunctivitis wasn't getting better. The lid in this case actually bled. It was very "friable." Apparently, the cervix in women with chlamydia is very similar. It bleeds very easily when cultured with a Q-Tip. Treatment:   Although chlamydia is not that common, you need to know how to treat it when it does appear in your chair. With chlamydia, you are NOT going to write a prescription for a regular pack or tri-pack of Zpak, but rather for a 1-gram dose of Azithromycin to be taken all at once. Azithromycin is the treatment of choice for chlamydia. The 1-gram dose of Azithromycin should be prescribed in one of the following ways: 250 mg, disp #4 (4 pills take at once) 500 mg, disp #2 (2 pills take at once) Powder (put in water and drink)--less expensive ($40) All patients you suspect of having chlamydia need to be cultured. This is a condition that will be reported to the Department of Health. The Department of Health will send you forms to be completed by the treating doctor. Referral for other STD testing, analysis, and counseling should be made as well as treating partners. Example of how to write the prescription for the powder form of Azithromycin.