SPECIAL REPORT
Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery Update on the ESCRS Endophthalmitis Study Peter Barry, MD, FRCS
To determine the use of intracameral cefuroxime at the end of cataract surgery since the beneficial results were first reported by the European Society of Cataract and Refractive Surgeons Endophthalmitis Study Group in 2006, 250 ophthalmic surgeons affiliated with both public and private hospitals and clinics across Europe were surveyed. The questions regarded their awareness of the results of the ESCRS endophthalmitis study and their current use or non-use of intracameral antibiotics in their cataract procedures. Seventy-four percent of respondents said they always or usually use intracameral antibiotics in their cataract surgery procedures. The most frequently cited reasons for not using cefuroxime or other intracameral antibiotics was the lack of an approved commercial preparation and related anxieties regarding the risk of dilution errors and contamination. More than 90% of respondents said they would use cefuroxime if an approved single-unit dose product were commercially available. Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:138–142 Q 2013 ASCRS and ESCRS
The European Society of Cataract and Refractive Surgeons (ESCRS) Endophthalmitis Study, the results of which were published in 2006,1 showed a 5-fold reduction in the endophthalmitis rate in patients randomly allocated to intracameral cefuroxime compared with those who did not receive intracameral antibiotics. The study's findings appeared to confirm data from the Swedish Cataract registry, which showed a reduction in endophthalmitis rate from Submitted: March 27, 2013. Final revision submitted: September 5, 2013. Accepted: September 8, 2013. From the Royal Victoria Eye and Ear Hospital and St Vincent’s University Hospital, Dublin, Ireland. Supported by the European Society of Cataract & Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. Presented at the XXX Congress of the European Society of Cataract & Refractive Surgeons, Milan, Italy, September 2012. Corresponding author: Peter Barry, MD, FRCS, The Eye Clinic, Herbert Avenue, Dublin 4, Ireland. E-mail: peterbarryfrcs@ theeyeclinic.ie.
138
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
0.48% to 0.06% after the Swedish ophthalmologists adopted the use of intracameral cefuroxime in 1996.2 Adoption of the prophylactic use of intracameral antibiotics following publication of the results of the ESCRS clinical trial has varied widely around the world. For example, a survey of American Society of Cataract and Refractive Surgery (ASCRS) and ESCRS members carried out in 2010 and presented at the XXVIII Congress of the ESCRS in 2011A showed that 60% of ESCRS respondents used intracameral antibiotics compared with only 20% of ASCRS respondents. These results showed no significant change from those in the survey that the ASCRS Cataract Clinical Committee conducted approximately 1 year after the ESCRS endophthalmitis study.3 Only 23% of more than 1300 ASCRS repondents were injecting intracameral antibiotics; however, 82% said they would do so if a reasonably priced commercial preparation were available. A survey of ophthalmic surgeons in the United Kingdom conducted in 2009 by Gore et al.4 found that 55% of respondents were injecting intracameral cefuroxime. Of those using intracameral cefuroxime, 48% switched after the publication of the ESCRS survey. The most common reason for not using 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.002
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
139
intracameral cefuroxime was the dilution risks associated with preparing the drug in the absence of a commercially available formulation. The ESCRS has published guidelines supporting the use of prophylactic intracameral antibiotics, specifically for cataract surgery, advising the use of intracameral cefuroxime.5 In their preferred practice guidelines for cataract surgery, the American Academy of Ophthalmology states that “only intracameral antibiotics at the end of the case guarantees suprathreshold antibiotic levels for an extended period of time.”6 The ESCRS conducted this survey to determine the current use of prophylactic intracameral antibiotics by European ophthalmic surgeons. MATERIALS AND METHODS The ESCRS commissioned the U.K.-based market research firm ASE to conduct up to 250 computer-assisted telephone interviews. Based on consultations with ASE, it was agreed to select 250 surgeons from a list of 500 randomized from the ESCRS membership database. The 500 selected were weighted by country according to each country's ESCRS membership. In the end, 193 telephone calls were completed, 77% of the targeted 250 calls, from 31 European countries. The interviews were conducted in English, although participants were offered the option to complete the interview in Spanish, French, German, or Italian. After answering some qualifying questions regarding type of practice, years in practice, and clinical specialty, the respondents were asked the questions in Figure 1.
RESULTS A total of 193 ESCRS-member surgeons participated in the survey. The distribution between hospitals, private practice, and university or government institutions is shown in Figure 2. The use of intracameral antibiotics among the 193 respondents is shown in Figure 3. Of the 74% who used intracameral antibiotics, 82% used cefuroxime and 18% used other agents, including vancomycin, moxifloxacin, and gentamicin. Reasons given by the 26% not using intracameral antibiotics are shown in Figure 4. The respondents' answers to the question of whether they would use a commercial single-dose preparation of cefuroxime if one became available are shown in Figure 5. Of the 14% who would not use a commercial preparation, 12 were already using intracameral cefuroxime and were satisfied with the results. They saw no need to switch to a commercial preparation. Conversely, of the 73% who said they would use a commercially available preparation of cefuroxime, 29% were not currently using intracameral antibiotics. Therefore, only 8% of the 193 surgeons interviewed would not use intracameral
Figure 1. Questions in the ESRS survey.
cefuroxime whether or not it was commercially available. With reference to a reasonable cost of a commercially prepared product, the respondents were equally divided on the reasonableness of V20 per patient. Of
Figure 2. Practice patterns of respondents.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
140
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
Figure 3. Frequency of use of intracameral antibiotics.
Figure 4. Reasons for nonuse of intracameral antibiotics.
the 45% who did not agree with a charge of V20, most thought the cost should be between V5 and V10.
one became available. That finding is particularly relevant given the recent introduction of a commercially produced single-unit dose of cefuroxime (Aprokam), which has been approved by the European Medicines Agency and more than 12 European countries at this writing. The reluctance of some surgeons, particularly those outside Europe, to adopt the use of intracameral antibiotics is not entirely unreasonable, since up to now it has required the use of off-label products that require additional preparation, often under conditions that are below the standards expected from industrial production facilities. Many hospitals use compounding pharmacies for their off-label preparations, and in the United States these facilities have lately acquired a poor reputation among physicians in general. Two years ago in the U.S., there was an outbreak of endophthalmitis in Florida among patients who had received intravitreal injections of bevacizumab that had been prepared at a compounding pharmacy.7 In 2012, there was an outbreak of fungal meningitis and other fungal infections in 678 patients who had epidural injection of steroids prepared at a single compounding pharmacy.8 Moreover, eye surgeons using intracameral cefuroxime have had their share of mishaps, including an outbreak in a hospital in Turkey of 8 cases of Fusarium endophthalmitis among cataract patients who received intracameral cefuroxime from doses that had been prepared in the operating room using a “kitchen pharmacy” method.9 In a hospital in Finland, an incorrect dilution resulted in a series of patients receiving intracameral cefuroxime at 50 to 100 times the recommended dose. Eight of the 16 eyes suffered severe and permanent visual loss.10 Despite the risks, the U.S. Food and Drug Administration's reluctance to approve new products will
DISCUSSION In our survey of European ophthalmic surgeons, we were pleasantly surprised to find the relatively high figure of 74% of respondents who always or almost always use intracameral antibiotics. Unfortunately, we did not ask a specific question as to whether these same respondents had been using intracameral antibiotics prior to the publication of the ESCRS study results. Use of intracameral antibiotics among respondents to this survey was meaningfully higher than those obtained in previous surveys. Furthermore, if one includes those already using intracameral antibiotics but unwilling to change, over 90% of respondents would use an approved commercial single-unit dose if
Figure 5. Responses to question about use of a commercial preparation of cefuroxime if it were available.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
inevitably lead to clinicians opting for products from compounding pharmacies because they are convinced of their clinical superiority. Moreover, new evidence in favor of the efficacy of intracameral antibiotics continues to accumulate. Findings include the latest report from the Swedish Cataract registry,11 which shows that during the years 2005 to 2010, the rate of endophthalmitis following cataract surgery among 464 996 operated eyes was only 0.029%. The number of endophthalmitis cases caused by strains resistant to intracameral cefuroxime has not increased in Sweden over the years, although such strains now account for a higher proportion of cases. Also impressive is the finding from a study conducted at a large surgery center in Northern California. The patients who received intracameral injection over the course of the 5-year study had a 22-fold lower rate of infection.12 The choice of cefuroxime as the preferred agent for intracameral antibiotic has met with criticism. Critics of its use point to the broader spectrum of activity afforded by fourth-generation fluoroquinolones and vancomycin. However, those agents have serious drawbacks of their own. In the case of fourth-generation fluoroquinolones, widespread use in the U.S. of topical moxifloxacin as a prophylaxis against endophthalmitis have exposed the periocular flora of a significant number of patients to the agent. Microorganisms that have developed resistance to these antibiotics have been implicated in cases of endophthalmitis.13 Alcon Laboratories, the manufacturer of moxifloxacin 0.5% (Vigamox), specifically states that the product is for topical and not for intraocular use.B Proponents of vancomycin, meanwhile, point to the fact that it is effective against methicillin-resistant Staphylococcus aureus (MRSA). However, screening at-risk patients, ie, those in long-term nursing home care or recent inpatient hospital care, for MRSA and treating them before surgery will eliminate most of the risk posed by such microorganisms. The Center for Disease Control in Atlanta, Georgia, U.S., have strongly advised against the routine use of vancomycin as a prophylaxis against endophthalmitis. In conclusion, the results of this survey indicate that the ESCRS Endophthalmitis Study has had a strong impact on the practice of endophthalmitis prophylaxis among European ophthalmic surgeons. Around three-fourths of survey respondents said they currently use intracameral antibiotics and more than 90% said they would do so if an approved preparation of cefuroxime were commercially available. The recent introduction of an approved commercially available single-unit dose of cefuroxime should therefore lead to an increased use of intracameral cefuroxime in cataract procedures by ophthalmic
141
surgeons across Europe, with a concomitant reduction in the incidence of postoperative endophthalmitis. REFERENCES 1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus R; for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a European multicenter study. J Cataract Refract Surg 2006; 32: 396–406; erratum, 709 2. Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2002; 28:977–981 3. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M; for the ASCRS Cataract Clinical Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery; results of the 2007 ASCRS member survey. J Cataract Refract Surg 2007; 33:1801–1805 4. Gore DM, Angunawela RE, Little BC. United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study. J Cataract Refract Surg 2009; 35: 770–773 s L, Gardner S. ESCRS Guidelines for Preven5. Barry P, Cordove tion and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions. Dublin, Ireland, European Society of Cataract and Refractive Surgeons, 2013. Available at: http://www.escrs.org/downloads/EndophthalmitisGuidelines.pdf. Accessed November 12, 2013 6. American Academy of Ophthalmology. Cataract in the Adult Eye; Preferred Practice Patterns. San Francisco, CA, American Academy of Ophthalmology, 2011; Available at: http://one.aao. org/Assets/8d66318f-ff50-408e-9bb1-73d277cf14ce/63496543 6146230000/cataract-in-the-adult-eye-pdf. Accessed October 8, 2013 7. Goldberg RA, Flynn HW Jr, Isom RF, Miller D, Gonzalez S. An outbreak of streptococcus endophthalmitis after intravitreal injection of bevacizumab. Am J Ophthalmol 2012; 153:204–208 8. Centers for Disease Control. Persons with Meningitis Linked to Epidural Steroid Injections by State. Available at: http://www. cdc.gov/hai/outbreaks/meningitis-map.html. Accessed October 8, 2013 € u _ lu S, Ҫekiҫ O, Bozkurt E, Alagoz N, Oks €z L, 9. Cakır M, Imamo g € An outbreak of early-onset endophthalmitis caused Yılmaz OF. by Fusarium species following cataract surgery. Curr Eye Res 2009; 34:988–995 € rssinen O. Ocular toxicity in cataract surgery because of inac10. Pa curate preparation and erroneous use of 50mg/ml intracameral cefuroxime. Acta Ophthalmol 2012; 90:e153–e154. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1755-3768.2010. 02103.x/pdf. Accessed October 8, 2013 €m M, Stenevi U, Montan P. Six-year incidence 11. Friling E, Lundstro of endophthalmitis after cataract surgery: Swedish National Study. J Cataract Refract Surg 2013; 39:15–21 12. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a North California eye department. J Cataract Refract Surg 2013; 39:8–14 13. Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW Jr. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006; 124:479–483. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9954/ ECS50028.pdf. Accessed October 8, 2013
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
142
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
OTHER CITED MATERIAL A. Leaming D, “Comparisons of 2010 ESCRS and ASCRS Practice Style Survey of Members,” Presented at XXIX Congress of the European Society of Cataract & Refractive Surgeons, Vienna, Austria, September 2011 B. Alcon Laboratories. ProductInformation 5.1 Warnings and Precautions. Available at: http://ecatalog.alcon.com/PI/Vigamox_ us_en.pdf. Accessed October 8, 2013
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
First author: Peter Barry, MD, FRCS The Eye Clinic, Dublin 4, Ireland
Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery Update on the ESCRS Endophthalmitis Study Peter Barry, MD, FRCS
To determine the use of intracameral cefuroxime at the end of cataract surgery since the beneficial results were first reported by the European Society of Cataract and Refractive Surgeons Endophthalmitis Study Group in 2006, 250 ophthalmic surgeons affiliated with both public and private hospitals and clinics across Europe were surveyed. The questions regarded their awareness of the results of the ESCRS endophthalmitis study and their current use or non-use of intracameral antibiotics in their cataract procedures. Seventy-four percent of respondents said they always or usually use intracameral antibiotics in their cataract surgery procedures. The most frequently cited reasons for not using cefuroxime or other intracameral antibiotics was the lack of an approved commercial preparation and related anxieties regarding the risk of dilution errors and contamination. More than 90% of respondents said they would use cefuroxime if an approved single-unit dose product were commercially available. Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:138–142 Q 2013 ASCRS and ESCRS
The European Society of Cataract and Refractive Surgeons (ESCRS) Endophthalmitis Study, the results of which were published in 2006,1 showed a 5-fold reduction in the endophthalmitis rate in patients randomly allocated to intracameral cefuroxime compared with those who did not receive intracameral antibiotics. The study's findings appeared to confirm data from the Swedish Cataract registry, which showed a reduction in endophthalmitis rate from Submitted: March 27, 2013. Final revision submitted: September 5, 2013. Accepted: September 8, 2013. From the Royal Victoria Eye and Ear Hospital and St Vincent’s University Hospital, Dublin, Ireland. Supported by the European Society of Cataract & Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. Presented at the XXX Congress of the European Society of Cataract & Refractive Surgeons, Milan, Italy, September 2012. Corresponding author: Peter Barry, MD, FRCS, The Eye Clinic, Herbert Avenue, Dublin 4, Ireland. E-mail: peterbarryfrcs@ theeyeclinic.ie.
138
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
0.48% to 0.06% after the Swedish ophthalmologists adopted the use of intracameral cefuroxime in 1996.2 Adoption of the prophylactic use of intracameral antibiotics following publication of the results of the ESCRS clinical trial has varied widely around the world. For example, a survey of American Society of Cataract and Refractive Surgery (ASCRS) and ESCRS members carried out in 2010 and presented at the XXVIII Congress of the ESCRS in 2011A showed that 60% of ESCRS respondents used intracameral antibiotics compared with only 20% of ASCRS respondents. These results showed no significant change from those in the survey that the ASCRS Cataract Clinical Committee conducted approximately 1 year after the ESCRS endophthalmitis study.3 Only 23% of more than 1300 ASCRS repondents were injecting intracameral antibiotics; however, 82% said they would do so if a reasonably priced commercial preparation were available. A survey of ophthalmic surgeons in the United Kingdom conducted in 2009 by Gore et al.4 found that 55% of respondents were injecting intracameral cefuroxime. Of those using intracameral cefuroxime, 48% switched after the publication of the ESCRS survey. The most common reason for not using 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.002
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
139
intracameral cefuroxime was the dilution risks associated with preparing the drug in the absence of a commercially available formulation. The ESCRS has published guidelines supporting the use of prophylactic intracameral antibiotics, specifically for cataract surgery, advising the use of intracameral cefuroxime.5 In their preferred practice guidelines for cataract surgery, the American Academy of Ophthalmology states that “only intracameral antibiotics at the end of the case guarantees suprathreshold antibiotic levels for an extended period of time.”6 The ESCRS conducted this survey to determine the current use of prophylactic intracameral antibiotics by European ophthalmic surgeons. MATERIALS AND METHODS The ESCRS commissioned the U.K.-based market research firm ASE to conduct up to 250 computer-assisted telephone interviews. Based on consultations with ASE, it was agreed to select 250 surgeons from a list of 500 randomized from the ESCRS membership database. The 500 selected were weighted by country according to each country's ESCRS membership. In the end, 193 telephone calls were completed, 77% of the targeted 250 calls, from 31 European countries. The interviews were conducted in English, although participants were offered the option to complete the interview in Spanish, French, German, or Italian. After answering some qualifying questions regarding type of practice, years in practice, and clinical specialty, the respondents were asked the questions in Figure 1.
RESULTS A total of 193 ESCRS-member surgeons participated in the survey. The distribution between hospitals, private practice, and university or government institutions is shown in Figure 2. The use of intracameral antibiotics among the 193 respondents is shown in Figure 3. Of the 74% who used intracameral antibiotics, 82% used cefuroxime and 18% used other agents, including vancomycin, moxifloxacin, and gentamicin. Reasons given by the 26% not using intracameral antibiotics are shown in Figure 4. The respondents' answers to the question of whether they would use a commercial single-dose preparation of cefuroxime if one became available are shown in Figure 5. Of the 14% who would not use a commercial preparation, 12 were already using intracameral cefuroxime and were satisfied with the results. They saw no need to switch to a commercial preparation. Conversely, of the 73% who said they would use a commercially available preparation of cefuroxime, 29% were not currently using intracameral antibiotics. Therefore, only 8% of the 193 surgeons interviewed would not use intracameral
Figure 1. Questions in the ESRS survey.
cefuroxime whether or not it was commercially available. With reference to a reasonable cost of a commercially prepared product, the respondents were equally divided on the reasonableness of V20 per patient. Of
Figure 2. Practice patterns of respondents.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
140
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
Figure 3. Frequency of use of intracameral antibiotics.
Figure 4. Reasons for nonuse of intracameral antibiotics.
the 45% who did not agree with a charge of V20, most thought the cost should be between V5 and V10.
one became available. That finding is particularly relevant given the recent introduction of a commercially produced single-unit dose of cefuroxime (Aprokam), which has been approved by the European Medicines Agency and more than 12 European countries at this writing. The reluctance of some surgeons, particularly those outside Europe, to adopt the use of intracameral antibiotics is not entirely unreasonable, since up to now it has required the use of off-label products that require additional preparation, often under conditions that are below the standards expected from industrial production facilities. Many hospitals use compounding pharmacies for their off-label preparations, and in the United States these facilities have lately acquired a poor reputation among physicians in general. Two years ago in the U.S., there was an outbreak of endophthalmitis in Florida among patients who had received intravitreal injections of bevacizumab that had been prepared at a compounding pharmacy.7 In 2012, there was an outbreak of fungal meningitis and other fungal infections in 678 patients who had epidural injection of steroids prepared at a single compounding pharmacy.8 Moreover, eye surgeons using intracameral cefuroxime have had their share of mishaps, including an outbreak in a hospital in Turkey of 8 cases of Fusarium endophthalmitis among cataract patients who received intracameral cefuroxime from doses that had been prepared in the operating room using a “kitchen pharmacy” method.9 In a hospital in Finland, an incorrect dilution resulted in a series of patients receiving intracameral cefuroxime at 50 to 100 times the recommended dose. Eight of the 16 eyes suffered severe and permanent visual loss.10 Despite the risks, the U.S. Food and Drug Administration's reluctance to approve new products will
DISCUSSION In our survey of European ophthalmic surgeons, we were pleasantly surprised to find the relatively high figure of 74% of respondents who always or almost always use intracameral antibiotics. Unfortunately, we did not ask a specific question as to whether these same respondents had been using intracameral antibiotics prior to the publication of the ESCRS study results. Use of intracameral antibiotics among respondents to this survey was meaningfully higher than those obtained in previous surveys. Furthermore, if one includes those already using intracameral antibiotics but unwilling to change, over 90% of respondents would use an approved commercial single-unit dose if
Figure 5. Responses to question about use of a commercial preparation of cefuroxime if it were available.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
inevitably lead to clinicians opting for products from compounding pharmacies because they are convinced of their clinical superiority. Moreover, new evidence in favor of the efficacy of intracameral antibiotics continues to accumulate. Findings include the latest report from the Swedish Cataract registry,11 which shows that during the years 2005 to 2010, the rate of endophthalmitis following cataract surgery among 464 996 operated eyes was only 0.029%. The number of endophthalmitis cases caused by strains resistant to intracameral cefuroxime has not increased in Sweden over the years, although such strains now account for a higher proportion of cases. Also impressive is the finding from a study conducted at a large surgery center in Northern California. The patients who received intracameral injection over the course of the 5-year study had a 22-fold lower rate of infection.12 The choice of cefuroxime as the preferred agent for intracameral antibiotic has met with criticism. Critics of its use point to the broader spectrum of activity afforded by fourth-generation fluoroquinolones and vancomycin. However, those agents have serious drawbacks of their own. In the case of fourth-generation fluoroquinolones, widespread use in the U.S. of topical moxifloxacin as a prophylaxis against endophthalmitis have exposed the periocular flora of a significant number of patients to the agent. Microorganisms that have developed resistance to these antibiotics have been implicated in cases of endophthalmitis.13 Alcon Laboratories, the manufacturer of moxifloxacin 0.5% (Vigamox), specifically states that the product is for topical and not for intraocular use.B Proponents of vancomycin, meanwhile, point to the fact that it is effective against methicillin-resistant Staphylococcus aureus (MRSA). However, screening at-risk patients, ie, those in long-term nursing home care or recent inpatient hospital care, for MRSA and treating them before surgery will eliminate most of the risk posed by such microorganisms. The Center for Disease Control in Atlanta, Georgia, U.S., have strongly advised against the routine use of vancomycin as a prophylaxis against endophthalmitis. In conclusion, the results of this survey indicate that the ESCRS Endophthalmitis Study has had a strong impact on the practice of endophthalmitis prophylaxis among European ophthalmic surgeons. Around three-fourths of survey respondents said they currently use intracameral antibiotics and more than 90% said they would do so if an approved preparation of cefuroxime were commercially available. The recent introduction of an approved commercially available single-unit dose of cefuroxime should therefore lead to an increased use of intracameral cefuroxime in cataract procedures by ophthalmic
141
surgeons across Europe, with a concomitant reduction in the incidence of postoperative endophthalmitis. REFERENCES 1. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, Wilhelmus R; for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: case for a European multicenter study. J Cataract Refract Surg 2006; 32: 396–406; erratum, 709 2. Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg 2002; 28:977–981 3. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M; for the ASCRS Cataract Clinical Committee. Prophylaxis of postoperative endophthalmitis after cataract surgery; results of the 2007 ASCRS member survey. J Cataract Refract Surg 2007; 33:1801–1805 4. Gore DM, Angunawela RE, Little BC. United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study. J Cataract Refract Surg 2009; 35: 770–773 s L, Gardner S. ESCRS Guidelines for Preven5. Barry P, Cordove tion and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions. Dublin, Ireland, European Society of Cataract and Refractive Surgeons, 2013. Available at: http://www.escrs.org/downloads/EndophthalmitisGuidelines.pdf. Accessed November 12, 2013 6. American Academy of Ophthalmology. Cataract in the Adult Eye; Preferred Practice Patterns. San Francisco, CA, American Academy of Ophthalmology, 2011; Available at: http://one.aao. org/Assets/8d66318f-ff50-408e-9bb1-73d277cf14ce/63496543 6146230000/cataract-in-the-adult-eye-pdf. Accessed October 8, 2013 7. Goldberg RA, Flynn HW Jr, Isom RF, Miller D, Gonzalez S. An outbreak of streptococcus endophthalmitis after intravitreal injection of bevacizumab. Am J Ophthalmol 2012; 153:204–208 8. Centers for Disease Control. Persons with Meningitis Linked to Epidural Steroid Injections by State. Available at: http://www. cdc.gov/hai/outbreaks/meningitis-map.html. Accessed October 8, 2013 € u _ lu S, Ҫekiҫ O, Bozkurt E, Alagoz N, Oks €z L, 9. Cakır M, Imamo g € An outbreak of early-onset endophthalmitis caused Yılmaz OF. by Fusarium species following cataract surgery. Curr Eye Res 2009; 34:988–995 € rssinen O. Ocular toxicity in cataract surgery because of inac10. Pa curate preparation and erroneous use of 50mg/ml intracameral cefuroxime. Acta Ophthalmol 2012; 90:e153–e154. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1755-3768.2010. 02103.x/pdf. Accessed October 8, 2013 €m M, Stenevi U, Montan P. Six-year incidence 11. Friling E, Lundstro of endophthalmitis after cataract surgery: Swedish National Study. J Cataract Refract Surg 2013; 39:15–21 12. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a North California eye department. J Cataract Refract Surg 2013; 39:8–14 13. Miller D, Flynn PM, Scott IU, Alfonso EC, Flynn HW Jr. In vitro fluoroquinolone resistance in staphylococcal endophthalmitis isolates. Arch Ophthalmol 2006; 124:479–483. Available at: http://archopht.jamanetwork.com/data/Journals/OPHTH/9954/ ECS50028.pdf. Accessed October 8, 2013
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
142
SPECIAL REPORT: ADOPTION OF INTRACAMERAL ANTIBIOTIC PROPHYLAXIS OF ENDOPHTHALMITIS
OTHER CITED MATERIAL A. Leaming D, “Comparisons of 2010 ESCRS and ASCRS Practice Style Survey of Members,” Presented at XXIX Congress of the European Society of Cataract & Refractive Surgeons, Vienna, Austria, September 2011 B. Alcon Laboratories. ProductInformation 5.1 Warnings and Precautions. Available at: http://ecatalog.alcon.com/PI/Vigamox_ us_en.pdf. Accessed October 8, 2013
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
First author: Peter Barry, MD, FRCS The Eye Clinic, Dublin 4, Ireland
