Abstract
Despite endophthalmitis being the most feared complication, antibioprophylaxis remains controversial in intravitreal injections. Therefore, we conducted a systematic review and meta-analysis on the effects of antibioprophylaxis in intravitreal injections in the prevention of endophthalmitis. The PubMed, Cochrane Library, Embase and Science Direct databases were searched for studies comparing groups with and without antibiotics in intravitreal injection, with the use of the following keywords: "antibiotic*", "endophthalmitis" and “intravitreal injection*”. To be included, studies needed to specify number of participants and number of endophthalmitis within each group (with and without antibiotics). We conducted meta-analysis on the prevalence of clinical endophthalmitis including both culture-proven and culture negative samples. Nine studies were included. A total of 88 incidences of endophthalmitis were reported from 174,159 injections (0.051% i.e., one incidence of endophthalmitis for 1979 injections). Specifically, 59 incidences of endophthalmitis were reported from 113,530 injections in the group with antibiotics (0.052% or one incidence of endophthalmitis for 1924 injections) and 29 incidences of endophthalmitis from 60,633 injections in the group without antibiotics (0.048% or one endophthalmitis for 2091 injections). Our meta-analysis did not report a significant difference in the prevalence of clinical endophthalimitis between the two groups with and without topical antibiotics: the odds ratio of clinical endophthalimitis was 0.804 (CI95% 0.384–1.682, p = 0.56) for the antibiotic group compared with the group without antibiotics. In conclusion, we performed the first large meta-analysis demonstrating that antibioprophylaxis is not required in intravitreal injections. Strict rules of asepsis remain the only evidence-based prophylaxis of endophthalmitis. The results support initiatives to reduce the global threat of resistance to antibiotics.
Highlights
Anti-VEGF intravitreal injections have demonstrated a relative efficacy to treat common diseases such as wet age-related macular degeneration, diabetic macular edema and central and branch retinal vein occlusion [1]
We reviewed all cohort studies found on Medline via Pubmed that compared two groups after intravitreal injections: one with antibiotics and one without
Our meta-analysis did not report a significant difference in the prevalence of clinical endophthalimitis between the two groups with and without topical antibiotics: the odds ratio of clinical endophthalimitis was 0.804 (CI95% 0.384–1.682, p = 0.56) for the antibiotics group compared with the group without antibiotics, with moderate heterogeneity between studies (I-squared = 47.2%, p = .056) (Fig 2)
Summary
Anti-VEGF intravitreal injections have demonstrated a relative efficacy to treat common diseases such as wet age-related macular degeneration, diabetic macular edema and central and branch retinal vein occlusion [1]. Rare [4,5,6,7], endophthalmitis is the most feared complication of intravitreal injections due to its poor functional prognosis [8]. Strategies for infection prophylaxis are generally based on the use of antiseptics and antibiotics. The use of povidone-iodine to the ocular surface along with aseptic techniques in anterior segment surgery have been the only type of intervention shown to be moderately important in reducing the risk of post-operative endophthalmitis [9]. Despite the absence of evidence-based data, the common clinical practice involved topical antibiotics before, concurrently with, or after the intravitreal injection [10]. The usefulness of antibiotics in the prevention of endophthalmitis after intravitreal injections has been more recently questioned. Topical antibiotics enhanced rapid development of antibiotic-resistant virulent bacteria on the ocular surface and spreading in the oral sphere [11,12]
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