Antibiotic Prophylaxis In Cataract Surgery Research Articles

A survey of Asian Eye Institutions on perioperative antibiotic prophylaxis in cataract surgery

PurposeTo determine current institutional practice patterns for the use of perioperative antibiotics and other measures to prevent infection after cataract surgery in Asia.MethodsAn online survey-based study of leading eye institutions in China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, Thailand and Vietnam was conducted. The survey was administered to 26 representative key opinion leaders from prominent tertiary eye institutions that are also national academic teaching institutions in Asia. Survey responses were collated and anonymized during analysis.ResultsAll surveyed institutions used povidone iodine for the preoperative antiseptic preparation of the eye, with notable variations in the concentration of povidone iodine used for conjunctival sac instillation. Preoperative topical antibiotics were prescribed by 61.5% and 69.2% of institutions in low-risk and high-risk cases, respectively. Regarding the use of intra-operative antibiotics, 60.0% and 66.7% of institutions administered intracameral antibiotics in low-risk and high-risk patients, respectively. Postoperative topical antibiotics use patterns were generally very similar in low-risk and high-risk patients. Over half of the institutions (52.2% and 68.0% in low-risk and high-risk patients, respectively) also indicated prolonged postoperative use of topical antibiotics (> 2 weeks). Not all surveyed institutions had established policies/protocols for perioperative antibiotic use in cataract surgery, endophthalmitis surveillance, and/or a monitoring program for emerging antimicrobial resistance.ConclusionThere are variations in antimicrobial prophylaxis approaches to preoperative, intra-operative and postoperative regimens in cataract surgery in Asia. More evidence-based research is needed to support the development of detailed guidelines for perioperative antibiotic prophylaxis to reduce postoperative infections.

All India Ophthalmological Society members survey results: Cataract surgery antibiotic prophylaxis current practice pattern 2017.

Purpose:The purpose of this article is to document the current practice pattern of Indian ophthalmologists for antibiotic prophylaxis in cataract surgery to prevent endophthalmitis.Methods:Fifteen structured questions were sent online to all ophthalmologists registered with the All India Ophthalmological Society. The questionnaire was divided into three main categories of prophylaxis – preoperative, intraoperative, and postoperative. A web-based anonymous survey was conducted, and a unique response link allowed completing the survey only once. We compared the results with a similar 2014 survey among the members of the American Society of Cataract and Refractive Surgeons (ASCRS).Results:The response was received from 30.2% (n = 4292/14,170) ophthalmologists. The results were as follows: all respondents do not prepare the eye with 5% povidone-iodine (83% of them use povidone iodine), majority (90%) use topical antibiotic both pre- and post-operatively, 46% use subconjunctival antibiotic at the end of surgery, and 40% use intracameral antibiotic (46% of them in high-risk patients only). Moxifloxacin was the preferred antibiotic for topical and intracameral use. Comparison with the 2014 ASCRS survey results showed a similarity in decision for pre- and post-operative antibiotics and intracameral antibiotic but dissimilarity in the choice of intracameral antibiotic and decision for subconjunctival antibiotic.Conclusion:The antibiotic prophylaxis practice by the Indian ophthalmologists is not too dissimilar from the practice in North American Ophthalmologists (ASCRS) though all ophthalmologists in India must be nudged to preoperative preparation of the eye with povidone-iodine and discontinue the practice of postoperative subconjunctival and systemic antibiotic.

Antibiotic prophylaxis in cataract surgery: Understanding the trends of the day.

Postoperative endophthalmitis (POE) remains the most dreaded complication for any cataract surgeon worldwide. Although with more stringent peri-operative prophylactic measures in place, the rates of POE have dropped to <0.1% all over the world, the perfect formula which would provide the maximum protection against ocular infection remains the Holy Grail. It is interesting to see the preferred practice patterns of cataract surgeons all over the world, and these surveys have often formed the recommendations in the absence of a fixed set of guidelines on this topic. The 2006 ESCRS study[12] had first recommended the routine use of intracameral (IC) cefuroxime at the end of the cataract surgery as a safe and effective measure against POE. Eight years down the line, the 2014 ESCRS survey[3] showed that 74% of its members had routinely inculcated IC antibiotic usage into their practice. However, this also means that approximately one-fourth of the respondents had not inculcated this effective measure in their practice in 8 years since the publication. Similarly, the endophthalmitis prophylaxis surveys of ASCRS, 2007 and 2014,[45] showed a growing trend of IC antibiotic use from 30% to 50% among its respondents. This again also indicates that 50% of respondents in 2014 were not using IC antibiotic. In the Indian subcontinent, the practice patterns of cataract surgeons have been seen to vary widely. Some robust studies from larger institutes such as by Haripriya et al. concluded that IC moxifloxacin prophylaxis is effective with a 3.5-fold reduction in the overall rate of POE.[6] This study acknowledges that, while this does not constitute Level 1 evidence and that there is no consensus that IC antibiotic prophylaxis should be the standard of care, IC moxifloxacin prophylaxis should be considered for high-risk eyes experiencing posterior capsule rupture with vitreous loss. Kelkar et al. in their article “Antibiotics prophylaxis practice patterns for cataract surgery in India – Results from an Online Survey”[7] could elicit responses from a small number of participants – 1228 respondents (8.2%), which may not be truly representative of the prevalent practices among cataract surgeons in India; however, it does provide insights into POE prevention. In this study, preoperative povidone-iodine antisepsis was adopted by 94% of the respondents. Unfortunately, this figure needs to be made 100%. Nearly 38% of the respondents reported IC antibiotic usage routinely after cataract surgery, but 68% believed that it is important to have a commercially approved drug for IC use. Nearly 48% of the respondents were not using intraocular antibiotics since they were not convinced of the need. The AIOS member survey by Maharana et al.[8] is a commendable effort in bringing out some glaring shortcomings, and we can hope it will be the step toward formulation of a recommended set of guidelines which every anterior-segment surgeon practicing in the country will be expected to adhere to. In addition, following up with repeated surveys with the same cohort in the future would help to assess the changes which could be brought by these recommendations. However, only 30.2% of participation in the survey is still a small number, and it can be hoped that this participation can be increased in future surveys. The revelation from the study that only 83% use of povidone-iodine is an eye-opener showing that <100% of the respondents perform mandatory preoperative preparations. Use of postoperative subconjunctival antibiotics by 46% of the respondents is another revelation highlighting rigid barriers to the changing protocols of postoperative antibiotic regimen. Thus, we do understand that preferred practice patterns should not only give mandatory protocols on specific disease issues from time to time, but the ophthalmological community must also institute measures to execute the same in the large interest of our patients. There is a strong need to educate our ophthalmologists across the country of the changed protocols of antibiotic prophylaxis in the current scenario. These are the interesting facts which prove that there is a major challenge in convincing the respondents on the use of safety measures.

Pathogens and antibiotic sensitivities in endophthalmitis.

Antibiotic prophylaxis in cataract surgery is intended to minimize endophthalmitis. We describe pathogenic organisms, antibiotic sensitivities and antibiotic prophylaxis in culture-proven endophthalmitis cases. Retrospective consecutive case series and community-based setting were used. Two hundred fifteen cases of endophthalmitis after cataract surgery performed during 2007-2012 in Kaiser Permanente, California. Descriptive analysis of isolated organisms and antibiotic sensitivities in relation to antibiotic prophylaxis in culture-proven endophthalmitis cases. The majority of culture-confirmed organisms (n=83) were Gram positive (96%), most notably coagulase-negative Staphylococci (n=34, 52%), of which all that underwent testing were sensitive to vancomycin (n=32). Among 19 cases that had received only topical antibiotic prophylaxis, seven (37%) were resistant to the antibiotic given: 50% of cases (5 of 10 isolates) that had received ofloxacin were resistant to this antibiotic, 40% (2 of 5 isolates) that had received gatifloxacin were resistant. In contrast, 100% of cases (n=4) that had received aminoglycosides were susceptible. Few culture-confirmed cases occurred in patients who received intracameral antibiotic (n=4). In cases where fluoroquinolones were administered as antibiotic prophylaxis, isolates demonstrated a degree of bacterial resistance. The majority of endophthalmitis cases isolated occured following topical antibiotic prophylaxis only and were attributed to Gram-positive organisms, while few occurred in association with intracameral antibiotic.

Natural language processing to ascertain two key variables from operative reports in ophthalmology.

Antibiotic prophylaxis is critical to ophthalmology and other surgical specialties. We performed natural language processing (NLP) of 743 838 operative notes recorded for 315 246 surgeries to ascertain two variables needed to study the comparative effectiveness of antibiotic prophylaxis in cataract surgery. The first key variable was an exposure variable, intracameral antibiotic injection. The second was an intraoperative complication, posterior capsular rupture (PCR), which functioned as a potential confounder. To help other researchers use NLP in their settings, we describe our NLP protocol and lessons learned. For each of the two variables, we used SAS Text Miner and other SAS text-processing modules with a training set of 10 000 (1.3%) operative notes to develop a lexicon. The lexica identified misspellings, abbreviations, and negations, and linked words into concepts (e.g. "antibiotic" linked with "injection"). We confirmed the NLP tools by iteratively obtaining random samples of 2000 (0.3%) notes, with replacement. The NLP tools identified approximately 60 000 intracameral antibiotic injections and 3500 cases of PCR. The positive and negative predictive values for intracameral antibiotic injection exceeded 99%. For the intraoperative complication, they exceeded 94%. NLP was a valid and feasible method for obtaining critical variables needed for a research study of surgical safety. These NLP tools were intended for use in the study sample. Use with external datasets or future datasets in our own setting would require further testing. Copyright © 2017 John Wiley & Sons, Ltd.

Antibiotic prophylaxis in cataract surgery - An evidence-based approach.

Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.

Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery

Intracameral injection is an effective method for preventing infection, but no controlled study has been published in the United States. We conducted an observational, longitudinal cohort study to examine the effect of topical and injected antibiotics on risk of endophthalmitis. We identified 315 246 eligible cataract procedures in 204 515 members of Kaiser Permanente, California, 2005-2012. The study used information from the membership, medical, pharmacy, and surgical records from the electronic health record. The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of antibiotic prophylaxis (route and agent) with risk of endophthalmitis was estimated using logistic regression analysis. We confirmed 215 cases of endophthalmitis (0.07% or 0.7/1000). Posterior capsular rupture was associated with a 3.68-fold increased risk of endophthalmitis (CI, 1.89-7.20). Intracameral antibiotic was more effective than topical agent alone (OR, 0.58; CI, 0.38-0.91). Combining topical gatifloxacin or ofloxacin with intracameral agent was not more effective than using an intracameral agent alone (compared with intracameral only: intracameral plus topical, OR, 1.63; CI, 0.48-5.47). Compared with topical gatifloxacin, prophylaxis using topical aminoglycoside was ineffective (OR, 1.97; CI, 1.17-3.31). Surgical complication remains a key risk factor for endophthalmitis. Intracameral antibiotic was more effective for preventing post-cataract extraction endophthalmitis than topical antibiotic alone. Topical antibiotic was not shown to add to the effectiveness of an intracameral regimen.

Survey of Japanese ophthalmic surgeons regarding perioperative disinfection and antibiotic prophylaxis in cataract surgery.

PurposeTo elucidate Japanese trends for perioperative disinfection and antibiotic selection during cataract surgeries.MethodsPerioperative iodine use and antibiotic prophylaxis for cataract surgery were surveyed in eight regions in Japan by mail or through interviews from February 1 to March 1, 2014.ResultsWe surveyed 572 surgeons, of whom 386 (67%) responded. Most of the surgeons (94%) used iodine compounds before surgery for periocular skin disinfection (povidone–iodine [PI]: 79%; polyvinyl alcohol-iodine [PAI]: 15%) or conjunctival disinfection (85%; PI: 36%; PAI: 49%). Preoperative conjunctival iodine was primarily used as an eye wash (irrigation: 95%) and less often as an eye drop (5%). It was determined that 31% of surgeons waited 30 seconds or more between periocular disinfection and conjunctival disinfection. During surgery, 14% of surgeons used iodine several times, including immediately before intraocular lens insertion, and 7% used the Shimada technique (repeated iodine irrigation). Preoperative antibiotic eye drops were used by 99% of surgeons, and antibiotics were added to the irrigation bottle by 22%. The surgeons reported use of subconjunctival antibiotic injections (23%), antibiotic ointments (79%), and intracameral antibiotics (7%: 22 moxifloxacin; 6 levofloxacin). All surgeons prescribed postoperative eye drops, with 10% initiating the drops on the day of surgery.ConclusionIodine compounds are commonly used preoperatively, but few institutions use iodine compounds intraoperatively, particularly with repeated application. The selection of antibiotic administration and disinfection technique has to be at the surgeon’s discretion. However, intracameral antibiotic and intraoperative iodine compound use are techniques that should be widely recognized.

Role of topical, subconjunctival, intracameral, and irrigative antibiotics in cataract surgery

To summarize current understanding of antibiotic prophylaxis in cataract surgery, with particular emphasis on available evidence and change in practice patterns over the past decade. Povidone-iodine application prior to cataract surgery remains a universal practice, and is backed by good quality evidence. Subsequent to the results of the European multicenter trial documenting decreased risk of endophthalmitis with intracameral cefuroxime injection at the end of surgery, similar benefit with intracameral antibiotic use has been reported in studies with large sample sizes from multiple centers around the world. There has been a distinct change in practice patterns in many countries, with intracameral antibiotic use becoming part of routine protocol. In the USA, topical fluoroquinolone application remains the most popular mode of antibiotic prophylaxis. A promising approach is the development of novel drug delivery methods like polymeric devices designed for sustained antibiotic release. Based on current evidence, the recommended measures for endophthalmitis prophylaxis are preoperative topical instillation of povidone-iodine and intracameral antibiotic injection at the end of cataract surgery.

A Japanese Survey of Perioperative Antibiotic Prophylaxis in Cataract Surgery.

The objective of this study was to identify trends in the use of perioperative antibiotic prophylaxis in cataract surgery in Japan. This was a national survey by mail or interview. The use of perioperative antibiotic prophylaxis in cataract surgery was evaluated by conducting a survey in 6 regions within Japan from October 1, 2011, to March 1, 2012. Responses were received from 285 (75%) of the 387 surgeons who were surveyed. The results revealed that 89% (255/285) administered ophthalmic antibiotic ointment. Forty-seven percent (133/285) used antibiotics in forms other than ophthalmic ointments within 6 hours after surgery, 7% (19/285) used eyedrops, 24% (67/285) used antibiotics via an irrigation bottle, 1% (2/285) used intracameral injections, and 24% (69/285) used subconjunctival injections. Although poor intraocular penetration of ophthalmic ointments has been reported, ophthalmic ointments are widely used. The fact that antibiotics should ideally be administered within 6 hours after surgery is not widely recognized. However, intracameral injection, which achieves much higher antibiotic concentration in the anterior chamber than other methods, is a technique that should be widely acknowledged.

Corneal penetration of various aminoglycosides and quinolones

Penetration of the aminoglycosides gentamicin and tobramycin and chinolones ciprofloxacin and ofloxacin applied as eyedrops and soaked disposable lenses (ACUVUE), used as antibiotic prophylaxis, was investigated. 217 patients received before undergoing cataract extraction 0.3% solutions of these antibiotics as eyedrops or by soaked ACUVUE-lenses. During surgery 50-100 microliters aqueous humor was aspirated; concentration of gentamicin and tobramycin was analysed by fluorescence polarisation immuno assay, concentration of ciprofloxacin and ofloxacin was analysed by high pressure liquid chromatography. After application of gentamicin and ofloxacin as eyedrops and via soaked ACUVUE-lenses as drug delivery system (DDS) we found higher concentrations than after application of tobramycin and ciprofloxacin by the same modes. After using of soaked lenses as DDS the aqueous humor concentrations of all tested substances were higher than the concentrations after the frequent instillation of eyedrops. Penetration of gentamicin through normal human cornea is higher than penetration of tobramycin; penetration of ofloxacin through normal human cornea is higher than penetration of ciprofloxacin. The aqueous humor concentrations of ofloxacin applied as eyedrops and DDS, of ciprofloxacin and gentamicin applied as DDS allow their use as antibiotic prophylaxis in cataract surgery.