Endophthalmitis Prophylaxis Research Articles

A review of preoperative manoeuvres for prophylaxis of endophthalmitis in intraocular surgery: topical application of antibiotics, disinfectants, or both?

Postoperative endophthalmitis is an ophthalmic surgeon's most feared complication, as it portends a high probability of visual loss. The purpose of this article is to review the literature on the subject of preoperative measures used for prevention of postoperative endophthalmitis and to determine the effectiveness of these measures. The present reviewed literature regarding topical prophylaxis of endophthalmitis in cataract surgery. There is strong evidence for the use of povidone-iodine preoperatively for prophylaxis of postoperative endophthalmitis in ocular surgery; the evidence for topical antibiotics is not as compelling.

Antibiotic prophylaxis: different practice patterns within and outside the United States.

Endophthalmitis remains a rare but important cause of visual loss. Prophylaxis strategies are important to reduce rates of endophthalmitis after cataract surgery, intravitreal injection, and other procedures. There is substantial variability between the US and the rest of the world. During cataract surgery, intracameral antibiotics are commonly used in many nations, especially in Europe, but are less commonly used in the US. A randomized clinical trial from the European Society of Cataract and Refractive Surgeons reported an approximately fivefold reduction in endophthalmitis rates associated with intracameral cefuroxime but these results are controversial. There are no randomized clinical trials regarding endophthalmitis associated with intravitreal injection. Topical antibiotics are commonly used in many nations, but are less commonly used in the US. At this time, there is no global consensus and it appears unlikely that additional major clinical trials will conclusively define the optimal endophthalmitis prophylaxis techniques.

Surgical, antiseptic, and antibiotic practice in cataract surgery: Results from the European Observatory in 2013

To report the results from the first iteration of the European Observatory of Cataract Surgery, which was initiated to track changes in surgical, antiseptic, and antibiotic practices in cataract surgery over the coming years. Practicing European cataract surgeons (n = 479). Internet-based declarative questionnaire or telephone questionnaire. The questionnaire comprised 37 questions divided into 8 categories as follows: screening, surgeon profile, surgical procedure used, product use before arrival at the operating room, techniques for mydriasis and anesthesia, product use during the surgery, product use after the patient leaves the operating room, and surgeon's attitude to guidelines. Cataract surgeons (n = 2700) were initially contacted, of whom 479 (17.7%) were included in the survey. The current baseline survey revealed considerable variation between countries in their implementation of infectious postoperative endophthalmitis (IPOE) prophylaxis. In some countries, adoption of intracameral cefuroxime is almost universal, whereas in others, the use of such prophylaxis is below one half. When intracameral cefuroxime is used, it is generally cefuroxime powder designed for parenteral use. A preparation specifically registered for intracameral use is now available, and this formulation is more commonly used in countries in which intracameral cefuroxime was most widely adopted. The baseline results from this ongoing survey suggest a considerable level of heterogeneity between European countries in IPOE prophylaxis. Further iterations of this survey will monitor whether a consensus begins to emerge. This work was supported by Laboratoires Théa, under the supervision of the expert group. Members of the expert group were remunerated by Laboratoires Théa. J.F. Stolz, MD, PhD, provided editorial assistance in manuscript preparation, for which he was remunerated by Laboratoires Théa. Anders Behndig, Rita Mencucci, and Jacek P. Szaflik report no relevant conflicts of interest.

Safety of undiluted intracameral moxifloxacin without postoperative topical antibiotics in cataract surgery

The objective of this study is to evaluate the safety of undiluted 0.5% intracameral moxifloxacin for postoperative endophthalmitis prophylaxis in cataract surgery patients without the use of additional postoperative topical antibiotics. All phacoemulsification cataract surgeries performed by a single surgeon (B.A.) at the John A. Moran Eye Center from June 2012 to May 2015 were reviewed retrospectively. From June 2012 to April 2014, patients were given topical 0.5% moxifloxacin postoperatively. From May 2014 to May 2015, all patients were given moxifloxacin intracamerally with no antibiotics postoperatively. The follow-up period was 1month after surgery. Preoperative visual acuity and postoperative visual acuity, corneal edema, and anterior chamber reaction were recorded and compared between the two groups. 384 cataract surgeries were performed during the study period. None of the 384 eyes in the study developed endophthalmitis. Of those 384 eyes, 222 were included in the study for analysis based on the inclusion and exclusion criteria. 131 were part of the topical antibiotic group and 91 were part of the intracameral group. The differences in uncorrected visual acuity at 1day postoperatively (p=0.595) and best corrected visual acuity at 1month postoperatively (p=0.099) were not statistically significant. Differences in corneal edema (p=0.370) and anterior chamber reaction (p=0.069) at 1day postoperatively and corneal edema (p=0.512) and anterior chamber reaction (p=0.512) at 1month postoperatively were also not statistically significant. Undiluted 0.5% moxifloxacin can be safely injected intracamerally following cataract surgery without additional postoperative antibiotic prophylaxis to prevent endophthalmitis without adverse effects on patient outcomes.

Efficacy of Intracameral Moxifloxacin Endophthalmitis Prophylaxis at Aravind Eye Hospital

To compare the rate of postoperative endophthalmitis before and after initiation of intracameral (IC) moxifloxacin for endophthalmitis prophylaxis in patients undergoing cataract surgery. Retrospective, clinical registry. All charity and private patients (116 714 eyes) who underwent cataract surgery between February 15, 2014, and April 15, 2015, at the Madurai Aravind Eye Hospital were included. Group 1 consisted of 37 777 eyes of charity patients who did not receive IC moxifloxacin, group 2 consisted of 38 160 eyes of charity patients who received IC moxifloxacin prophylaxis, and group 3 consisted of 40 777 eyes of private patients who did not receive IC moxifloxacin. The electronic health record data for each of the 3 groups were analyzed, and the postoperative endophthalmitis rates were statistically compared. The cost of endophthalmitis treatment (groups 1 and 2) and the cost of IC moxifloxacin prophylaxis (group 2) were calculated. Postoperative endophthalmitis rate before and after initiation of IC moxifloxacin endophthalmitis treatment cost. Manual, sutureless, small incision cataract surgery (M-SICS) accounted for approximately all of the 75 937 cataract surgeries in the charity population (97%), but only a minority of the 40 777 private surgeries (21% M-SICS; 79% phacoemulsification). Thirty eyes in group 1 (0.08%) and 6 eyes in group 2 (0.02%) were diagnosed with postoperative endophthalmitis (P < 0.0001). The group 3 endophthalmitis rate was 0.07% (29 eyes), which was also higher than the second group's rate (P < 0.0001). There were no adverse events attributed to IC moxifloxacin in group 2. The total cost of treating the 30 patients with endophthalmitis in group 1 was virtually identical to the total combined cost in group 2 of routine IC moxifloxacin prophylaxis and treatment of the 6 endophthalmitis cases. Routine IC moxifloxacin prophylaxis achieved a highly significant, 4-fold reduction in postoperative endophthalmitis in patients undergoing M-SICS. Compared with previous studies, having such a high volume of patients undergoing surgery during a relatively short 14-month time period strengthens the conclusion. This study provides further evidence that moxifloxacin is an effective IC prophylactic antibiotic and suggests that IC antibiotics should be considered for M-SICS and phacoemulsification.

Antibiotics.

The Endophthalmitis Vitrectomy Study (EVS) provided ophthalmologists with evidence-based management strategies to deal with endophthalmitis for the first time. However, since the completion of the EVS, numerous unresolved issues remain. The use of oral antibiotics has important implications for the ophthalmologist, particularly in the prophylaxis and/or management of postoperative, posttraumatic, or bleb-associated bacterial endophthalmitis. One can reasonably conclude that significant intraocular penetration of an antibiotic after oral administration may be a property unique to the newer-generation fluoroquinolones. Prophylactic use of mupirocin nasal ointment resulted in significant reduction of conjunctival flora with or without preoperative topical 5% povidone-iodine preparation. Ocular fungal infections have traditionally been very difficult to treat due to limited therapeutic options both systemically and intravitreally. Because of its broad spectrum of coverage, low MIC90 levels for the organisms of concern, good tolerability, and excellent bioavailability, voriconazole through various routes of administration may be useful to the ophthalmologist in the primary treatment of or as an adjunct to the current management of ocular fungal infections.

Effects of intracameral cefuroxime injection on the prophylaxis of endophthalmitis after cataract surgeries: a Meta-analysis

Effects of intracameral cefuroxime injection on the prophylaxis of endophthalmitis after cataract surgeries: a Meta-analysis

Formulation and evaluation of cefuroxim loaded submicron particles for ophthalmic delivery

Chitosan gelatin particles could be the ideal candidate for intraocular drug delivery due to their desirable properties. Double crosslinking in double emulsion has been used as an original and reliable method for particles preparation and their morphology has been optimized considering the main synthesis parameters such as polymers ratio, crosslinker amount, stirring speed, tensioactive amount and ionic crosslinking time, respectively. The particles have been analyzed for their physical–chemical properties (swelling degree, drug loading and release capacity, surface characteristics, etc.), the enzymatic degradation properties along with in vivo ocular investigations (ocular biodistribution, in vivo drug release). In the present study cefuroxim was used as a model drug, which is generally used in the prophylaxis of postoperative endophthalmitis following cataract surgery after intraocular administration. The present study proved that the dimensions and the physical–chemical properties of the particles can be modulated (by varying the preparation parameters) to facilitate the administration, the biodistribution and the drug release in the specific segment of the eye. This experimental study demonstrated also the ability of fluorescent nanoparticles to penetrate ocular tissues close to the administration site (intravitreal injection) and especially their tendency to migrate deep in the retina at time intervals of 72h.

Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey

A 2014 online survey of the American Society of Cataract and Refractive Surgery members indicated increasing use of intracameral antibiotic injection prophylaxis compared with a comparable survey from 2007. Forty-seven percent of respondents already used or planned to adopt this measure. One half of all surgeons not using intracameral prophylaxis expressed concern about the risks of noncommercially prepared antibiotic preparations. Overall, the large majority (75%) said they believe it is important to have a commercially available antibiotic approved for intracameral injection. Assuming reasonable cost, the survey indicates that commercial availability of Aprokam (cefuroxime) would increase the overall percentage of surgeons using intracameral antibiotic injection prophylaxis to nearly 84%. Although the majority used topical perioperative antibiotic prophylaxis, and gatifloxacin and moxifloxacin were still the most popular agents, there was a trend toward declining use of fourth-generation fluoroquinolones (60%, down from 81% in 2007) and greater use of topical ofloxacin and ciprofloxacin (21%, up from 9% in 2007).

Tolerability of intracameral cefuroxime during cataract surgery in case of penicillin allergy

Since the results of the ESCRS study in 2007 and then the AFSSAPS recommendations of 2011, postoperative endophthalmitis prophylaxis in cataract surgery has evolved toward intracameral cefuroxime. Penicillin allergy is frequent and is not considered as a contra-indication to cefuroxime injection, but cross-reactions do exist. The goal of this study was to assess the tolerability of intracameral cefuroxime in patients with a penicillin allergy. In this monocentric open prospective study, adult patients undergoing cataract surgery and declaring themselves penicillin-allergic were included. A subcutaneous test of cefuroxime was performed preoperatively. If negative, patients received the intracameral injection of cefuroxime at the conclusion of the surgical procedure. The primary assessment criteria, evaluated on the day after the surgery, was the occurrence of allergic reactions. Forty-eight eyes of 40 patients, 72 ± 8 years old, were included. Forty-three skin tests were performed: 1 was positive and one was unreliable. Thirty-six patients were examined in our center the day after the surgery: 2 presented a conjunctival allergic reaction. No severe anaphylactic reaction was reported. Of our patients, 95.3% declaring a penicillin allergy had a negative pre-operative cefuroxime test. According to literature, 80 to 90% of presumed penicillin allergic patients would not actually be allergic to cefuroxime. In our population, we reported 2 benign conjunctival cross-reactions. Intracameral cefuroxime injection during cataract surgery seems well-tolerated in penicillin-allergic patients with a negative preoperative skin test.

Gatifloxacin and Iodopovidine preoperatively of phacectomy: Influence on counting bacterial colonies

Objetivo: Analisar dois metodo de reducao da microbiota conjuntival em individuos submetidos a facectomia. Metodos: Ensaio clinico, com amostra de conveniencia de 57 pacientes, com diagnostico de catarata senil (57 olhos), submetidos a facoemulsificacao com implante de lente intraocular em Recife entre 2011 a 2013. Os pacientes foram alocados em dois grupos: ATB (27 olhos) no qual foi instilado colirio antibiotico (gatifloxacino a 0,3%) e ASS (30 olhos) colirio antisseptico (iodopovidine a 5%), ambas as medicacoes foram instiladas tres vezes (uma gota a cada 20 minutos, uma hora previamente a cirurgia). Os grupos foram avaliados a partir de duas coletas de material conjuntival: a primeira antes de instilar algum colirio e a segunda imediatamente apos a cirurgia. Foi realizada bacterioscopia, cultura e antibiograma. Resultados: Comparando-se a reducao no numero de bacterias encontrado nas lâminas no pre e pos-operatorio, nao se verificou diferenca estatistica significativa nos dois grupos. Conclusao: Tanto o uso do antisseptico como do antibiotico usados como profilaticos para a endoftalmite reduzem a microbiota conjuntival

Endophthalmitis: state of the art.

Endophthalmitis is an uncommon diagnosis but can have devastating visual outcomes. Endophthalmitis may be endogenous or exogenous. Exogenous endophthalmitis is caused by introduction of pathogens through mechanisms such as ocular surgery, open-globe trauma, and intravitreal injections. Endogenous endophthalmitis occurs as a result of hematogenous spread of bacteria or fungi into the eye. These categories of endophthalmitis have different risk factors and causative pathogens, and thus require different diagnostic, prevention, and treatment strategies. Novel diagnostic techniques such as real-time polymerase chain reaction (RT-PCR) have been reported to provide improved diagnostic results over traditional culture techniques and may have a more expanded role in the future. While the role of povidone-iodine in prophylaxis of postoperative endophthalmitis is established, there remains controversy with regard to the effectiveness of other measures, including prophylactic antibiotics. The Endophthalmitis Vitrectomy Study (EVS) has provided us with valuable treatment guidelines. However, these guidelines cannot be directly applied to all categories of endophthalmitis, highlighting the need for continued research into attaining improved treatment outcomes.

Ocular Toxıcıty after High Dose Cefuroxime Injection to the Anterior Chamber

Sefalosporinler beta-laktam turevi antibiyotiklerdir ve bakteri hucre duvari sentezini bozarak bakterisidal etki gosterirler (1). Sefuroksim 2. kusak sefalosporindir ve ozellikle intrakamaral yolla sefuroksim kullanimi katarakt cerrahisi profilaksisinde yaygin olarak kullanilmaktadir. Ulkemizde bircok ticari preparati mevcuttur. Intrakamaral sefuroksimin uygulanmasi sonrasinda en az 1 saat terapotik duzeyde kalabilmektedir (2). Bu yazida, intraokuler cerrahi sonrasinda sefuroksimin on kamaraya, olmasi gereken dozun 2,5 kati Abstract Cephalosporins are beta-lactam antibiotics and, like penicillin derivatives, they show bacteriostatic effect by disrupting bacterial cell wall synthesis. Cefuroxime is a second generation cephalosporin and the use of intracameral cefuroxime after cataract surgery has been widely used in the endophthalmitis prophylaxis. A 78-year-old male patient was operated for cataracts in both eyes about 8 years ago. Ocular trauma has occurred in the left eye nine months ago. Vitrectomy surgery combined with intraocular lens extraction was performed and the patient was left aphakic. Secondary intraocular lens implantation was performed. In this paper, we present postoperative ocular findings in a patient who was given cefuroxime into the anterior chamber 2.5 times higher than the recommended dose (25 mg/ml) after secondary intraocular lens implantation.

Endophthalmitis : An Update

Endophthalmitis is inflammation of the intraocular cavities consequent to introduction of microbes. In the absence of aggressive intervention, this often results in poor visual outcome due to irreversible damage to the retinal photoreceptor cells. Endophthalmitis is usually the sequel of intraocular surgery (Postoperative endophthalmitis), trauma (Posttraumatic endophthalmitis) or systemic infection (Endogenous endophthalmitis) or spread from adjacent periocular tissues. The presentation could be fulminant, acute or chronic. Special situations such as endophthalmitis after intravitreal injections and bleb related are a special cause of concern.The majority of cases are due to bacterial infection, although fungal infections also occur. Endophthalmitis is characterised by a massive infiltration of the vitreous by inflammatory cells, especially neutrophils that clinically manifests as vitritis. Progression of inflammation beyond this stage leads to hypopyon and a painful eye, which if not treated leads to blinding sequelae such as corneal perforation, orbital cellulitis, panophthalmitis and phthisis. Early diagnosis and prompt cum aggressive treatment are crucial to save vision. Improvements in surgical techniques, standardization of operating protocols with emphasis on hygienic standards, emergence of powerful antimicrobial drugs, early vitrectomy have lead to a decreased incidence of and better prognosis in endophthalmitis. This review focuses on current principles, techniques, newer types of endophthalmitis and novel antimicrobial drugs, recent experimental and clinical efforts in prophylaxis and management of endophthalmitis.

The problem of bacterial resistance in medicine and in ophthalmology

AbstractIn 2013 US Centers for Disease Control and Prevention released its first ever report on antibiotic resistance and pointed that antimicrobial resistance is one of the most serious health threats nowdays. The same year report on global risks by the World Economic Forum argued that “the greatest risk … to human health comes in the form of antibiotic‐resistant bacteria”. Although it is mainly caused by agricultural use of antibiotics, the other factors include overuse of antibiotics for systemic infections, inappropriate durations of treatment, prophylactic use of antibiotics, use of subtherapeutic dosages of antibiotics by non‐compliant patients, and misuse of antibiotics for non‐bacterial infections. The most common use of antibiotic in ophthalmology include conjunctivities, intravitreal injections and post‐cataract endophthalmitis prophylaxis. There is increasing number of evidance that their use should be re‐considered and often limited or eliminated. Finally, limiting the use of antibiotics is consistent with both ethics of rationing and ethics of waste avoidance.

The evidence: the intraoperative antibiotic

AbstractThe evidence on which the " ESCRS Guidelines on Endophthalmitis prophylaxis following cataract surgery (2013) " is based will be presented. This comprises studies from Sweden, Spain, France, South Africa, Asia, North America and Japan showing a reduction in infection rates reducing by factors of 3 ‐ 22 fold when the intracameral route was introduced. Risks and relative contraindications will also be discussed.

Intracameral cefuroxime and moxifloxacin used as endophthalmitis prophylaxis after cataract surgery: systematic review of effectiveness and cost-effectiveness.

Postoperative endophthalmitis is one of the most serious potential complications of ocular lens surgery. Its incidence can be reduced by means of antibiotic prophylaxis. Although the prophylactic use of intracameral cefuroxime has been extended, other drugs, such as moxifloxacin, have arisen as alternatives. We performed a systematic literature review on the effectiveness and efficiency of intracameral cefuroxime and moxifloxacin for the prophylaxis of postoperative endophthalmitis after cataract surgery. Several bibliographic databases were searched up to October 2010 and were updated up to January 2013. Outcomes were the onset of endophthalmitis after surgery and the cost-effectiveness ratio of using both antibiotic prophylaxis alternatives. The following were included: a clinical trial reported in two papers, six observational studies, and an economic evaluation. All studies assessed cefuroxime compared with another antibiotic prophylaxis or no prophylaxis. The only randomized controlled trial performed by the European Society of Cataract and Refractive Surgery found that intracameral cefuroxime is significantly more effective than not using prophylaxis or the use of a topical antibiotic. The observational studies support these results. The economic evaluation compared different prophylaxis regimens and concluded that intracameral cefuroxime showed the best cost-effectiveness ratio. Both the observational studies and the economic evaluation have methodological limits that reduce their validity. This review confirmed that cefuroxime can prevent endophthalmitis after cataract surgery. Further randomized controlled trials, with large sample sizes, are required to compare different antibiotic prophylaxis regimens.

PP-011 Implementation of a process optimisation protocol for the preparation of ready-to-use (RTU) intracameral cefuroxime for endophthalmitis prophylaxis (EP) after cataract surgery

BackgroundThe use of intracameral cefuroxime is becoming more widely accepted for endophthalmitis prophylaxis (EP) after cataract surgery. Recently, the European Medicines Agency approved a single, sterile, unit dose of intracameral...

Analysis of conjunctival bacterial flora in the preparation of patients for cataract surgery

In most cases, microorganisms responsible for intraocular infection are identical to the organisms on the ocular surface of the patient's ocular adnexa. The preoperative and postoperative infection prophylaxis aims to reduce the risk of infection from bacterial flora of the eye and adnexa and to eliminate bacteria that can contaminate the wound during surgery. The aim of our study was the microbiological analysis of the bacterial flora of the conjunctiva, preoperative eradication in terms of prophylaxis of endophthalmitis following cataract surgery and to determine the effectiveness of ofloxacin 0.3 % in bacteria reduction. The study included 120 patients suffering from senile cataract selected at the Department of Ophthalmology, Clinical Centre Niš, divided into two groups of 60 patients. The control group of 60 patients did not receive antibiotics preoperatively. The second group of 60 patients was treated topically with ofloxacin 0.3% in the form of drops, four times a day for four days prior to surgery, and four times for two hours prior to surgery. Examination of the conjunctival flora was carried out using standard microbiological procedures. The conjunctival swabs were collected from all patients at the time of the selection for surgery (the first swab), four days prior to surgery (second swab) and immediately before the operation and on entering the operating room (third swab). In the control group of patients, the first and second conjunctival swabs were positive in 9 and negative in 51 patients. The third swab findings did not change (9 positive and 51 negative swabs). There was no statistically significant difference between the findings of the first, second and third swabs of patients in the control group (χ2 test, p>0.05). In the therapy group of patients, the first and second conjunctival swabs were positive in 6 cases and negative in 54 patients. Detection of the third sample from this group was sterile in all 60 patients. There was a statistically significant difference between the findings of the second and third swabs of patients in the treatment group, ie. there was a correlation between the response to therapy and the outcome of patients (χ2 test, p<0,05). Among the 15 positive conjunctival swab findings the most common cause of infection were Staphylococcus aureus (6 swabs) and Staphylococcus epidermidis (5 swabs), Enterobacter spp. (2 swabs), Proteus mirabilis and Pseudomonas aeruginosa in one swab respectively. Topical ofloxacin 0.3 % for four days prior to surgery, and four times in two hours before the operation is effective in the elimination of the bacterial flora of the conjunctiva and the sterility is achieved in all cases.

Evaluation of Intracameral Cefuroxime Injection for Endophthalmitis Prophylaxis Following Cataract Surgery in a China Ophthalmology Department During 2009-2013

Evaluation of Intracameral Cefuroxime Injection for Endophthalmitis Prophylaxis Following Cataract Surgery in a China Ophthalmology Department During 2009-2013