Doi:10.1016/j.jcrs.2007.07.009

Prophylaxis of postoperative endophthalmitis David F. Chang, MD, Rosa Braga-Mele, MD, Nick Mamalis, MD, Samuel Masket, MD, Kevin M. Miller, MD, Louis D. Nichamin, MD, Richard B. Packard, MD, Mark Packer, MD, for the ASCRS Cataract Clinical Committee An online survey of members of the American Society of Cataract and Refractive Surgery indicateda strong preference for preoperative and postoperative topical antibiotic prophylaxis, with mostsurgeons favoring latest generation topical fluoroquinolones. A significant percentage of surgeonsreported being concerned about the risks of homemade intracameral antibiotic preparations, andthere was a strong desire to have a commercially available antibiotic approved for intracameralinjection. This is reflected in the fact that 77% of respondents were still not injecting intracameralantibiotics, but 82% would likely do so if a reasonably priced commercial preparation wereavailable.
J Cataract Refract Surg 2007; 33:1801–1805 Q 2007 ASCRS and ESCRS The preliminary findings of the European Society of at the end of surgery. Levofloxacin 0.5% was Cataract & Refractive Surgeons (ESCRS) endophthal- administered as 1 drop 1 hour before surgery, 1 drop mitis study,announced in 2006, generated much 30 minutes before surgery, and 3 drops at 5-minute controversy and confusion. The trial showed a sev- intervals commencing immediately after surgery. All eral-fold decrease in the rate of infectious endophthal- patients were prepped with povidone–iodine 5% mitis with the use of intracameral cefuroximeThe drops 3 minutes before surgery, and all were pre- scribed levofloxacin 0.5% drops 4 times daily for Twenty-four ophthalmology units in Austria, 6 days starting the day after surgery.
Belgium, Germany, Italy, Poland, Portugal, Spain, Twenty-nine patients presented with endophthal- Turkey, and the United Kingdom participated in mitis; of these, 20 were classified as culture-proven ESCRS’ prospective randomized partially masked infective endophthalmitis. Patients not receiving intra- multicenter study. A total of 16603 patients were cameral cefuroxime prophylaxis incurred a 4.92-fold recruited as subjects. The study was based on a 2 Â 2 increase (95% confidence interval [CI], 1.87-12.9) in factorial design, with intracameral cefuroxime and the risk for total endophthalmitis and a 5.86-fold topical perioperative levofloxacin factors resulting in increase (95% CI, 1.72-20.0) in the risk for proven 4 treatment groups. Cefuroxime as 1 mg in 0.1 mL endophthalmitis. In addition, the use of clear corneal normal saline was injected into the anterior chamber incisions compared with the use of scleral tunnelswas associated with a 5.88-fold increase (95% CI,1.34-25.9) in total risk and a 7.43-fold increase (95%CI, 0.97-57.0) in the risk for proven endophthalmitis.
Accepted for publication July 27, 2007.
The use of silicone intraocular lens optic material com-pared with the use of acrylic was associated with No author has a financial or proprietary interest in any material a 3.13-fold increase (95% CI, 1.47-6.67) in total risk.
The presence of surgical complications increased the Presented at the ASCRS Symposium on Cataract, IOL and Refrac- total risk 4.95-fold (95% CI, 1.68-14.6).
tive Surgery, San Diego, California, USA, April 2007.
Believing that the evidence had become conclusive, Corresponding author: David F. Chang, MD, 762 Altos Oaks Drive, the investigators terminated the study and recommen- Suite 1, Los Altos, California 94024, USA. E-mail: ded adoption of this prophylactic measure. Although this is the first prophylactic antiinfective regimen SPECIAL REPORT: 2007 ASCRS MEMBER SURVEY ON ENDOPHTHALMITIS PROPHYLAXIS to have been proved effective by a prospective Table 2. Distribution of respondents by annual cataract volume.
randomized controlled study, there is currently nocommercially available antibiotic formulation for in- To better understand the implications and impact of the ESCRS study, the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee surveyed the global membership ofASCRS about its current antibiotic prophylacticpractices for cataract surgery.
In January 2007, a link to an online survey was sent to the Table 3. Individual endophthalmitis rate.
approximately 4000 ASCRS member e-mail addresses on file. The online anonymous survey consisted of 14 questions that took approximately 2 minutes to complete. The shows the questionnaire.
A total of 1312 members responded. A majority of re- spondents (69%) were from the United States, and the entire spectrum of low- to high-volume surgeons waswell represented ). All respondentswere asked to list their rate of infectious endophthal-mitis per 1000, and the results are shown in .
Of note, 90% had an infection rate of 1/1000 or lower.
Only 3% of respondents had a rate of 0.3% (3/1000) or Table 4. Perioperative and postoperative use of antibiotic Most surgeons (91%) used topical antibiotic prophy- ASCRS members prescribing topical antibiotics, 4th-generation fluoroquinolones (gatifloxacin or mox-ifloxacin) were preferred by 81%; other respondents preferred levofloxacin, ofloxacin or ciprofloxacin, and or another antibiotic agent (). It should be noted that topical fourth-generation fluoroquinolones are not commercially available in much of Europe.
Eighty-eight percent of surgeons said they initiated topical antibiotics preoperatively (Roughly one-half of them prescribed antibiotics 3 days beforesurgery, while the other half started them the day ofsurgery or 1 day before surgery (). Virtuallyall surgeons (98%) prescribed topical antibiotics post-operatively ). Approximately two thirds Table 5. Preferred perioperative topical antibio Table 1. Distribution of respondents by practice location.
*Of those using a perioperative antibiotic J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007 SPECIAL REPORT: 2007 ASCRS MEMBER SURVEY ON ENDOPHTHALMITIS PROPHYLAXIS Table 8. Method of antibiotic administration at the conclusion *Of those using a preoperative antibiotic *Respondents could check more than 1 method; thus the percentages total (66%) started them on the day of surgery, while onethird (34%) waited until the first day postoperatively.
The latter group presumably included patients whowere patched. Seventy-three percent of surgeonsstopped the postoperative antibiotics by 1 week(); others used postoperative antibiotics for Table 9. Intracameral antibiotic preferences.
several weeks or tapered them over several weeks.
Ninety percent of surgeons were administering some type of antibiotic at the conclusion of surgery (Of these, 83% applied topical antibiotic drops; roughly equal percentages of surgeons used a subconjunctival injection or an intracameral injec- tion, and a small percentage used a collagen shield Intracameral antibiotics were used by 30% of sur- *Of those using an intracameral antibiotic geons, who were equally divided between those inject-ing the antibiotic intracamerally and those placing it inthe irrigating bottle (). Of those using intracam-eral antibiotics, 61% used vancomycin; other antibi-otics used were cephalosporin, a quinolone, andother agents When intracameral antibioticswere used, most were prepared by the operating Table 10. Person who prepares the intracameral room nursing staff (77%); other respondents said the pharmacy or surgeon prepared the antibiotics( What impact did the ESCRS study have on ASCRS the effect on antibiotic use after the study results had been announced; 77% did not plan to start injecting in- tracameral antibiotic for a variety of reasons. shows the reasons for not injecting an intracameral an-tibiotic; 89% said they believed that further study wasneeded.
The poll asked whether surgeons had ever experi- enced a complication using intracameral antibiotics.
Table 11. Impact of ESCRS study on use of intracameralantibiotics.
Table 7. Duration of postoperative topical antibiotic use.
Intracameral Antibiotics (Direct Injection) ESCRS Z European Society of Cataract & Refractive Surgeons J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007 SPECIAL REPORT: 2007 ASCRS MEMBER SURVEY ON ENDOPHTHALMITIS PROPHYLAXIS topical agent of only 3% of ASCRS respondents pre- Table 12. Reasons for not injecting antibiotics after release of scribing topical antibiotics. The other arm was not treated with any preoperative antibiotic, which re- flects what only 12% of ASCRS respondents reporteddoing. Only 34% of respondents said they waited until the day after surgery to initiate postoperative topical antibiotics, as was universally done in the ESCRS trial.
Based on this survey, the most common antibiotic *Asked of those not injecting intracameral antibiotic; because respondents prophylactic practices appears to be topical 4th-gener- could check more than 1 reason, the percentage exceeds 100.
ation fluoroquinolones prescribed at least 1 to 3 dayspreoperatively and resumed immediately postopera-tively. In contrast, the only topical antibiotic used in Eighty-six percent of those using intracameral antibi- the ESCRS study was levofloxacin, which was admin- otics said no. Fifty-seven respondents (14% of those istered shortly before surgery in half the patients, using intracameral antibiotics) reported having had while the other half did not receive any preoperative antibiotic. Postoperatively, topical levofloxacin was not started until the first postoperative morning. We Regarding the impact of the ESCRS study on the in- acknowledge there has never been a randomized con- terest in intracameral antibiotic availability, 54% of re- trolled clinical trial demonstrating the prophylactic spondents said they thought it was important to have benefit of any preoperative or postoperative topical a commercially available broad-spectrum antibiotic antibiotic. Nevertheless, the ESCRS study does not ad- formulated for direct intracameral injection, 11% dress whether intracameral cefuroxime was equal to, thought it was not important, and 35% were not superior to, or of adjunctive benefit to the most com- sure. Forty-seven percent would use such a product, monly used topical antibiotic protocols.
18% would not, and 35% would consider using it de- Finally, the possible risks of administering ‘‘home- made’’ intracameral antibiotic mixtures were a signifi-cant concern to 45% of surgeons not currently using them. These risks might include dilution errors,bacterial contamination, or toxic anterior segment syn- It may be surprising that only 6% of respondents re- drome. Indeed, 14% of respondents using intracameral ported injecting intracameral cefuroxime, which the antibiotics said they believe they have experienced ESCRS study showed to be effective in reducing the complications of the practice at some point. These con- rate of endophthalmitis. The study apparently did cerns seem to be affirmed by the fact that more than not have an impact on the practice of the 77% of re- 80% of ASCRS members would most likely inject intra- spondents who said they still did not plan to institute cameral antibiotics routinely if a commercially ap- the use of intracameral antibiotics of any kind. One can proved preparation were available at a reasonable cost.
only speculate about the reasons for these findings Certainly, one cannot draw definitive conclusions from an online survey because there are many poten- The study’s control group did not reflect current tial biases in the responses. Nonetheless, the results prophylactic antibiotic practices for the majority of re- indicate that most surgeons use preoperative and post- spondents. For example, 1 arm of the ESCRS study operative topical fluoroquinolone antibiotics off label control group received topical levofloxacin immedi- and presumably believe they are safe and effective.
ately before and after surgery, which was the preferred The ESCRS study has certainly had some impact be-cause although only 16% of surgeons reported usinga direct intracameral antibiotic injection before the Table 13. Complications of homemade intracameral antibiotic study, a majority of surgeons said they would like to use this approach if a cost-effective commercial prepa- ration were available. We believe that this is a strongmessage for the ocular pharmaceutical industry to *Respondents could check more than 1 complication; thus, the percentage A large online survey of ASCRS members indicated a strong preference for preoperative and postoperative J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007 SPECIAL REPORT: 2007 ASCRS MEMBER SURVEY ON ENDOPHTHALMITIS PROPHYLAXIS topical fourth-generation fluoroquinolone prophylaxis.
8. When do you start postoperative topical antibiotic? With a significant percentage of surgeons concerned about the risks of homemade intracameral antibiotic preparations, there is a strong desire to have a commer- cially available antibiotic agent for this purpose. That 9. For how long do you continue postoperative topical 77% of respondents were still not injecting intracameral antibiotics but 82% would likely do so if a reasonably priced commercial preparation were available suggests that for most surgeons, the ESCRS study did not con-vincingly prove a strong enough benefit–risk ratio.
10. Estimate your number of infectious endophthalmitis cases 11. Did you alter your regimen following the ESCRS study? ( ) Nodstill do not inject intracameral antibiotic [check all that ( ) because of risk of mixing ( ) because of cost ( ) because ( ) Nodwas already injecting intracameral antibiotic ( ) Yesdhave now started or plan to start injecting intracameral 12. Is it important to have a commercially available broad- 3. Your preferred perioperative topical antibiotic spectrum antibiotic formulated for direct intracameral 4. When do you start preoperative topical antibiotic? 14. Have you ever had a complication from using ‘‘home- ( ) Cephalosporin (eg, cefuroxime) direct injection 6. Who prepares your intracameral antibiotic? 1. Seal DV, Barry P, Gettinby G, et al. ESCRS study of prophy- laxis of postoperative endophthalmitis after cataract surgery;case for a European multicenter study; the ESCRS Endoph- thalmitis Study Group. J Cataract Refract Surg 2006; 32:396– 2. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis 7. Do you administer antibiotics at the conclusion of surgery? of postoperative endophthalmitis after cataract surgery; prelimi- nary report of principal results from a European multicenter study; the ESCRS Endophthalmitis Study Group. J Cataract Refract 3. ESCRS Endophthalmitis Study Group. Prophylaxis of postop- erative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors.
J Cataract Refract Surg 2007; 33:978–988 J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007

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