Intracameral antibiotics use keeps endophthalmitis at bay

Using intracameral cefuroxime in most patients produced a two-fold reduction in endophthalmitis. Extending intracameral antibiotics to 100% of patients produced a 22-fold reduction in postoperative infections.

"The take-home message for me is to use intracameral antibiotics in 100% of patients," said lead author Dr Neal H. Shorstein, ophthalmologist and associate chief of quality for Kaiser Permanente in Walnut Creek, California, USA. "Intracameral antibiotic injection works in the US as it was demonstrated to work in the large European study several years ago."

The researchers reviewed 16264 consecutive phacoemulsification surgeries performed by 14 different surgeons at the Kaiser Permanente facility in Walnut Creek, California, USA, from 2007 to 2011.

The study compared three different time periods:

Before the use of intracameral antibiotics, there were nine cases of endophthalmitis in 2878 surgeries, a rate of 3.13 per 1000.

Internal quality review found that there was no identified environmental cause and no trends by surgeon, Dr Shorstein noted.

After results from the European trial were published, all 14 surgeons added intracameral cefuroxime to their usual antibiotic regimen except in patients with an allergy to a penicillin or cephalosporin, or posterior capsular rupture.

Five of the surgeons also switched from tobramycin drops postoperatively to gatifloxacin.

Three surgeons stopped prescribing eye drops altogether for patients with uncomplicated surgery who received intracameral cefuroxime. The practice change was instituted in September 2007.

The results were striking - nine cases of endophthalmitis in 6278 surgeries, a two-fold decrease from the initial period. However, the decrease to an infection rate of 1.43 per 1000 was not statistically significant (p = 0.09).

Six of the nine infections occurred in patients who had not received intracameral cefuroxime, Dr. Shorstein noted.

Four had an allergy to cephalosporin, and two had posterior capsular rupture. Culture resulted in three cases of coagulase negative Staph, one methicillin-resistant Staph aureus, one Enterococcus faecalis and four with no growth.