Eyeworld

MAY 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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42 EW FEATURE Methicillin-resistant continued from page 39 "This includes the more ad- vanced generation of fluoro- quinolones like gatifloxacin and moxifloxacin," Dr. O'Brien said. Besifloxacin, however, is still holding strong, but Dr. O'Brien believes it's "only a matter of time" before it shows resistance, too. Savvy strategies Ophthalmologists may not be the culprits of antibiotic resistance, "but we may be the victims," said Dr. O'Brien. Even so, there are strategies ophthalmologists can take to mini- mize the problem. For example, Penny Asbell, M.D., professor of ophthalmology, Mount Sinai School of Medicine, New York, "strongly recommends" cataract surgeons use antibiotics the way they were intended and not taper them post-cataract surgery. "Keep it at the level that's ap- propriate for that antibiotic accord- ing to its package insert," she said. "Tapering is not the right way to go with an antibiotic. You either use it or you don't." She also does not recommend fluoroquinolones for treating MRSA, calling them "not the drug of choice for MRSA treatment or even prophy- laxis." Of the commercially available drugs, Dr. Asbell suggests using poly- trim. "If you're absolutely certain it's MRSA, and it's a significant infection like a corneal ulcer or endoph- thalmitis, I'd switch to van- comycin," she said. Dr. Mah's primary pearl is to vary the classes of antibiotics used. "The issue we're having specifi- cally with MRSA is there's an adop- tion of the newer generation and newer classes of antibiotics, and we aren't using the other classes that were around before," he said. "I think that leads to more resistance toward specific classes. For example, in ophthalmology there's a lot of fluoroquinolone use, and probably 10 years ago systemically there was a lot of fluoroquinolone use. That led to bacteria that were specifically resistant to fluoroquinolones." Dr. Mah also asks cataract sur- geons to be intelligent with how they use antibiotics and prophylaxis agents. "Think about what you're using and how you're using it," he said. "These agents aren't approved for cataract surgery, and there's nothing approved in the U.S. for cataract sur- gery prophylaxis. I would suggest [physicians] identify with their local hospital and try to find out their resistant patterns for S. aureus and S. epidermidis." Furthermore, it's helpful to ask patients some simple questions that could identify them as high risk for infection, such as "Do you work in healthcare?" and "Have you been on antibiotics or in a hospital recently?" "Try to identify the high-risk patients, and based on those things, choose the appropriate antibiotic instead of having everyone use the same one," Dr. Mah said. What's next? Getting a new class of antibiotics through the pipeline is a slow-going process. So slow, in fact, that big pharma is getting out of antibiotic research and development, which is bad news for the medical industry. Because the next agent isn't there, methicillin-resistant Staphylococcus infections continue to grow. "It's a business decision for big pharma to decrease the R&D [re- search and development] of antibi- otics," Dr. Mah said. "There's less money in antibiotics because they're acute and short term, not like hypertensives or cholesterol medications. Those are chronic medications, and patients will be on them for the rest of their lives. The other [factor] is the FDA is making it harder for antibiotics to get ap- proved. Studies are becoming more expensive, and [the FDA] is requir- ing more patients and adverse-event safety monitoring. It's appropriate, but it's costing a lot more money for antibiotic development." Consequently, most of the busi- nesses looking into antibiotics, an- tivirals, and antifungal agents are smaller start-up companies. Dr. Mah believes the strongest area of basic research is with innate immunities. "There's a lot of good research looking at innate immunities and what our bodies do to defend our- selves on a minute-to-minute basis against bacteria," he said. The result of that research could be an antibiotic that's natural, already found in people, and could potentially kill everything including fungus and bacteria. Another area of promising research is quorum sens- ing. "Bacteria don't just grow and grow and grow," he said. "They have certain rules that they follow; if the food source is gone, they'll stop multiplying, go into shutdown mode, and have enough bacteria to survive on the food available. If you can identify that shutdown mode, maybe you could shut down the bacteria that's causing the infec- tion." Although new antibiotics on the horizon are limited, it isn't time to panic. "We should be concerned about resistance for sure, but in day-to-day caring for patients, we haven't seen a lot of patients who don't respond, even when we use a drug that in the lab would appear to be resistant," said Dr. Asbell. "Yes, resistance is inevitable and growing," Dr. Mah said. "MRSA is something that needs to be on everyone's consciousness. However, it's not the epidemic that some peo- ple will say it is or want [others] to think [it is]." EW Editors' note: Drs. Asbell, Mah, and O'Brien have no financial interests related to this article. Contact information Asbell: penny.asbell@nyc.rr.com Mah: mahfs@upmc.edu O'Brien: tpob3333@hotmail.com February 2011 Perioperative pharmacology May 2012 Monthly Pulse Keeping a Pulse on Ophthalmology The current Monthly Pulse, which focuses on perioperative pharmacology in cataract surgery, again reflects the progressive nature of EyeWorld readers and survey respondents. However, de- spite continued evolution of surgical techniques, almost 25% of surgeons still depend on some form of injection anesthesia for routine cataract cases. I expect that this number will continue to decrease with time. The use of intracameral antibiotics is steadily increasing in popularity with 23% of respondents using them for uncomplicated surgery and 71% wishing for a commercially available, FDA-approved formulation. Despite these sentiments and the recent ESCRS study, I doubt we'll see an industry-sponsored, U.S. clinical trial in the near future, due to the expense, number of patients required, and FDA hurdles inherent in conducting such a study. Finally, it looks like most surgeons use topical NSAIDs before and/or after cataract surgery in an effort to prevent CME. While the literature supports their use, it also adds economic challenges for our patients, which adds some complexity to the issue. Mitchell Weikert, M.D., cataract editorial board member

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