Eyeworld

EW FEATURE 46 Intracameral antibiotics January 2015 At the conclusion of surgery, 36% of respondents are now directly injecting an antibiotic, which is up from 14% in 2007. When tabulated by region, 70% of European respon- dents inject intracameral antibiotic, compared to only 30% of American surgeons. For those using intra- cameral antibiotics, 5% are using Aprokam, 6% prepare it themselves, 65% have the operating room nurses prepare the drug, and 24% use a hospital (14%) or outside (9%) compounding pharmacy. A total of 47% either already use or are planning to initiate direct intracameral antibiotic injection in the next 6 months (Figure 3). What are the reasons that 53% still do not plan to inject an intracameral antibiotic? Cost was cited by 19%, lack of convincing evidence by 65%, and 49% worried about the risks of mixing or compounding these drugs. Among surgeons not inject- ing antibiotic in 2007, these reasons were cited by 17%, 89%, and 45%, respectively. Respondents who did not have access to Aprokam were asked whether they would use it if it were available to them. Assuming reasonable cost, 69% said "yes," 17% said "no," and 14% would use a different intracameral antibiotic. In 2007, a nearly identical 18% said they would not use a commercially approved intracameral antibiotic. How important is intracameral antibiotic prophylaxis? Fourteen percent said "not necessary," 41% said "very important," and 26% said "important, but other methods are sufficient." When asked specifically whether it is important to have an approved antibiotic commercial preferring latest generation topical fluoroquinolones (gatifloxacin or moxifloxacin) decreased from 81% in 2007 to 60% in 2014. This change mirrored a shift to greater use of ofloxacin or ciprofloxacin (21% compared to 9% in 2007). Preoper- ative topical antibiotics are used by 85% of respondents and are initiated on arrival at the ambulatory surgery center by 20%, 1 day preoperatively by 32%, and 3 days preoperatively by 48%. These distributions are virtually unchanged from the 2007 survey, which registered 22%, 26%, and 52%, respectively, among the 3 timeframes. Postoperative topical antibiotics are used by 96% of the respondents (essentially unchanged from 98% in 2007). They are initiated on the day of surgery by 73% and on postop day 1 by 23% (compared to 65% and 33% in 2007). They are discontinued within 1 week (no taper) by 72%, after several weeks (no taper) by 21%, and tapered over the course of several weeks by 7%. This is virtually identical to the results from 2007. Use of intracameral antibiotics has increased to 50%, compared to 30% in 2007. Among these re- spondents, the proportion of those directly injecting antibiotic (as opposed to placing it in the infusion bottle) is now 84%, compared to 52% in 2007 (Figure 2). The choice of antibiotic for intracameral use is also changing. Moxifloxacin is used by 33%, vancomycin is used by 37%, and cefuroxime is used by 26%. Looking at American surgeons only, these same agents are used by 31%, 52%, and 14%, respectively. preparation for direct intracameral injection, 75% said "yes," 9% said "no," and 16% were not sure. This was a significant difference from 2007 when the responses were 54%, 11%, and 35%, respectively. In conclusion, there has been a distinct trend toward greater use of intracameral antibiotic by ASCRS members since 2007. The majori- ty of this is by direct intracameral injection, and fewer are placing the antibiotic in the irrigating solution. Direct intracameral injection at the conclusion of surgery has risen from 15% (2007) to 36% of respondents currently. It appears that half of those not injecting intracameral antibiotics are concerned about mix- ing or compounding risks because no approved commercial product is available to them. The percentage of respondents saying that it is import- ant to have a commercially available antibiotic for direct intracameral in- jection has risen from 54% (2007) to 75%, and roughly 7/10 say that they would use the commercial formula- tion, Aprokam, if it were available to them at a reasonable cost. Clearly, there is a strong desire to have an approved commercial intracameral antibiotic in the U.S. We are in the process of sharing the results of this survey with the pharmaceutical in- dustry and with the Food and Drug Administration. EW References 1. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M. Prophylaxis of postoperative endophthalmitis after cataract surgery; results of the 2007 ASCRS member survey; the ASCRS Cataract Clinical Committee. J Cataract Refract Surg 2007; 33:1801–1805. 2. ESCRS Study Group. Prophylaxis of post- operative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33:978–988. 3. American Academy of Ophthalmology Cataract and Anterior Segment Panel. Pre- ferred Practice Pattern Guidelines. Cataract in the Adult Eye. San Francisco, CA: American Academy of Ophthalmology; 2011. Available at www.aao.org/ppp. 4. Packer M, Chang, DF, Dewey SH, Little BC, Mamalis N, Oetting TA, Talley-Rostov A, Yoo SH. Prevention, diagnosis and management of acute postoperative bacterial endophthalmitis. J Cataract Refract Surg 2011;37:1699–1714. 5. Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg 2013;39:15–21. 6. Shorstein NH, Winthrop KL, Herrington LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg 2013;39:8–14. 7. Barry P, Cordoves L, Gardner S. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgery. Published by the European Society of Cataract & Refractive Surgeons. 2013. 8. Barry P. Adoption of intracameral antibiotic prophylaxis of endophthalmitis following cataract surgery. Update on the ESCRS Endophthalmitis Study. J Cataract Refract Surg 2014;40:138–142. 9. Braga-Mele R, Chang DF, Henderson BA, Mamalis N, Talley-Rostov A, Vasavada A. Intracameral antibiotics: Safety, efficacy, and preparation. J Cataract Refract Surg 2014; 40(12):2134-2142. Contact information Chang: dceye@earthlink.net Results continued from page 44 • 67% said intracameral antibiotic prophylaxis is "important" • 47% already inject intracameral antibiotics or plan to start in the next 6 months • 49% of those not using intracameral antibiotics cite compounding or mixing risk • 75% said having an approved commercial intracameral antibiotic is "important" • 84% would inject an intracameral antibiotic if Aprokam were available at a reasonable cost 2014 ASCRS endophthalmitis prophylaxis survey highlights EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews

• Cover