Eyeworld

EW FEATURE 44 Intracameral antibiotics January 2015 by David F. Chang, MD, EyeWorld chief medical editor I n 2007, the ASCRS Cataract Clinical Committee surveyed the membership regarding endophthalmitis antibiotic prophylaxis practice patterns. 1 The prospective, randomized ESCRS endophthalmitis prophylaxis trial first reported in 2006 had shown a 5-fold reduction in endophthalmitis rates with intracameral injection of cefuroxime at the conclusion of cataract surgery (0.07% versus 0.34% without intracameral cefuroxime). 2 The goal of the ASCRS survey was to evaluate the use of both topical and intracameral antibiotic prophy- laxis and to assess the impact of the ESCRS study in terms of the use or perceived need for direct intracameral antibiotic injection. A total of 1,312 members re- sponded to the 2007 online survey (an 18% response rate). Of the 30% who were using intracameral antibiotics, there was a 50/50 split between those placing antibiotic in the infusion bottle versus those in- jecting it directly. Vancomycin was the most popular agent, preferred by 61% of those using an intracameral antibiotic. Finally, 82% indicated that they would use a commercially available antibiotic for direct injec- tion if it were reasonably priced. In the intervening period, numerous large retrospective studies have been published supporting the efficacy of intracameral cefuroxime. Both the 2011 American Academy of Ophthalmology Cataract Preferred Practice Patterns and a 2011 white paper by the ASCRS Cataract Clini- cal Committee noted that there was stronger evidence supporting direct AT A GLANCE • In 2007, the Cataract Clinical Committee surveyed the ASCRS membership regarding endophthalmitis antibiotic prophylaxis practice patterns. • The membership was resurveyed in August 2014, and most of the same questions from 2007 were repeated so that differences and trends could be analyzed. • The 2014 survey found there has been a distinct trend toward greater use of intracameral antibiotics by ASCRS members since 2007. Results of 2014 ASCRS endophthalmitis antibiotic prophylaxis survey intracameral injection than for any other method of antibiotic pro- phylaxis. 3,4 The 6-year incidence of endophthalmitis from the Swedish National Cataract Register (where intracameral cefuroxime is standard) was reported to be 0.029%. 5 Finally, a 2012 retrospective study from Kaiser documented a 22-fold decrease in endophthalmitis rates over a 4-year period when intracameral antibiotic injection was routinely used with cataract surgery. 6 The other significant devel- opment has been the approval of Aprokam (cefuroxime, Thea Group, Clermont-Ferrand, France), a com- mercial preparation of cefuroxime for intracameral injection, in 24 European countries. 7,8 To date, the company has sold more than 1.3 million units with no significant safety issues. The ESCRS published endophthalmitis prophylaxis guide- lines in 2013 that reviewed the liter- ature supporting direct intracameral injection of cefuroxime. 8 In light of these developments, the ASCRS Cataract Clinical Com- mittee recently published a paper (see page 22 for more information) reviewing the off-label options for intracameral antibiotic use in the U.S., where no commercial product is approved. 9 We also resurveyed our membership regarding endoph- thalmitis antibiotic prophylaxis practice patterns. Most of the same questions from 2007 were repeated so that differences and trends could be analyzed. The 2014 survey was conduct- ed in August 2014. The link to a 2-minute online survey was emailed to the ASCRS membership and 1,147 members responded (a 15% response rate). A unique response URL was generated so that it was impossible to complete the survey more than once. Most of the respondents (65%) were from the U.S., with the rest coming from Latin/South America/ Mexico (13%), Europe (9%), Africa (7%), Canada (5%), and Asia/Aus- tralia (1%). The respondents were active surgeons, with 67% doing at least 300 cases/year, and 41% per- forming more than 500 cases/year. The survey found that perioper- ative topical antibiotics are used by 90% of the respondents (unchanged from 91% in 2007) (Figure 1). Those Figure 2. Responses of survey participants using intracameral antibiotics Figure 3. The survey asked, "Have you initiated intracameral antibiotic injections during the past 2 years?" 47% already or plan to use intracameral antibiotic injections. Source (all): David F. Chang, MD Figure 1. Preferred perioperative topical antibiotic continued on page 46

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