Eyeworld

EW FEATURE 50 Intracameral antibiotics January 2015 may be a problem in properly fol- lowing the procedure," he said. When to start—and stop— antibiotic use Three percent of respondents opt not to use any postop topical anti- biotic, but just under half of the re- spondents said not only do they use intracameral antibiotics, they use topical antibiotics postoperatively. readily available. In the U.S., the OR nursing staff will typically mix the solution (which is not a concern when using something like moxi- floxacin), but in Europe where the trend is to use cefuroxime, "that's a complicated, several-step procedure to mix it properly," Dr. Mamalis said. In a busy surgery center, the more complicated the procedure is, "the greater the chance that there "That's a belt-and-suspenders type of approach," Dr. Mamalis said. "If you believe that intracameral antibiotics are all it takes to stave off endophthalmitis, then there is less need for a topical antibiotic to supplement it." There's been "some compelling data" that shows bacteria on the surface of the eye at the beginning of the case exists, and that would be Trends continued from page 49 from the patient's lid and conjunc- tival flora. As far as Dr. Mamalis is concerned, "the most important thing is sterilizing preoperatively with topical povidone-iodine as well as topical antibiotics," he said, to decrease the amount of surface bacteria at the start of surgery. He thinks tapering the antibiotic postoperatively is not recommended. Tapering runs the risk of increasing resistance and reduces efficacy. Some surgeons will have patients buy the topical antibiotic ahead of time, have the operating room team open it and draw what is needed, and have the patient use the same bottle postop for 7 days, Dr. Mamalis said, which reduces the cost for the patient. Of those who do not inject intracamerally, almost half cite mix- ing/compounding issues and cost as barriers. "If we could eliminate the mixing risk, the compounding risk with an approved single use antibi- otic, we could eliminate two-thirds of the reasons people don't use them," Dr. Mamalis said, adding the additional cost to the surgery would be negligible. Yet there's "an interesting dichotomy" in that 41% of respon- dents believe intracameral antibiotic prophylaxis is very important, but 53% of respondents are not inject- ing, Dr. Mamalis said. Down the road Although a commercial formula- tion of cefuroxime is available in Europe, it is unlikely U.S. regulators will approve the same formulation based on European study results showing both safety and efficacy. A safety study would only entail around 1,000 patients to show no adverse side effects from injecting intracamerally, but to power a study for efficacy would necessitate tens of thousands of patients given the low incidence of endophthalmitis. Ideally, the Food and Drug Administration should require safety data only, as it's fairly well accepted these drugs are efficacious. "If the FDA requires efficacy data, we are unlikely to have an ap- proved intracameral antibiotic in the near future," Dr. Mamalis said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Braga-Mele: rbragamele@rogers.com Mamalis: nick.mamalis@hsc.utah.edu

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