EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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38 EW FEATURE February 2011 Perioperative pharmacology May 2012 Methicillin-resistant Staphylococcus infections in ophthalmology by Faith A. Hayden EyeWorld Staff Writer AT A GLANCE • Community acquired MRSA and MRSE is on the rise • Fourth-generation fluoroquinolones such as gatifloxacin and moxi- floxacin are showing resistance • It's important to use antibiotics according to package labeling What cataract surgeons can do to minimize resistance W hen it comes to con- trolling methicillin-re- sistant Staphylococcus infections, there's good and bad news. On a positive note, the Centers for Disease Control and Prevention reported an 18% decrease in the number of people developing healthcare-associated methicillin-re- sistant Staphylococcus aureus (MRSA) infections in 2010. The bad news, Update continued from page 37 "It's easy; you take the whole bottle of moxifloxacin, you aspirate into a syringe, and then you aspirate 7 ccs more of BSS, and that's it," he explained. Dr. Arbisser said she has the pa- tient bring in an unopened bottle of Vigamox and uses that intracamer- ally. She has also continued to use topical antibiotics 1 hour pre-op and for a week post-op. "I continue to do that, even though intracameral Vigamox and Betadine [povidone iodine, Purdue Pharma L.P., Stamford, Conn.] are the reasons I am 10,000 cases in without any endophthalmitis," she said. Timing is everything There are no clinical trials surgeons can refer to as a guide for when to start topical prophylactic antibiotics. Dr. Arshinoff administers topi- cal antibiotics 1 hour before patients are wheeled into the operating suite. He cited a study in JCRS by Lindsay Ong-Tone, F.R.C.S.C., illus- trating that the amount of antibi- otics that gets placed in the eye is maximized by giving patients the drops four times during the hour before surgery. "You also know they got it be- cause you gave it to them," he said, adding that compliance always seems to be a concern. Dr. Masket said he prescribes topical antibiotics four times a day starting 1 day prior to surgery for routine cases. For patients who are immunologically compromised or who have a Jones lacrimal tube or prosthetic fellow eye, he prescribes systemic Avelox (moxifloxacin, Merck, Whitehouse Station, N.J.) 2 days prior, the day of surgery, and 2 days after—each one dose of 400 mg. The surgeons agreed that post- op antibiotics haven't been proven to be effective, but they aren't will- ing, just yet, to stop the regimen on the chance that they are beneficial. "I think we do it because we're afraid," Dr. Arshinoff said. "Some patients rub their eyes and may make the incisions leak. We may get high enough doses in the eye to kill most bugs by giving them post-op drops." "Do we need all the topical antibiotics?" Dr. Arbisser asked. "Frankly, there's no evidence that we do, but I haven't been bold enough to stop." EW References Barry P, Seal D, Gettinby G, Lees F, Peterson M, Revie C. ESCRS study of prophylaxis of post-operative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006; 32:407-410. Arshinoff SA, Bastianelli PA. Incidence of post- operative endophthalmitis after immediate se- quential bilateral cataract surgery. J Cataract Refract Surg. 2011 Dec;37(12):2105-14. O'Brien TP, Arshinoff SA, Mah FS. Perspectives on antibiotics for postoperative endophthalmi- tis prophylaxis: potential role of moxifloxacin. J Cataract Refract Surg. 2007 Oct;33(10): 1790-800. Endophthalmitis Study Group, European Soci- ety of Cataract & Refractive Surgeons. Pro- phylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identifica- tion of risk factors. J Cataract Refract Surg. 2007 June;33(6):978-88. Ong-Tone L. Aqueous humor penetration of gatifloxacin and moxifloxacin eyedrops given in different concentrations in a wick before cataract surgery. J Cataract Refract Surg. 2008 May;34(5):819-22. Editors' note: Dr. O'Brien has financial interests with Alcon, Allergan (Irvine, Calif.), and Bausch + Lomb (Rochester, N.Y.). Contact information Arbisser: 563-323-2020, drlisa@arbisser.com Arshinoff: 416-745-6969, ifix2is@sympatico.ca Mah: 412-647-2211, mahfs@upmc.edu Masket: architart@aol.com O'Brien: 561-515-1544, tobrien@med.miami.edu Methicillin-resistant Staphylococcus aureus bacteria Source: SCIENCE SOURCE/Getty Images however, is these infections are no longer a club exclusive to healthcare workers and sickly patients. Cataract surgeons now have to assume all patients undergoing cataract surgery are colonized with methicillin- resistant organisms. A multicenter study published in the December 2010 issue of Clini- cal Ophthalmology (2010:4 1505-