Bacteriology and cefuroxime resistance in endophthalmitis following cataract surgery before and after the introduction of prophylactic intracameral cefuroxime: a retrospective single-centre study

Endophthalmitis after cataract surgery and effect of different intracameral antibiotic regimes in Sweden 2011-2017: national registry study

PURPOSE

To study the incidence, predictive factors, etiology, and visual consequences of postoperative endophthalmitis (PE) in relation to 3 intracameral (IC) antibiotic regimes.

SETTING

Swedish National Cataract Register entries from 2011 through 2017.

DESIGN

Observational retrospective study.

METHODS

PE incidence, influencing factors, bacteriology, and visual outcome were analyzed regarding the 3 major prophylactic IC protocols.

RESULTS

The overall incidence of PE was 0.023% or 177 cases in 764 513 cataract procedures. Analyzed per IC regime, the rates of PE were 0.024% (126 cases in 514 916 surgeries) for cefuroxime, 0.020% (25 cases in 122 340 surgeries) for moxifloxacin, and 0.017% (20 cases in 121 045 surgeries) for combined cefuroxime-ampicillin. Incidences were not statistically significantly different from one another. Gram-positive bacteria caused 89.0% of culture positive cases. Enterococci as pathogens were significantly more frequent with IC cefuroxime than with moxifloxacin, P = .006, or cefuroxime-ampicillin, P < .001, while streptococci other than enterococci were more common with moxifloxacin than with cefuroxime, P < .001. Bacterial susceptibility to the given antibiotics was demonstrated in 21.3% of PE cases treated with cefuroxime, which was statistically significantly lower than proportions found with cefuroxime-ampicillin, 60.0%, P = .015, or with moxifloxacin, 88.2%, P < .001. Visual outcome worse than 20/200 was similar in the groups ranging from 42.0% to 53.7%.

CONCLUSIONS

No statistically significant differences in PE incidence or visual outcome results between treatment groups were demonstrated. However, differences in etiology and bacterial sensitivity were found between the prophylactic IC treatments.

Prophylactic Intracameral Antibiotics and Endophthalmitis After Cataract Surgery

Importance

Although the effectiveness of intracameral antibiotics to prevent postoperative endophthalmitis is described, selective use of antibiotics combined with 1% povidone iodine disinfection might be equally effective and could lead to cost reduction and avoidance of unnecessary use of antibiotics.

Objective

To compare the incidence of postoperative endophthalmitis when 1% povidone iodine disinfection is applied in combination with selective intracameral antibiotics with the incidence after routine use of intracameral antibiotics in combination with 5% povidone iodine.

Design, Setting, and Participant

This was a retrospective cohort study using incidence data from the ongoing endophthalmitis register of the Rotterdam Eye Hospital, a specialized hospital providing both secondary and tertiary ophthalmological care, when intracameral antibiotics were used only during cataract procedures with occurrence of a posterior capsular tear in comparison with results from cohorts described in the literature where routine antibiotics were used. All patients who had cataract (phacoemulsification) surgery at the Rotterdam Eye Hospital between 1993 and 2022 were included. No cataract surgical procedures combined with other intraocular procedures were included.

Exposure

Povidone iodine disinfection and intracameral antibiotics during cataract surgery either routinely or only in case of posterior capsular tears.

Main Outcome and Measure

Postoperative endophthalmitis incidence.

Results

Postoperative endophthalmitis incidence after 56 598 cataract (phacoemulsification) surgical procedures in the Rotterdam Eye Hospital between 2016 and 2022 was 0.000 (95% CI, 0.000-0.000). A PubMed literature search until September 2023 with respect to the incidence of postoperative endophthalmitis after routine antibiotic prophylaxis yielded 37 publications with an overall postoperative endophthalmitis incidence of 0.000 (95% CI, 0.000-0.000).

Conclusions and Relevance

No difference was observed between the postoperative endophthalmitis incidence during the last 7 years in the Rotterdam Eye Hospital and the overall postoperative endophthalmitis incidence after routine intracameral antibiotics prophylaxis as described in the literature. Disinfection with 1% povidone iodine in combination with selective antibiotic prophylaxis may be equally effective as routine antibiotic use and 5% povidone iodine.

Immediate sequential bilateral cataract surgery: a 13-year real-life report of 56 700 cataract operations

BACKGROUND/AIMS

To assess the frequency of immediate sequential bilateral cataract surgery (ISBCS) and endophthalmitis during 13-year period in Tays Eye Centre, Tampere University Hospital, Tampere, Finland.

METHODS

All cataract surgeries performed between 1 January 2008 and 31 December 2020, and all endophthalmitis cases during the same period were searched from electronic patient records. Numbers and frequencies of ISBCS, and complications, including endophthalmitis and vitreous loss, were recorded and compared with unilateral operations.

RESULTS

The study included 56 700 cataract surgeries in 34 797 patients of whom 39% (n=13 445) had ISBCS. The median age of the patients was 75 (IQR 68-80, range 0.08-99) years at the time of surgery. The proportion of ISBCS patients increased from 4.2% in 2008 to 46% in 2020. Vitreous loss occurred in 480 (0.9%) of cataract surgeries. There were no postoperative endophthalmitis after cataract surgery (n=0) during the 13-year period.

CONCLUSION

The proportion of patients undergoing ISBCS increased from 4.2% in 2008 to 46% in 2020. No endophthalmitis were found to be associated with ISBCS.

Susceptibility of Ocular Surface Bacteria to Various Antibiotic Agents in a Romanian Ophthalmology Clinic

Periodic assessment of bacterial contamination is necessary as it allows proper guidance in cases of eye infections through the use of appropriate antibiotics. Due to the extensive use of antibiotic treatment, many strains of the microbiota that cause infections are resistant to the usual ophthalmic antibiotics. The present study provides an updated assessment of the susceptibility of Gram-positive and Gram-negative bacteria found on the ocular surface to the most commonly used antibiotic agents in patients undergoing cataract surgery. A total of 993 patients were included in the study with ages between 44 and 98 years old. Conjunctival cultures were collected 7 days before cataract surgery. The response of Gram-positive and Gram-negative bacteria to various antibiotic classes, such as glycopeptides, cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, phenicols, tetracyclines, rifamycins, macrolides and penicillins, was assessed. From the tested antibiotics, vancomycin had 97.8% efficacy on Gram-positive bacteria. In the cephalosporin category, we observed a high level of resistance of the cefuroxime for both Gram-positive and negative bacteria. Antibiotics that have more than 90% efficacy on Gram-positive bacteria are meropenem, imipenem, netilmicin, amikacin and rifampicin. On Gram-negative bacteria, we found 100% efficacy of all tested fluoroquinolones, i.e., aminoglycosides (except for tobramycin), doxycycline, azithromycin, clarithromycin and chloramphenicol. The current study illustrates patterns of increased resistance in certain bacteria present on the ocular surface to some of the commonly used antibiotics in ophthalmological clinical practice. One such revealing example is cefuroxime, which has been highly used as an intracameral antibiotic for the prevention of bacterial endophthalmitis after cataract surgery.

Effect of cefuroxime intracameral injection antibiotic prophylactic on postoperative endophthalmitis wound post‐cataract: A meta‐analysis

To assess the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract, we conducted a meta-analysis. A thorough review of the literature up to July 2022 revealed that there were 1 167 197 participants with surgery of cataract at the start of the research; 1 004 425 of these subjects received an injection of intracameral of cefuroxime, while 162 772 did not get an antibiotic as a control. Using dichotomous approaches and a random or fixed-effect model, odds ratios (OR) with 95% confidence intervals (CIs) were estimated to evaluate the impact of cefuroxime injection of intracameral prophylaxis antibiotic on after endophthalmitis operative wound following surgery of cataract. When comparing no antibiotic in participants who had surgery of cataract, the cefuroxime injection of intracameral significantly reduced the after endophthalmitis operative wound (OR, 0.14; 95% CI, 0.07-0.29, P = 0.001) with high heterogeneity (I2 = 95%). When comparing participants who received no antibiotic after surgery of cataract, the after endophthalmitis operative wound from the cefuroxime injection of intracameral was considerably lower. Although none of the 22 studies encompassed in the meta-analysis had a study with a small sample size, it is nevertheless advisable to proceed with caution when analysing the results.

Prophylactic antibiotics for postcataract surgery endophthalmitis: a systematic review and network meta-analysis of 6.8 million eyes

To reveal optimal antibiotic prophylactic regimen for postoperative endophthalmitis (POE), we conducted systematic review and network meta-analysis. A total of 51 eligible original articles, including two randomized controlled trials, were identified. In total, 4502 POE cases occurred in 6,809,732 eyes (0.066%). Intracameral injection of vancomycin had the best preventive effect (odds ratio [OR] 0.03, 99.6% confidence interval [CI] 0.00-0.53, corrected P-value = 0.006, P-score = 0.945) followed by intracameral injection of cefazoline (OR 0.09, 99.6% CI 0.02-0.42, corrected P-value < 0.001, P-score = 0.821), cefuroxime (OR 0.18, 99.6% CI 0.09-0.35, corrected P-value < 0.001, P-score = 0.660), and moxifloxacin (OR 0.36, 99.6% CI 0.16-0.79, corrected P-value = 0.003, P-score = 0.455). While one randomized controlled trial supported each of intracameral cefuroxime and moxifloxacin, no randomized controlled trial evaluated vancomycin and cefazoline. Sensitivity analysis focusing on the administration route revealed that only intracameral injection (OR 0.19, 99.4% CI 0.12-0.30, corrected P-value < 0.001, P-score = 0.726) significantly decreased the risk of postoperative endophthalmitis. In conclusion, intracameral injection of either vancomycin, cefazoline, cefuroxime, or moxifloxacin prevented POE.

A Rare Case of Endophthalmitis with Rhizobium radiobacter, Soon after a Resolved Keratitis: Case Report

Background: Rhizobium (Agrobacterium) species are plant aerobic bacteria, which in some cases can produce endophthalmitis in humans after corneal trauma. Case presentation: A 42-year-old female patient presented in the Emergency Department of the Emergency County Hospital of Craiova, Romania, reporting pain, epiphora, and blurry vision in her right eye for about five days. This initial infectious keratitis episode was successfully resolved, but after 20 days she presented again after trauma with a leaf with corneal abscess. In the conjunctival secretion, R. radiobacter was identified. Despite antibiotherapy, the patient’s state did not improve, and ultimately the eye was eviscerated. Methods: A search was performed in the ProQuest, PubMed, and ScienceDirect databases for the terms Agrobacterium, Rhizobium, radiobacter, and eye. We eliminated non-human studies, editorials and commentaries, and non-relevant content, and excluded the duplicates. Results: In total, 138 studies were initially obtained, and then we selected 26 studies for retrieval. After the selection process, we ended up including 17 studies in our analysis. Most studies reported R. radiobacter endophthalmitis after ocular surgical procedures or outdoor activities that involve exposure to soil. Conclusion: R. radiobacter is a rare cause of endophthalmitis after eye trauma that generally responds well to usual antibiotherapy, but occasionally can evolve to severe, leading to the loss of the eye.

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Eye Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Ocular surgery encompasses a wide range of procedures, including surgery of the tear ducts, eyelid, cornea and conjunctiva, lens, ocular muscle, and vitreoretinal and iris surgery. Operations are also performed for the removal of tumors, repairs of ocular trauma and, finally, corneal transplantation. Antibiotic prophylaxis for the prevention of surgical site infections (SSIs) in ocular surgery is a complex field in which shared lines of action are absent. In light of the scarcity of shared evidence in the use of ocular antimicrobial prophylaxis for the pediatric population, this consensus document aims to provide clinicians with a series of recommendations on antimicrobial prophylaxis for patients of neonatal and pediatric age undergoing eye surgery. The following scenarios are considered: (1) intraocular surgery; (2) extraocular surgery; (3) ocular trauma; (4) ocular neoplasm; (5) ocular surface transplantations; (6) corneal grafts. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding clinical actions in the peri-operative environment in eye surgery. The application of uniform and shared protocols aims to improve surgical practice, through the standardization of procedures, with a consequent reduction of SSIs, also limiting the phenomenon of antimicrobial resistance.

Establishing in vitro and in vivo Co-culture Models of Staphylococcus epidermidis and Enterococcus faecalis to Evaluate the Effect of Topical Fluoroquinolone on Ocular Microbes

Purpose: To establish in vitro and in vivo ocular co-culture models of Staphylococcus epidermidis and Enterococcus faecalis and to study how various concentrations of moxifloxacin affect the survival of these two endophthalmitis-causing bacteria. Methods: Standard strains of S. epidermidis and E. faecalis were used. Color detection agar plates were employed to distinguish their colonies. To establish the in vitro and in vivo co-culture models, S. epidermidis and E. faecalis were co-cultivated at different ratios for various periods. For the in vivo model, various volumes and concentrations of either a mono-culture or co-culture were inoculated into the lower conjunctival sac of rabbits. Finally, the newly developed in vitro and in vivo co-culture models were subjected to the moxifloxacin treatment to access its effect on S. epidermidis and E. faecalis. Results: When S. epidermidis and E. faecalis were cultured separately in tryptic soy broth, their growth peaked and plateaued at approximately 16 and 6 h, respectively. When they were co-cultured, the growth peak of S. epidermidis got delayed, whereas the growth peak of E. faecalis did not change. The number of E. faecalis was significantly higher in the co-culture than that in the mono-culture. Treatment with moxifloxacin in the in vitro co-culture model rapidly decreased the number of S. epidermidis cells at doses ≥ 0.125 μg/ml. In contrast, the number of E. faecalis did not change significantly up to 16 μg/ml moxifloxacin. In in vivo co-culture (at 1:1), the S. epidermidis count decreased in a pattern similar to that seen in in vivo mono-culture and was barely detectable at 24 h after inoculation. In contrast, the of E. faecalis count increased up to 16 h and then decreased. When moxifloxacin was applied (zero, one, or two times) to this model, the S. epidermidis count decreased in proportion to the number of treatments. In contrast, the E. faecalis count increased with moxifloxacin treatment. Conclusions: The in vitro and in vivo co-culture models of S. epidermidis and E. faecalis were established to determine the influence of moxifloxacin eye drops on these bacteria. The results clearly show that the moxifloxacin eye drops can make E. faecalis dominant on the ocular surface.

Association between the clinical and demographic characteristics of patients undergoing cataract surgery and their prevalence of conjunctival bacteria

PURPOSE

To identify characteristics of patients undergoing cataract surgery associated with pathogenic and antibiotic-resistant conjunctival bacteria.

SETTING

Spanish tertiary hospital.

DESIGN

Retrospective cross-sectional study.

METHODS

Records of consecutive patients undergoing cataract surgery between July 2005 and September 2014, contained data on patient characteristics and conjunctival bacteria systematically identified with preoperative tests and anesthetic evaluation. A multivariate logistic regression associated 12 bacterial groups with every category of 17 characteristics. Odds ratio (OR), 95% CIs expressed colonization risk.

RESULTS

In 14883 patients, categories associated with pathogenic bacteria were age older than 79 years with nonfermentative gram-negative bacilli (NFGNB) (OR 1.74, 1.12-2.71), enterococci (OR 1.90, 1.36-2.65), Enterobacteriaceae (OR 2.17, 1.65-2.87), and Staphylococcus aureus (OR 1.37, 1.16-1.62); obesity with S aureus (OR 1.52, 1.30-1.78), enterococci (OR 1.99, 1.47-2.68), and Enterobacteriaceae (OR 2.17, 1.70-2.77); dacryocystorhinostomy history with S aureus (OR 1.90, 1.48-2.44), Haemophilus spp. (OR 2.06, 1.37-3.11), Streptococcus pneumoniae (OR 3.14, 2.14-4.62), NFGNB (OR 2.23, 1.28-3.88), and enterococci (OR 1.80, 1.16-1.81); diabetes with S aureus (OR 1.27, 1.13-1.44), enterococci (OR 1.49, 1.19-1.87), and Enterobacteriaceae (OR 1.27, 1.04-1.54); smoking habit with Enterobacteriaceae (OR 2.11, 1.56-2.86); autumn with NFGNB (OR 2.0, 1.35-3.0); hot weather with S aureus (OR 1.23, 1.03-1.47); and lung, renal, and some heart insufficiencies with S aureus. Other staphylococci, highly antibiotic-resistant, were associated with old age, obesity, and hot weather.

CONCLUSIONS

Old age, obesity, diabetes, dacryocystorhinostomy history, smoking habit, and autumn and summer seasons increased the prevalence of enterococci, staphylococci, Enterobacteriaceae, and/or NFGNB. Obesity and humid-warm weather are key for choosing a cataract surgery prophylaxis.

Postoperative Endophthalmitis in Immediate Sequential Bilateral Cataract Surgery: A Nationwide Registry Study

PURPOSE

To report the incidence of postoperative endophthalmitis (PE) after immediate sequential bilateral cataract surgery (ISBCS) in Sweden.

DESIGN

Retrospective cohort registry study.

PARTICIPANTS

Patient data from 1 457 172 cataract extractions, including 1 364 934 unilateral surgeries and 92 238 ISBCSs.

METHODS

Endophthalmitis cases reported to the Swedish National Cataract Register (NCR) during a 16-year period (2002-2017) were analyzed in comparison to all control cases with regard to patient characteristics, surgical technique, and capsule complication.

MAIN OUTCOME MEASURE

Incidence and determinants for PE in ISBCS compared with unilateral surgeries.

RESULTS

A total of 422 cases of PE were identified in 1 457 172 cataract extractions, yielding an overall incidence of 0.029% (95% confidence interval [CI], 0.0262-0.0317). For unilateral procedures, the rate was 0.0299% (95% CI, 0.0270-0.0328) or 408 cases in 1 364 934 operations, whereas that for ISBCS was 0.0152% (95% CI, 0.0072-0.0231) or 14 incidents in 92 238 operations (P = 0.01). In a logistic regression model including all cataract procedures, nonuse of intracameral (IC) antibiotics (ABs), capsule complication, age 85 years or more, male gender, and ocular comorbidity were found to be independent risk factors for PE. All these parameters were less frequent in ISBCS. Notwithstanding, in the same multivariate analysis, ISBCS in itself was associated with a significantly lower risk for PE. At follow-up, 5 of the 14 PE cases in the ISBCS cohort had a visual acuity (VA) of 20/200 or worse. Of these, one 93-year-old ISBCS patient developed bilateral infection.

CONCLUSIONS

After ISBCS in Sweden, PE occurred once in 6600 surgeries. The risk of sustaining a final VA of 20/200 or less was 1 incident in 18 000 operated eyes. When counseling potential ISBCS patients about the risk of PE, it seems reasonable to state that the reported risk in the literature is lower than that with unilateral surgery but not negligible. Precautions remain necessary.

Emerging Enterococcus isolates in postoperative endophthalmitis by selection pressure of fluoroquinolones: an 11-year multicenter and experimental study

Postoperative endophthalmitis (PE) is the devastating complication that frequently results in vision loss. Recently, enterococcus have emerged as a major cause of PE in several countries and resulted in poor visual outcome. However, the reason remains elusive. We investigate whether selection pressure of fluoroquinolone exerts effects on microorganism profiles isolated from PE. Medical records of patients who were diagnosed with PE at eight resident training institutions between January 2004 and December 2015 were reviewed. The most common isolate was Enterococcus faecalis (28.0%), followed by Staphylococcus epidermidis (18.6%) and other coagulase negative Staphylococci (7.6%). However, the rates of E. faecalis isolated from conjunctival microbes were 6.2% (16/257) and their resistance to fluoroquinolones was higher than those of S. epidermidis. In vitro and in vivo co-culture models of E. faecalis and S. epidermidis were established for survival assays after administration of fourth-generation fluoroquinolone. In in vitro co-culture model, the survival assay of E. faecalis and S. epidermidis against the treatment of moxifloxacin showed that E. faecalis survived significantly better than S. epidermidis in the presence of moxifloxacin 1 µg/mL and more. In in vivo co-culture model, E. faecalis survived significantly better than S. epidermidis after topical treatment of moxifloxacin (5 mg/mL). E. faecalis has been the most common causative strain of PE in Korea. We suggest that the increase of E. faecalis in PE could be associated with the selection pressure of fourth-generation fluoroquinolone.

Summary:Enterococcus spp. have emerged as a leading causative strain of postoperative endophthalmitis in 11-year clinical data. We suggest that the increase of Enterococcus spp. is associated with the selection pressure of fourth-generation fluoroquinolone.

Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update

Improved surgical techniques have led to an increase in the number of outpatient ophthalmic procedures. In spite of decreased surgical times and overall improved outcomes, endophthalmitis remains one of the most severe complications of ophthalmic surgery. Although there are well known risk factors for postoperative endophthalmitis, some prophylaxis strategies remain controversial. A category of noninfectious postoperative inflammation, known as toxic anterior segment syndrome (TASS), is a rare but important complication of cataract surgery. While several worldwide outbreaks of TASS have occurred, it is challenging to identify an etiology in order to reduce the risk of further cases. Endophthalmitis and TASS cannot be prevented completely, but their rates may be decreased through risk reduction strategies supported by peer-reviewed evidence. This review highlights the current evidence in the prevention strategies for postoperative endophthalmitis and TASS.

Drop-free approaches for cataract surgery

PURPOSE OF REVIEW

Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence.

RECENT FINDINGS

Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved.

SUMMARY

Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.