Eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of 18,839 injections by a single surgeon

Incidence and Visual Outcomes of Endophthalmitis After Intravitreal Injection of Dexamethasone Implant vs Ranibizumab

Purpose

To compare the incidence and visual outcomes of endophthalmitis after injection of an intravitreal dexamethasone implant and injection of intravitreal ranibizumab.

Methods

This retrospective cohort study assessed endophthalmitis in eyes receiving an intravitreal injection of a 0.7 mg dexamethasone implant (DEX group), 0.5 mg ranibizumab (R5 group), or 0.3 mg ranibizumab (R3 group) between January 1, 2016, and May 31, 2018, at 2 large retina practices in the United States.

Results

Suspected endophthalmitis occurred in 5 eyes after 4973 DEX injections, 43 eyes after 163 974 R5 injections, and 6 eyes after 18 954 R3 injections. Suspected endophthalmitis was significantly more common in the DEX group (1/995) than in the R5 group (1/3813) (P = .008) but not than in the R3 group (1/3159) (P = .10). Visual acuity outcomes were similar in the 3 groups.

Conclusions

Suspected endophthalmitis might be more common after 0.7 mg dexamethasone injections than after 0.5 mg ranibizumab injections. Culture-positive endophthalmitis rates were similar across all 3 medications.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

The Impact of Physician Face Mask Use on Endophthalmitis After Intravitreal Anti-Vascular Endothelial Growth Factor Injections

PURPOSE

To evaluate the effect of physician face mask use on rates and outcomes of postinjection endophthalmitis.

DESIGN

Retrospective, comparative cohort study.

METHODS

Setting: Single-center. StudyPopulation: Eyes receiving intravitreal anti-vascular endothelial growth factor injections from July 1, 2013, to September 1, 2019.

INTERVENTION

Cases were divided into "Face Mask" group if face masks were worn by the physician during intravitreal injections or "No Talking" group if no face mask was worn but a no-talking policy was observed during intravitreal injections. MainOutcomeMeasures: Rate of endophthalmitis, visual acuity, and microbial spectrum.

RESULTS

Of 483,622 intravitreal injections administered, 168 out of 453,460 (0.0371%) cases of endophthalmitis occurred in the No Talking group, and 9 out of 30,162 (0.0298%) cases occurred in the Face Mask group (odds ratio, 0.81; 95% confidence interval, 0.41-1.57; P = .527). Sixteen cases of oral flora-associated endophthalmitis were found in the No Talking group (1 in 28,341 injections), compared to none in the Face Mask group (P = .302). Mean logMAR visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the No Talking group compared to the Face Mask group (17.1 lines lost from baseline acuity vs 13.4 lines lost; P = .031), though no difference was observed at 6 months after treatment (P = .479).

CONCLUSION

Physician face mask use did not influence the risk of postinjection endophthalmitis compared to a no-talking policy. However, no cases of oral flora-associated endophthalmitis occurred in the Face Mask group. Future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly attributable to oral flora.

Endophthalmitis following Intravitreal Anti-Vascular Endothelial Growth Factor Therapy: Changes in Incidence and Outcomes over a 9-Year Period

Aims: To evaluate whether the incidence, microbial spectrum, and visual outcomes of endophthalmitis following intravitreal injections have changed over time.Methods: Retrospective cohort study of endophthalmitis in eyes receiving intravitreal injection of anti-vascular endothelial growth factor between 2009-2012 and 2016-2017 at a single, large retina practice.Results: A total of 283,315 injections resulted in 96 suspected infectious endophthalmitis cases. Comparing 2009-2012 and 2016-2017, the rate of suspected endophthalmitis changed from 1 in 2,663 injections to 1 in 3,195 injections (p = .37). Visual outcomes 6 months after endophthalmitis were significantly better during the latter period (p = .04), with an average loss of 6.3 lines of VA in 2009-2012 compared to a loss of 3.6 lines in 2016-2017. In multivariate analysis, a "no-talking" policy during injections resulted in a trend towards a decrease in endophthalmitis incidence (p = .08). Cessation of post-injection topical antibiotic use did not independently decrease endophthalmitis incidence (p = .24) when the effect of a "no-talking" policy was taken into account. A lower rate of endophthalmitis was seen after prefilled vs. conventionally prepared ranibizumab syringe use for injection (0.014% vs. 0.035%, respectively), though this difference did not meet statistical significance (p = .16).Conclusion: The incidence of endophthalmitis after intravitreal injection decreased and visual outcomes improved between the periods of 2009-2012 and 2016-2017. A "no-talking" policy during injections was associated with a trend toward a decrease in endophthalmitis rate.

The Impact of Prefilled Syringes on Endophthalmitis Following Intravitreal Injection of Ranibizumab

PURPOSE

To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation.

DESIGN

Multicenter retrospective cohort study.

METHODS

All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum.

RESULTS

A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group.

CONCLUSION

In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

Topical antibiotics and intravitreal injections

There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy. Despite this, in many countries, it is still common practice to use pre- and/or postinjection topical antibiotics. This review outlines the general principles of effective antibiotic prophylaxis, and the evidence regarding topical antibiotic use as a prophylactic measure for endophthalmitis following intravitreal injections. A key distinguishing feature of intravitreal injections from most other invasive procedures is the fact that they are often repeated on multiple occasions to the same eye. Given the lack of evidence to support topical antibiotics as an effective method of prophylaxis for postinjection endophthalmitis, it appears that more widespread education of ophthalmologists is required to avoid continued inappropriate use. Revision of drug labels in some jurisdictions, and amendment of local/professional society guidelines, may be required to assist in achieving this goal. Emphasis should be placed on antisepsis and aseptic technique, which are the major proven methods of endophthalmitis prevention, rather than antibiotics.

POOLED ESTIMATES OF INCIDENCE OF ENDOPHTHALMITIS AFTER INTRAVITREAL INJECTION OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS WITH AND WITHOUT TOPICAL ANTIBIOTIC PROPHYLAXIS

PURPOSE

To assess the effect of topical antibiotic prophylaxis on postoperative endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents.

METHODS

A systematic literature search was performed from inception to March 2016 using PubMed, Medline, Web of Science, Embase, and the Cochrane Library, to identify articles that reported cases of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. We used a pooled analysis to estimate the incidence of cases of endophthalmitis who developed after injections performed with and without topical antibiotic prophylaxis. We used regression analysis to explore the effects of study characteristics on heterogeneity.

RESULTS

From our search of electronic databases, we identified and screened 4,561 unique records. We judged 60 articles to have reported findings for cohorts of patients who met our inclusion criteria, (12 arms of randomized clinical trials, 11 prospective cohort studies, and 37 retrospective cohort studies), which included 244 cases of endophthalmitis and 639,391 intravitreal injections of anti-vascular endothelial growth factor agents. The final pooled estimate endophthalmitis proportions were 9/10,000 (95% confidence interval, 7/10,000-12/10,000) in the antibiotic-treated group and 3/10,000 (95% confidence interval, 2/10,000-5/10,000) in the untreated group. The estimated incidence of endophthalmitis with topical antibiotic prophylaxis was approximated three times the incidence without prophylaxis. Random effects regression showed that none of the study characteristics significantly affected the effect size in either group.

CONCLUSION

Topical antibiotic after intravitreal injection of anti-vascular endothelial growth factor agents is associated with a higher risk of endophthalmitis.

RESOLUTION OF TREATMENT-RESISTANT SUBRETINAL FLUID IN A PATIENT WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION FOLLOWING ENDOPHTHALMITIS

PURPOSE

This is the first report to the best of the authors' knowledge to show resolution of subretinal fluid and treatment requirement in a case of exudative age-related macular degeneration (eAMD) with persistent fluid despite treatment that resolved following an episode of culture-positive bacterial endophthalmitis.

METHODS

A 73-year-old man with history of eAMD of the right eye presented with acute postinjection bacterial endophthalmitis 3 days after injection. He had a history of only partially treatment-responsive eAMD that had been treated over a period of 8 years.

RESULTS

After tap-and-inject treatment of endophthalmitis with ceftazidime, vancomycin, and dexamethasone, the patient returned for follow-up with visual improvement and resolution of the subretinal fluid. The previously treatment-resistant eAMD remains quiescent without further treatment after 10 months of follow-up.

CONCLUSION

It is possible that some aspect of the infection, inflammation, or treatment of endophthalmitis had a disease-modifying impact on the eAMD. Further research into the components of endophthalmitis and its treatment may result in the discovery of new treatment approaches or treatment targets.

Endophthalmitis After Intravitreal Injections in Patients With Self-reported Iodine Allergy

PURPOSE

To present cases of endophthalmitis following intravitreal injections where povidone-iodine (PI) was not used as part of the surgical preparation.

DESIGN

Retrospective case series.

METHODS

All cases of presumed injection-related endophthalmitis presenting to the Massachusetts Eye and Ear Infirmary between June 2008 and November 2014 and Dean McGee Eye Institute between January 2010 and January 2015 were identified. Patients who did not receive PI preparation owing to documented self-reported allergy to iodine, iodine-containing contrast material, or shellfish were identified and their injection histories and clinical courses reviewed.

RESULTS

The combined rate of postinjection endophthalmitis at these 2 centers was 0.019%. Among 42 patients with postinjection endophthalmitis, 5 (11.9%) did not receive PI prophylaxis. The mean number of intravitreal injections without PI before the development of endophthalmitis was 10.6 with a 9.4% rate of endophthalmitis (5 cases per 53 injections). All patients underwent tap-and-inject procedures with vancomycin 1 mg and ceftazidime 2 mg. Two patients did not receive PI at the time of tap and inject; 1 of these patients required subsequent pars plana vitrectomy for worsening clinical course. Cultures were positive in 4 of 5 cases; all positive cultures grew coagulase-negative Staphylococcus. All patients who received subsequent intravitreal injections received PI prophylaxis without allergic reactions, thus demonstrating a lack of true PI allergy.

CONCLUSIONS

Avoiding PI owing to self-reported iodine "allergy" risks substantial ocular morbidity. Allergy testing can be pursued per patient request or in rare cases of suspected true PI allergy; however, in cases where delayed treatment would adversely affect visual outcome, the clinician should feel confident that minimal allergic risk exists.

Antibioprophylaxis in Prevention of Endophthalmitis in Intravitreal Injection: A Systematic Review and Meta-Analysis

Despite endophthalmitis being the most feared complication, antibioprophylaxis remains controversial in intravitreal injections. Therefore, we conducted a systematic review and meta-analysis on the effects of antibioprophylaxis in intravitreal injections in the prevention of endophthalmitis. The PubMed, Cochrane Library, Embase and Science Direct databases were searched for studies comparing groups with and without antibiotics in intravitreal injection, with the use of the following keywords: "antibiotic*", "endophthalmitis" and “intravitreal injection*”. To be included, studies needed to specify number of participants and number of endophthalmitis within each group (with and without antibiotics). We conducted meta-analysis on the prevalence of clinical endophthalmitis including both culture-proven and culture negative samples. Nine studies were included. A total of 88 incidences of endophthalmitis were reported from 174,159 injections (0.051% i.e., one incidence of endophthalmitis for 1979 injections). Specifically, 59 incidences of endophthalmitis were reported from 113,530 injections in the group with antibiotics (0.052% or one incidence of endophthalmitis for 1924 injections) and 29 incidences of endophthalmitis from 60,633 injections in the group without antibiotics (0.048% or one endophthalmitis for 2091 injections). Our meta-analysis did not report a significant difference in the prevalence of clinical endophthalimitis between the two groups with and without topical antibiotics: the odds ratio of clinical endophthalimitis was 0.804 (CI95% 0.384–1.682, p = 0.56) for the antibiotic group compared with the group without antibiotics. In conclusion, we performed the first large meta-analysis demonstrating that antibioprophylaxis is not required in intravitreal injections. Strict rules of asepsis remain the only evidence-based prophylaxis of endophthalmitis. The results support initiatives to reduce the global threat of resistance to antibiotics.

Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review

The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure's possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.