EyeWorld India March 2015 Issue

March 2015 10 EWAP FEATURE Intracameral antibiotics: The Kaiser Permanente protocol by Ellen Stodola EyeWorld Staff Writer Research from one institution has shown intracameral antibiotics like cefuroxime, vancomycin, and moxifloxacin may be helpful to prevent infection R isk for postoperative infection, including endophthalmitis, is a major concern following cataract surgery. Intracameral antibiotics are a potential solution to help decrease the incidence of postoperative infection. In the study of intracameral antibiotics in the U.S., physicians at Kaiser Permanente have been involved in the debate of the use of these drugs. Richard Kent Stiverson, MD , Lakewood, Colo., and Neal Shorstein, MD , Walnut Creek, Calif., discussed their experience and research on the topic. What prompted the study? “In Colorado, we were bothered by the relatively poor outcomes of our patients who got endophthalmitis,” Dr. Stiverson said. In some cases, intravitreal antibiotics or a vitrectomy worked, but vision was still compromised. “For most of our patients, the visual outcome from endophthalmitis was devastating,” he said. “We were extremely fortunate to have two ophthalmologists with research backgrounds who appreciated the importance of a large sample size for any discussion about endophthalmitis.” Those two ophthalmologists were Dr. Shorstein, who published the Northern California results in 2013, and Lee Schelonka, MD , in Colorado, who analyzed a large number of cataract surgery data modeled after the ESCRS Endophthalmitis Study Group’s work. Dr. Shorstein said indications that the infection rate was particularly high in Northern California in 2007 prompted the study in that region, which began in 2011 and 2012. “Because we’re an integrated organization, we had the luxury of having our regional risk and infection control surveyors come in and do a top to bottom inspection and analysis of our surgery center,” he said. Out of this came suggestions related to the sterilization and cleaning processes, but no root cause was identified. AT A GLANCE • Kaiser Permanente continues to lead the way in the U.S. study of intracameral antibiotics. • A study published by Dr. Shorstein and others indicates that using an intracameral antibiotic helped to lower the rate of postoperative endophthalmitis. • The ESCRS Endophthalmitis Study Group’s work on the use of cefuroxime was a major in uence on the recent U.S. study. “At the same time, the physicians got together and tried to figure out what it was that we could do to improve the infection rate,” Dr. Shorstein said. Wound construction and management were discussed, and the ESCRS study was embraced. “We decided to embark on the ESCRS protocol of using intracameral cefuroxime after cataract surgery,” he said. Beginning in 2008, the 14 surgeons began using cefuroxime in patients. “It was not clear to us that it was safe to use after complicated surgery, for example in cases of posterior capsule rupture, so we injected the non- allergic and non-complicated eyes, which accounted for about 80 to 85% of surgeries.” At the end of 2009, Dr. Shorstein was able to look at infection results for the years 2008 and 2009, and the rate had decreased by half. Two-thirds of the patients who did get endophthalmitis had not received cefuroxime because of an allergy or complication. By that point, there were articles in the literature that showed moxifloxacin was being used safely, he said. “Going forward, we collectively agreed to continue to use cefuroxime as the first line drug because that had the most support in the literature from the ESCRS study and other newer studies showing safety and effectiveness,” Dr. Shorstein said. The group added a second line drug, moxifloxacin, and a third line drug, vancomycin, for patients with allergies. All eyes were injected with one of the three antibiotics at the conclusion of surgery. “We are at an advantage Intracameral injection Source: Karl Brasse, MD, Eyeland Design