EyeWorld India March 2015 Issue

March 2015 11 EWAP FEATURE at Kaiser Permanente because we work together in a close department. There was also an inpatient pharmacist at the surgery center who was very helpful in developing the compounding protocols and had the facility to do it. Even in a large organization, we’ve found it helpful to have a very experienced compounding pharmacy,” Dr. Shorstein said. Did the change elicit much debate? Dr. Shorstein said that involving all of the members of the group reviewing the evidence within and outside of the department helped to build consensus on the topic. “We took a look at the literature and agreed on a protocol together,” he said. Dr. Stiverson said the revision after the study elicited much debate in Colorado. “Our internal experience seems to mimic what is occurring nationally based on the ASCRS surveys,” he said. “Despite concerted effort to standardize what we do with respect to intracameral antibiotics, California and Colorado are not doing the exact same thing, and within regions, not all of our doctors are willing to standardize.” However, he noted that in Colorado, every patient is either getting vancomycin in the balanced salt solution bottle or moxifloxacin intracamerally at the end of the case, with most debate pertaining to topical medications. “All of us in Colorado continue to use polymyxin B and trimethoprim drops along with vancomycin or moxifloxacin injection,” Dr. Stiverson said. “In California, several doctors are using only intracameral injection with no topical antibiotic.” He finds the current debate fascinating because of the “passion and relative lack of science.” Dr. Stiverson said the major internal dilemma at Kaiser Permanente Colorado is which antibiotic is best and whether to use topical treatment at all. Dr. Shorstein’s work included all three antibiotics, but with cefuroxime as the first line drug. However, there are arguments for moxifloxacin and vancomycin use. “I believe it will be difficult to ever show that intracameral injection of cefuroxime, moxifloxacin, and vancomycin are different with respect to endophthalmitis prophylaxis, and it may not make much difference because concentrations in the eye exceed MIC90s by hundreds,” Dr. Stiverson said. “As such, safety and cost should weigh in.” Current protocol and implementation process “When we first started doing the injections in our department in 2008, we made an agreement that the staff in the surgery center would help us ensure that every patient would receive the injection,” Dr. Shorstein said. From 2008 to 2013 the pharmacy automatically compounded the antibiotic, and it was provided to the surgery center for every cataract patient, he said. If the patient was allergic, there was a specific protocol so they could furnish the second or third line drug. “We can now show in a controlled, statistically valid fashion that intracameral antibiotics are very effective,” Dr. Shorstein said. “Our infection rate now is so low that it’s difficult to match head-to-head cefuroxime and moxifloxacin.” About 80% of eyes were injected with intracameral antibiotics in 2013, Dr. Shorstein said, and although he has not yet examined data from 2014, it is likely close to 100% of patients receiving these drugs. In Colorado, the standard is polymyxin B/trimethoprim QID starting the day before surgery and continuing QID for 1 week after surgery. Additionally, povidone- iodine is used as part of the prep, and the balanced salt solution irrigation bottle has vancomycin compounded by the pharmacy that is also used for stromal hydration, Dr. Stiverson said. “About half of our cataract surgeons also inject moxifloxacin intracamerally at the end of the case,” he said. Results since changing protocols The results of changing the protocols were impressive. “We haven’t had a cataract surgery endophthalmitis in 6 years,” Dr. Stiverson said. “Prior to vancomycin we had about 1 endophthalmitis per 1,000 cases and then a spike to 2 per 1,000 cases, which led to a review of our procedures.” “If we have had good success with a particular way of doing things, it is very difficult to let go,” he said. “There has never been an inviolate standard of care for endophthalmitis,” Dr. Stiverson said. “Intracameral antibiotics make a difference.” Dr. Shorstein has become passionate about the potential vision savings that intracameral injection of antibiotics offer, especially as he has worked firsthand with the drugs and results of studies. “I think the biggest barrier to U.S. surgeons injecting intracamerals is procuring prepared drugs,” he said. He hopes that these drugs will become available soon, through the cooperation of the FDA and manufacturers of the drugs, because he sees major potential for benefits for patients. EWAP References 1. Barry P, Seal DV, Gettinby G, et al. ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32: 407–10. 2. Shorstein NH, Winthrop KL, Herrinton LJ. Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013; 39: 8–14. Editors’ note: Drs. Stiverson and Shorstein have no financial interests related to their comments. Contact information Shorstein: neal.shorstein@gmail.com Stiverson: rkstiverson@live.com