September 2009

 

CATARACT/ IOL

 

Perspective on IC cefuroxime


by Matt Young EyeWorld Contributing Editor

   

Two views of post-op endophthalmitis Source: Nick Mamalis, M.D.

While many Europeans were taken aback by the results of the European Society of Cataract and Refractive Surgery (ESCRS) endophthalmitis study—which demonstrated the efficacy of intracameral cefuroxime to prevent endophthalmitis—not many Americans were. A new survey notes that while 48% of European-based study respondents switched to using intracameral cefuroxime after publication of the ESCRS report, only 6% of ASCRS members were using the drug. Certainly, the intelligence of ASCRS members is not in question. Rather, the survey, by lead author Daniel M. Gore, M.R.C.Ophth., Moorfields Eye Hospital, London, suggests that while Europeans have good reason to switch and many have, there are also sufficient reasons to stay away from intracameral cefuroxime for the moment. The bottom line is that Dr. Gore’s survey of European ophthalmologists is worth a read, regardless of whether you want to consider the use of intracameral cefuroxime or just solidify your argument for why you don’t use it.

Survey says

Dr. Gore’s survey, published in the April 2009 issue of the Journal of Cataract & Refractive Surgery, was mailed in June 2008 to consultant members of the United Kingdom and Ireland Society of Cataract & Refractive Surgeons (UKISCRS). Ninety-eight members completed the survey. Indeed, a great many—48%—of respondents switched to using intracameral cefuroxime after publication of the ESCRS study, with a total of 55% reporting using the agent. Certainly, the ESCRS study’s favorable intracameral cefuroxime findings had a great impact in Europe, but they were not completely convincing. Although 95% of ophthalmologists surveyed claimed to know the recommendations of the ESCRS study, and 85% broadly agreed with them, some of these same surgeons were not embracing intracameral cefuroxime. Why? “Of those not using intracameral cefuroxime, 52% had no plans to use it, with the remaining 48% (19% of the total surveyed) planning to do so in the near future,” Dr. Gore reported. “One respondent was currently prohibited from using it by the relevant National Health Service Trust.”

It’s interesting that nearly half still intended to use intracameral cefuroxime but just hadn’t gotten around to it for some reason.

It’s also worthwhile noting the main fear among those who didn’t use the drug. “The most common reason cited for not using intracameral cefuroxime was the dilution risks associated with preparing the drug for injection in the absence of a commercially available preformulated preparation,” Dr. Gore reported. “If one were to be commercially produced, 67% of surgeons not currently using intracameral cefuroxime said they would do so.”

Although the benefits of intracameral cefuroxime were demonstrated in the ESCRS study, the lack of a commercial agent is restricting wider acceptance, Dr. Gore concluded.

Dr. Gore provided commentary as to the concerns about the ESCRS study itself, which also likely has prevented further uptake of intracameral cefuroxime. Although intracameral cefuroxime was shown to reduce post-op endophthalmitis from 0.26% to 0.06%, the study was performed at a time when the powerful fourth-generation fluoroquinolones were not available in Europe. “In 2003, the fourth-generation fluoroquinolones moxifloxacin and gatifloxacin were marketed outside Europe, potentially rendering the ESCRS’ choice out of date due to theoretical advantages in terms of bactericidal activity, ocular penetration, and pharmokinetics,” Dr. Gore noted. Evidence also suggests that fourth-generation fluoroquinolones have the upper hand in certain respects. “Although cefuroxime has good coverage against gram-positive organisms, there are significant absences in its gram-negative cover, notably some Enterococcus species and Pseudomonas,” Dr. Gore reported. “There are no in vivo published data directly comparing the efficacy of cefuroxime, moxifloxacin, and gatifloxacin; however, in vitro kill-curve studies show markedly greater bacteriocidal activity against staphylococcal strains for moxifloxacin compared with cefuroxime.”

Survey respondents here also highly criticized the ESCRS study (68% did so) for not analyzing subconjunctival cefuroxime, which has traditionally been a popular intraoperative antibiotic prophylaxis method in the United Kingdom. Given the limitations of the ESCRS study, and of intracameral cefuroxime itself, it’s understandable why some European ophthalmologists and many American ones aren’t switching to the drug as prophylaxis.

The fact remains that a “majority of UKISCRS members inject intracameral cefuroxime,” Dr. Gore noted. “Based on respondents’ answers, further uptake is expected if a commercially available preparation were available.”

Mark Packer, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., agreed that more surgeons in the U.S. as well would use an intracameral agent if it were approved by the Food and Drug Administration. “What makes people nervous about doing this on their own is that there is a risk of TASS [toxic anterior segment syndrome] from a homemade antibiotic preparation,” Dr. Packer said. “You don’t have a good level of scrutiny for how that’s being done.” Hence, using an intracameral agent also becomes a liability risk in the United States, he said. Interestingly, Dr. Packer does use vancomycin as an intracameral antibiotic. “I’ve been using that for 10 years,” Dr. Packer said. “I just put it in the irrigation fluid.” He noted there’s no need to go to a compounding pharmacy for this. Dr. Packer is more enthusiastic about vancomycin because of its broad activity against gram-positive organisms, which cause most cases of endophthalmitis. Finally, Dr. Packer said he believes the greatest agent used in the prevention of endophthalmitis isn’t an antibiotic at all. Rather, it’s 5% povidone iodine, which helps sterilize the surgical field. The second best agents are pre-op antibiotics, he said.

Intracameral antibiotics don’t make the top two most important methods of prophylaxis for Dr. Packer because turnover of the aqueous occurs quickly, so they don’t stay in the eye for very long, he said.

Editors’ note: Drs. Gore and Packer have no financial interests related to their comments.

Contact information

Gore: danielmgore@gmail.com
Packer: 541-687-2110, mpacker@finemd.com

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