January 2017

 

CATARACT

 

Experts discuss 2016 ASCRS antibiotics survey


by Liz Hillman EyeWorld Staff Writer

 
   
Diagram choices antibiotic

One question the survey asked was, “If you use an antibiotic during routine cataract surgery, which of the following is your antibiotic of choice?” Source: ASCRS

ASCRS members asked about antibiotic practices

Most ophthalmologists use some form of antibiotic prophylaxis in cataract surgery cases to prevent vision- threatening infections. With a wide range of practices that have evolved over the last 20 years, just how are ophthalmologists using antibiotics prophylactically? The ASCRS Research Council sought answers to these questions in a July 2016 survey. The results of this survey, as described in “Report for Antibiotic Eyedrop Regimen for Cataract Surgical Patients Survey,” will be used to help inform a prospective, randomized, controlled trial to establish level 1 evidence for the use of antibiotic prophylaxis in cataract surgery. The report is available at ascrs.org/node/28067. “I think the creation of the Research Council is part of ASCRS’ continued growth forward. ASCRS is a phenomenal organization already for education and advocacy,” said the council’s chairman, Douglas Rhee, MD, Department of Ophthalmology and Visual Sciences, University Hospitals, Cleveland. “It has been a forum for the discussion of research … but I think one of the next steps in the evolution of the organization is to initiate and facilitate research that will change the way we practice ophthalmology. One of the long-term questions that has been out there has … to do with the prophylactic use of antibiotics after cataract surgery.” As Bonnie Henderson, MD, clinical professor of ophthalmology, Tufts University School of Medicine, Boston, put it, this survey is important to help understand practice patterns in order to evaluate the effectiveness of those methods. “This survey can be used as a starting point to investigate whether the route and/or type of antibiotic is related to the development of endophthalmitis. Once we understand what is being done currently, we can track any changes in incidence rates if practice patterns change,” Dr. Henderson said. The survey, completed by 556 domestic ASCRS members, found that 75.1% prescribed ophthalmic drops preoperatively and postoperatively; the remaining 24.9% only administered drops immediately before surgery and postoperatively. The most popular preop topical antibiotic of choice was moxifloxacin (39.9%), followed by the “other” category (27.6%), in which respondents noted drugs like besifloxacin and ofloxacin (18.9%). Most of the respondents said they begin antibiotics for routine cataract surgery 3 days preop (36.6%). About 22.6% begin antibiotics 1 day preop, and 22.0% start them on the day of surgery.

The survey also asked about dosage of drops and length of time patients are instructed to continue drops postop. The majority of respondents said they have patients start a postop regimen the same day as surgery, if not immediately afterward. The majority prescribe drops for 1 week, and 54.5% recommend dosing four times a day. Of antibiotics used during routine cataract surgery, 31.3% of respondents used moxifloxacin, 22.1% vancomycin, 6.0% cefuroxime, and 40.6% “other,” with most in the latter group stating they didn’t use antibiotics during routine cataract surgery. Of those who did use antibiotics during surgery, 35.9% said they performed an anterior chamber injection, 9.7% administered via the irrigating bottle, and 7.3% injected into the posterior chamber. Neal H. Shorstein, MD, Departments of Ophthalmology and Quality, Kaiser Permanente, Walnut Creek, California, said the study shows an immediate opportunity to update surgeons on the recommended prescribing patterns of topical drops. The randomized control trial of intracameral cefuroxime conducted by the European Society of Cataract and Refractive Surgeons in 2007 showed no benefit of preoperative administration of the fourth generation fluoroquinolone levofloxacin, Dr. Shorstein said, explaining that the ASCRS survey revealed 84% of respondents are prescribing preop drops. “Povidone-iodine instillation on the eye at the time of prep renders this practice unnecessary,” he said. He added that the surgeons prescribing antibiotic drops for 2 weeks or more after surgery (16%) could increase antibiotic resistance of organisms on the eyelid, which could pose a problem should the second eye be operated on within a short time frame. David F. Chang, MD, Los Altos, California, shared his thoughts about the survey results, focusing on intracameral antibiotic prophylaxis. He noted that the survey was initiated just prior to ASCRS and the American Society of Retina Specialists issuing a clinical alert on hemorrhagic occlusive retinal vasculitis (HORV), which was reported in 36 eyes of 23 patients who had received intraocular vancomycin. As such, Dr. Chang said he would expect that intracameral vancomycin use has dropped since that time. Among other observations, Dr. Chang noted the continued drop in intraocular antibiotics being administered through the irrigating bottle. Prior ASCRS surveys showed that of those surgeons employing intraocular antibiotic prophylaxis, 48% used the irrigating bottle in 2007 compared to only 16% in 2014, and 18% in the current survey. Francis Mah, MD, Scripps Clinic, La Jolla, California, said the results of the survey, overall, were what he would have expected, but he was “pleasantly surprised” to see a larger number of respondents using intracameral antibiotics. “I was happy that the medical literature has swayed a lot of people into intracamerals. I thought it would have been a lower number,” he said. Dr. Henderson said based on these numbers, “intracameral antibiotics appear to be becoming the standard of care in the U.S.” Dr. Shorstein said the uptick of this practice “points out the need to continue pursuit of an FDA-approved drug.” The Research Council is designing a trial that “will definitively show the benefit of antibiotic prophylaxis, and we’re looking at both topical vehicle delivery systems and intraocular,” Dr. Rhee said.

Dr. Mah thinks this is an important issue to research as well. “There is not in the United States an FDA-approved, commercially available medication, regardless of if it’s drops or intracameral, that’s approved for prophylaxis of endophthalmitis or post-cataract surgery infections,” Dr. Mah said. “I think U.S. surgeons deserve a medication or at least some proof to support the use of these medications.”

References

1. Chang DF, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg. 2007;33:1801–5.

2. Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg. 2015;41:1300–5.

Editors’ note: Dr. Mah has financial interests with Bausch + Lomb (Bridgewater, New Jersey), Alcon (Fort Worth, Texas), and Allergan (Dublin, Ireland). Drs. Chang, Henderson, Rhee, and Shorstein have no financial interests related to their comments.

Contact information

Chang
: dceye@earthlink.net
Henderson: bahenderson@eyeboston.com
Mah: Mah.Francis@scrippshealth.org
Rhee: dougrhee@aol.com
Shorstein: nshorstein@eyeonsight.com

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Experts discuss ASCRS antibiotics survey Experts discuss ASCRS antibiotics survey
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