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Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery

  • Neal H. Shorstein
    Correspondence
    Inquiries to Neal H. Shorstein, 320 Lennon Lane, Walnut Creek, CA 94598, USA
    Affiliations
    From the Departments of Ophthalmology and Quality, Kaiser Permanente, Walnut Creek, California, USA (N.H.S.), Division of Research, Kaiser Permanente Northern California, Oakland, California (L.L, L.H.), Department of Ophthalmology, Kaiser Permanente San Rafael, California (J.A.C.)
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  • Liyan Liu
    Affiliations
    From the Departments of Ophthalmology and Quality, Kaiser Permanente, Walnut Creek, California, USA (N.H.S.), Division of Research, Kaiser Permanente Northern California, Oakland, California (L.L, L.H.), Department of Ophthalmology, Kaiser Permanente San Rafael, California (J.A.C.)
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  • James A. Carolan
    Affiliations
    From the Departments of Ophthalmology and Quality, Kaiser Permanente, Walnut Creek, California, USA (N.H.S.), Division of Research, Kaiser Permanente Northern California, Oakland, California (L.L, L.H.), Department of Ophthalmology, Kaiser Permanente San Rafael, California (J.A.C.)
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  • Lisa Herrinton
    Affiliations
    From the Departments of Ophthalmology and Quality, Kaiser Permanente, Walnut Creek, California, USA (N.H.S.), Division of Research, Kaiser Permanente Northern California, Oakland, California (L.L, L.H.), Department of Ophthalmology, Kaiser Permanente San Rafael, California (J.A.C.)
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Published:February 08, 2021DOI:https://doi.org/10.1016/j.ajo.2021.02.007

      Highlights

      • No statistical difference exists in endophthalmitis rate between moxifloxacin and cefuroxime.
      • Successful endophthalmitis prophylaxis depends on intracameral moxifloxacin dose.
      • Intracameral cefuroxime does not cover Enterococcus and Pseudomonas.

      Purpose

      To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery.

      Design

      Retrospective clinical cohort study.

      Methods

      We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV).

      Results

      Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin.

      Conclusions

      Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.
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