Intracameral cefuroxime is best option for endophthalmitis prophylaxis, physician says

HONG KONG — Despite the fact that topical fluoroquinolones have become standard of care in the United States, intracameral perioperative antibiotic injections are the best route for prevention of postoperative endophthalmitis, according to a speaker here. Peter Barry, FRCS, made his case for why intracameral cefuroxime, and not topical fluoroquinolones, should be the standard of care for surgical prophylaxis during Cataract and Refractive Surgery Subspecialty Day, held prior to the World Ophthalmology Congress.

Peter Barry

"There can never be an ideal antibiotic for prophylaxis. Cefuroxime is the best for now," Dr. Barry said.

Dr. Barry acknowledged that cefuroxime is an old drug and is not effective against methicillin-resistant Staphylococcus aureus, Enterococcus and Pseudomonas. Furthermore, it is inexpensive and, therefore, is not a feasible financial option for a company to produce in the high numbers necessary. It is also not approved by the U.S. Food and Drug Administration.

However, "most importantly, it works," he said.

The efficacy and safety of cefuroxime have been proven in more than 8,000 patients who received the drug in the European Society of Cataract and Refractive Surgeons endophthalmitis study and in a study of 425,000 Swedish patients conducted by Mats Lundstrom and colleagues.

"Importantly, emerging resistance to fourth-generation fluoroquinolones would argue against their role in the future," Dr. Barry said.

He noted that he believes the popularization of latest-generation antibiotics such as gatifloxacin and moxifloxacin is too little too late, based on reports of their emerging resistance and on the use of the drugs in animal husbandry.

Dr. Barry said a study evaluating the efficacy of topical fluoroquinolones in a large cohort of patients would be desirable to provide an evidence-based standard for surgeons. Yet the prospect of undertaking such a study is "out of the question."

"You would need an enormous number of patients to prove equivalence, the cost would be prohibitive, recruiting patients would be very difficult, and the study would be superfluous unless ... there is something wrong with cefuroxime," he said.

Dr. Barry also outlined the results of the ESCRS endophthalmitis study, the results of which were released at the society's 2006 meeting in London. The study, which enrolled some 16,000 patients, found that cefuroxime injection lowers the chances of bacterial contamination by a factor of 5.

"This means that the risk rate is reduced to less than five in 10,000 cases," Dr. Barry said. He noted that the rate of infection, which was criticized in an editorial in Ophthalmology, is consistent with the Swedish study conducted by Dr. Lundstrom and colleagues.