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BLOG: What are we doing and what should we be doing to prevent infection?
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Ten years ago, the prevailing sentiment among anterior segment surgeons was that the best way to prevent infection from aggressive bacteria was to use “fourth-generation” fluoroquinolone eye drops.
That was before methicillin-resistant Staphylococcus aureus (MRSA).
The 2013 ARMOR study showed us that nearly half of S. aureus and S. epidermidis isolates causing ocular infections may be methicillin-resistant. MRSA in particular is highly pathogenic on the ocular surface, and a number of case reports have described corneal melts leading to perforation within days of PRK or other procedures.
So, what are surgeons doing now to prevent infection? Many anterior segment surgeons, including myself, routinely use Polytrim (polymyxin B and trimethoprim, Allergan) as our agent of choice because of its broad-spectrum coverage and excellent, if not complete, coverage against MRSA. Polytrim is extremely inexpensive, gentle on the ocular surface, and rarely causes allergy. Besifloxacin, a unique fluoroquinolone with activity against MRSA that is nearly equivalent to vancomycin, may be another choice, although its DuraSite vehicle has been associated with delayed healing in PRK when it is trapped beneath a contact lens and in LASIK when in the flap interface.
That’s what many surgeons are doing, but what should we be doing? In the case of PRK or ocular surface surgery, it’s reasonable to consider using Polytrim plus a second antibiotic, perhaps a fluoroquinolone, for better gram-negative coverage, as suggested in the cover story of this issue of OSN. Doing so, however, adds to the cost and complexity of surgery and creates compliance problems.
For intraocular surgery, only about one-third of U.S. surgeons are using intracameral antibiotics, according to the 2016 ASCRS clinical survey of U.S. surgeons. This is despite ample evidence from Europe and other large studies that intraocular cefuroxime or moxifloxacin dramatically reduced postoperative endophthalmitis compared with topical therapy alone. When surveyed, most surgeons report that they choose not to use intracameral antibiotics because no FDA-approved formulation exists; many surgeons are appropriately wary of compounded medications. In my own practice, we use topical Polytrim or besifloxacin for routine cataract patients coupled with intraocular moxifloxacin for high-risk patients in whom compliance or hygiene is in question.
Whether for ocular surface or intraocular surgery, we need better antibiotic options. Meanwhile, making reasonable choices with affordable, broad-spectrum antibiotics, coupled with individualized antibiotic regimens for high-risk patients, makes perfect sense.
Disclosure: Hovanesian reports he is a consultant to Bausch + Lomb, which makes Besivance (besifloxacin).