Postoperative nosocomial endophthalmitis: is perioperative antibiotic prophylaxis advisable? A single centre’s experience

Summary

We report the endophthalmitis rate after cataract surgery in patients preoperatively given topical povidone-iodine and gentamicin-containing irrigation fluid as prophylaxis without intracameral cefuroxime or perioperative topical antibiotics. In a retrospective clinical study, we included patients undergoing cataract surgery over a 12-year period at one large university teaching hospital. Data from 26 566 cataract procedures were analysed. Cases of postoperative endophthalmitis were identified and diagnosed both clinically and microbiologically. A total of 26 566 cataract procedures were reviewed, and we identified 16 patients with postoperative endophthalmitis (rate: 0.6 per 1000 operations, or 0.06%; 95% confidence interval: 0.03–0.09%). A causative micro-organism was detected in 81.3% (13/16) of the cases. Most organisms were Gram-positive bacteria (10/13) with susceptibility to cefuroxime (9/10) and/or fluoroquinolones (4/8), and/or resistance to aminoglycosides (10/10). The three Gram-negative pathogens were susceptible to cefuroxime, aminoglycosides, and fluoroquinolones. Using our regimen of topical povidone-iodine and gentamicin irrigation, we observed a low postoperative endophthalmitis rate not differing from the infection rates recently reported in other large studies. We speculate that neither intracameral cefuroxime nor perioperative levofloxacin eye drops are necessary to minimise postoperative infectious complications following cataract surgery, and we suggest that the European Society of Cataract and Refractive Surgery guidelines (in which perioperative antibiotics are mandatory) therefore be revisited to permit alternative effective regimens for the prevention of postoperative infections following cataract surgery.

Introduction

Postoperative endophthalmitis is a serious complication following intraocular surgery. The incidence rates vary between <1 and almost 4 cases per 1000.1, 2, 3, 4, 5, 6, 7, 8, 9 Several procedures have been proposed for the prevention of postoperative endophthalmitis, including the topical application of antiseptics such as PVP (povidone)-iodine and chlorhexidine and/or the perioperative administration of antibiotics, either topically preoperatively, intracamerally, intraoperatively by irrigation while performing cataract surgery, postoperatively or even systemically.10, 11, 12, 13 The bacteria causing postoperative endophthalmitis are usually found among the normal bacterial flora of the patient’s conjunctiva and eyelid.¹⁴ A multicentre study performed in 2007 investigated the prophylactic effect of administering perioperative antibiotics and applying cefuroxime intracamerally.¹⁵ Those results provided the basis for the European Society of Cataract and Refractive Surgery’s (ESCRS) new guideline.¹⁶ The authors recommended fluoroquinolone six-hourly on the preoperative day and immediately before surgery, as well as povidone-iodine, 1 mg cefuroxime intraoperatively, fluoroquinolone every 1–2 h postoperatively, and six-hourly over the following 1–2 weeks. As an alternative to fluoroquinolone, they cite the application of polymyxin B/bacitracin/neomycin or chloramphenicol.¹⁶

There is ongoing debate about the clinical consequences of the ESCRS study, in particular concerning their guidelines and recommendations not corresponding to the study results.¹⁷ We therefore analysed retrospectively the endophthalmitis rate in our patients without pre- and postoperative antibiotic prophylaxis and discuss here the ESCRS guidelines in light of our results from an epidemiological and pharmacological perspective.