Risks of Cefuroxime Prophylaxis for Postcataract Endophthalmitis

Exploring the safety and feasibility of intracameral Aprokam® (cefuroxime sodium) in pediatric cataract surgery

PURPOSE

To describe the safety and assess the feasibility of using intracameral cefuroxime sodium (Aprokam®) during congenital cataract surgery as a preventive measure for endophthalmitis.

DESIGN

Monocentric, prospective, observational pilot study.

SETTING

San Giuseppe Hospital, University of Milan, Milan, Italy.

STUDY POPULATION

Pediatric patients with a mean age of 21.4 ± 40.52 weeks with congenital cataracts. 65 eyes from 65 patients, i.e. only one eye for each patient was included in the study. At the end of the surgery, patients received the administration of intracameral Aprokam. The efficacy endpoint was assessed by excluding postoperative intra-ocular infections, while the safety endpoint was assessed by recording vital signs (body temperature, heart rate, blood pressure, respiratory rate) and local effects (corneal edema, toxic anterior segment syndrome, presence of cells or fibrin formation in anterior chamber, intraocular pressure, conjunctival hyperemia) after the administration of the substance.

RESULTS

Aprokam intracameral administration at the end of the cataract surgery prevented the occurrence of intraocular infection in all of our patients. Among the analyzed systemic parameters, breath frequency was the only one showing a statistically significant increase after the drug delivery (∆(post-pre) 0.4 breaths/minute ± 1.74; p = 0.022). Regarding the local adverse effects, a statistically significant increase of intraocular pressure has been detected from the first week (∆7 days-1 day: 0.9 mmHg ± 2.28, p = 0.042), and remained constantly elevated in the first month. The presence of conjunctival hyperemia noticed in the first week after surgery showed a significant decrease over time, with a statistically significant reduction after one month (8 cases vs 0, p = 0.009).

CONCLUSIONS

Intracameral administration of Aprokam in pediatric cataract surgery appears safe and promising as a preventive measure for post-operative endophthalmitis. It may be considered suitable for an optimal post-operative management of intra-ocular post-operative infections in congenital cataract surgery.

Repositioning of Antibiotics in the Treatment of Viral Infections

Drug repurposing, also known as drug repositioning, is a currently tested approach by which new uses are being assigned for already tested drugs. In this case there are antibiotics that are used to combat bacterial infections. However, antibiotics are among the drugs that have been studied for possible antiviral activities. Therefore, the aim of this work is to carry out a review of the studies of antibiotics that could be repositioned for the treatment of viral infections. Among the main antibiotics that have demonstrated antiviral activity are macrolides and glycopeptides. In addition, several antibiotics from the group of tetracyclines, fluoroquinolones, cephalosporins and aminoglycosides have also been studied for their antiviral activity. These antibiotics have demonstrated antiviral activity against both RNA and DNA viruses, including the recent pandemic virus SARS-CoV-2. Some of these antibiotics were selected in addition to its antiviral activity for their immunomodulatory and anti-inflammatory properties. Of the antibiotics that present antiviral activity, in many cases the mechanisms of action are not exactly known. The use of these antibiotics to combat viral infections remains controversial and is not generally accepted, since clinical trials are required to prove its effectiveness. Therefore, there is currently no antibiotic approved as antiviral therapy. Hence is necessary to present the studies carried out on antibiotics that can be repositioned in the future as antiviral drugs.

The Routine Use of Intracameral Antibiotics to Prevent Endophthalmitis After Cataract Surgery: How Good is the Evidence?

Post-operative endophthalmitis (POE) following cataract surgery is an uncommon, vision-threatening complication that has been reported to occur at rates of between approximately 0.03% and 0.2%. Prompt diagnosis and treatment of endophthalmitis is critical for minimizing vision loss, but most recent efforts have focused on the prophylactic administration of antibiotics to prevent the development of endophthalmitis. Surgeons from around the world have different topical and intracameral antibiotic usage patterns to prevent endophthalmitis, and to date no general consensus regarding best practice has emerged. Several studies have reported on the routine use of intracameral cefuroxime, moxifloxacin, and vancomycin, including a single randomized clinical trial by the European Society of Cataract and Refractive Surgery (ESCRS) in 2007. These studies have notable shortcomings, but many authors suggest that intracameral cefuroxime together with topical antibiotics probably decreases the risk of endophthalmitis. However, the deleterious effects of routine prophylactic antibiotics, which include toxicity, cost, and increasing antimicrobial resistance, among others, are noteworthy. In contrast, aseptic technique with pre-operative instillation of povidone-iodine remains the only technique supported by level I evidence to reduce the incidence of endophthalmitis. Although the routine use of intracameral antibiotics continues to increase throughout the world, data from multicenter, randomized, prospective trials is needed to provide better guidance regarding the prophylactic use of antibiotics.

Antibiotic prophylaxis in cataract surgery - An evidence-based approach

Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.