Cataract Surgery, Refractive Surgery, Retina/Vitreous

touchINSIGHT Antibiotic Stewardship in Ophthalmic Clinical Practice

Since the introduction of antibiotics, bacterial resistance has continued to pose an ongoing problem across all infectious diseases,1 and ocular infection pathogens are no exception. Antibiotic resistance in ophthalmology has become an important global health issue. A total of 4.5 million cataract surgeries are performed each year.2 These carry a risk of postoperative infection, particularly endophthalmitis, a severe sight-threatening inflammation of the eye.3,4 As a result, a number of common antibiotics are prescribed to prevent infections.5 Since up to 97% of ophthalmologists use post-operative antibiotics, this is equivalent to 61 million days per year of antibiotic exposure.6 Antibiotics are also used in the treatment of common ophthalmic infections such as acute infective conjunctivitis, which is one of the most common issues encountered in primary care and constitutes a significant healthcare burden.7 Antimicrobial resistance, which develops naturally through gene mutations, has been identified as a major healthcare threat worldwide, largely due to overuse and misuse of antibiotics. The presence of antibiotic resistance among ocular pathogens is a major concern, as it complicates the choice of antibiotic and may lead to treatment failure.8

The need for responsible use of antibiotics is increasingly recognised, and in recent years, the concept of antimicrobial stewardship has developed. Antibiotic stewardship has been defined in a consensus statement from the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the Pediatric Infectious Diseases Society as ‘coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration’.9

Santen have recently launched the Re-SOLVE Antibiotic Resistance initiative, which aims to promote antibiotic stewardship by recommending a set of actions which encourage the sustainable and effective use of antibiotics, including selection of an antibiotic therapy.10 In an expert interview, Mr Ali Mearza describes the aims of the RE-SOLVE initiative.

Q. Could you tell us a little about the aims of the Re-SOLVE antibiotic initiative?

The campaign launched in October 2020 and was dedicated to the importance and benefits of sustainable antibiotic use in ophthalmology.10 The Re-SOLVE campaign aims to rapidly and responsibly raise awareness of the threat of antibiotic resistance in ophthalmology; catalyse an environment of urgent action and antibiotic stewardship in the ophthalmology community; and promote awareness of, and access to, medical education opportunities and networks of helpful experts.

Q. What practical advice would you give to ophthalmologists in terms of the use of prophylactic antibiotics during and after cataract surgery, and infectious complications such as endophthalmitis?

During cataract surgery, there is now good evidence to support the use of povidone-iodine in the conjunctival sac prior to the commencement of surgery, followed by intracameral antibiotic (either cefuroxime or moxifloxacin) at the end of surgery.11,12 This has been showed to lower the incidence of endophthalmitis significantly. Following surgery, a short course of antibiotic x4/day for a week, makes more sense rather than a prolonged 4-week course as is the case still in many centres.

Q. What is the importance of selecting a therapy with short duration to minimise antibiotic use in everyday practice?

Short-term therapy (1 week) may be enough post-operatively as an additional measure above using povidone-iodine and intracameral antibiotics during cataract surgery. Additionally, no tapering – these two factors could positively impact the lowering antibiotic exposure and slow down the development of antibiotic resistance.

Q. How else can ophthalmologists select antibiotic therapies that will minimise antibiotic use in everyday practice?

It is important that, where possible, the most appropriate antibiotic is selected and used for the shortest duration of time possible. Most departments work closely with their microbiology colleagues to develop guidelines on the most appropriate use of antibiotics and these should be reviewed yearly in line with changes in antibiotic resistance. Antibiotics should not be used where not indicated, and ongoing training and education will help instil the message of appropriate use for the next generation of ophthalmologists.

References 

  1. World Health Organisation. Antimicrobial resistance. Available at: www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance (accessed 4 November 2020).
  2. Eurostat. Cataract surgery: how countries compare. Available at: https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20190108-1 (accessed 4 November 2020).
  3. Gower EW, Lindsley K, Tulenko SE, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev. 2017;2:Cd006364.
  4. Garg P, Roy A, Sharma S. Endophthalmitis after cataract surgery: epidemiology, risk factors, and evidence on protection. Curr Opin Ophthalmol. 2017;28:67–72.
  5. ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions 2013. Available at: www.escrs.org/downloads/Endophthalmitis-Guidelines.pdf (accessed 4 November 2020).
  6. Haripriya A. Antibiotic prophylaxis in cataract surgery – An evidence-based approach. Indian J Ophthalmol. 2017;65:1390–5.
  7. Ryder EC, Benson S. Conjunctivitis. [Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available at: Available from: www.ncbi.nlm.nih.gov/books/NBK541034/ (accessed 4 November 2020).
  8. Asbell PA, DeCory HH. Antibiotic resistance among bacterial conjunctival pathogens collected in the Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) surveillance study. PLoS One. 2018;13:e0205814.
  9. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the infectious diseases society of america and the society for healthcare epidemiology of America. Clin Infect Dis. 2016;62:e51–77.
  10. Santen joins forces with ophthalmologists in the fight against antibiotic resistance. Available at: www.santen.eu/our-vision/emea-news/santen-joins-forces-ophthalmologists-fight-against-antibiotic-resistance (accessed 4 November 2020).
  11. Ahmed Y, Scott IU, Pathengay A, et al. Povidone-iodine for endophthalmitis prophylaxis. Am J Ophthalmol. 2014;157:503–4.
  12. Titiyal JS, Kaur M. Role of intracameral antibiotics in endophthalmitis prophylaxis following-cataract surgery. Indian J Ophthalmol. 2020;68:688–91.

Author profile: Mr Ali Mearza is Director and founding partner of Ophthalmic Consultants of London, UK. He is also the Clinical Director of Ophthalmology at London’s Imperial College Healthcare NHS Trust, London, the UK’s first Academic Health Sciences Centre. His specialist interests are in laser and lens vision correction techniques, cataract surgery and corneal transplantation. He has a keen interest in clinical research and has over 30 peer-reviewed publications to his name and is an invited journal reviewer. His publications range from case reports, book chapters, clinical reviews and studies looking at new techniques and technologies. Many of his surgical techniques are featured on his YouTube channel which has over 300 000 views to date. He’s also featured in the media with television appearances on the Discovery Channel as well in mainstream media publications.

Disclosures: Ali Mearza has nothing to disclose in relation to this expert interview.

Support: Commissioned, edited and supported by Touch Medical Media, who commissioned the interview in liaison with Santen. Writing assistance was provided by Katrina Mountfort from Touch Medical Media.

Published: 27 January 2021

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