Incidence of Endophthalmitis and Use of Antibiotic Prophylaxis after Intravitreal Injections

doi:10.1016/j.ophtha.2012.02.014

Ophthalmology

Volume 119, Issue 8, August 2012, Pages 1609-1614

Presented at: Eleventh Euretina Congress, May 2011, London, England; 29th Annual Meeting of the Canadian Ophthalmology Society, June 2011, Vancouver, Canada; and the 115th Annual Meeting of the American Academy of Ophthalmology, October 2011, Orlando, Florida.

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Purpose

To report the incidence of endophthalmitis in association with different antibiotic prophylaxis strategies after intravitreal injections of anti–vascular endothelial growth factors and triamcinolone acetonide.

Design

Retrospective, comparative case series.

Participants

Fifteen thousand eight hundred ninety-five intravitreal injections (9453 ranibizumab, 5386 bevacizumab, 935 triamcinolone acetonide, 121 pegaptanib sodium) were reviewed for 2465 patients between January 5, 2005, and August 31, 2010. The number of injections was determined from billing code and patient records.

Methods

The indications for injection included age-related macular degeneration, diabetic macular edema, central and branch retinal vein occlusion, and miscellaneous causes. Three strategies of topical antibiotic prophylaxis were used by the respective surgeons: (1) antibiotics given for 5 days after each injection, (2) antibiotics given immediately after each injection, and (3) no antibiotics given.

Main Outcome Measures

The primary outcome measures were the incidence of culture-positive endophthalmitis and culture-negative cases of suspected endophthalmitis.

Results

Nine eyes of 9 patients with suspected endophthalmitis after injection were identified. Three of the 9 cases had culture-positive results. The overall incidence of endophthalmitis was 9 in 15 895. The incidence of culture-negative cases of suspected endophthalmitis and culture-proven endophthalmitis after injection was 6 in 15 895 and 3 in 15 895, respectively. Taking into account both culture-positive endophthalmitis and culture-negative cases of suspected endophthalmitis, the incidence per injection was 5 in 8259 for patients who were given antibiotics for 5 days after injection, 2 in 2370 for those who received antibiotics immediately after each injection, and 2 in 5266 who received no antibiotics. However, if considering culture-proven endophthalmitis alone, the use of topical antibiotics, given immediately or for 5 days after injection, showed lower rates of endophthalmitis compared with those without postinjection antibiotics. The risk of endophthalmitis after intravitreal injection varied among agents that were used. Among the 9 cases of clinically suspected endophthalmitis, regardless of prophylactic strategies used, the incidence of endophthalmitis per injection was 2 in 935 for triamcinolone acetonide, 3 in 9453 for ranibizumab, and 4 in 5386 for bevacizumab.

Conclusions

The overall rate of intravitreal injection-related endophthalmitis is greater with the use of topical antibiotics, given immediately or for 5 days after the injection, compared with no antibiotics.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Patients and Methods

This study protocol was approved by the research ethics boards of both study sites. Consecutive cases of patients who received intravitreal injections of 2 and 4 mg triamcinolone acetonide (Kenalog-40; Bristol-Myers Squibb, Princeton, NJ), 1.25 mg bevacizumab (Avastin; Roche, Mississauga, ON), 0.5 mg ranibizumab (Lucentis; Novartis, Dorval, QC), and 0.3 mg pegaptanib (Macugen; Eyetech/Pfizer, New York, NY) between January 2005 and August 2010 were reviewed retrospectively. Patients included in

Results

A total of 15 895 intravitreal injections (9453 ranibizumab, 5386 bevacizumab, 935 triamcinolone acetonide, 121 pegaptanib) were performed for 2465 patients between January 2005 and August 2010. Of the 15 895 injections, 13 430 were reinjections. Nine eyes of 9 patients with suspected endophthalmitis were identified, and 3 of these cases demonstrated positive culture results. The mean age of the study patients was 72.2 years. Patients were examined after an average of 3.6 days after the

Discussion

The current management of age-related macular degeneration and diabetic macular edema is not curative and requires prolonged monthly or nearly monthly intravitreal injections. The most severe complication of this procedure is endophthalmitis, and accordingly, more than two thirds of retinal specialists reported the use of topical antibiotics after injection in a recent survey.¹² However, there is a lack of evidence to demonstrate the effectiveness of topical antibiotics in reducing the risk of

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: Manuscript no. 2011-1394.

: Financial Disclosure(s): The author(s) have made the following disclosure(s): Wai-Ching Lam - Consultant - Allergan; Financial support - Novartis, Snell Publishing

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Original articleIncidence of Endophthalmitis and Use of Antibiotic Prophylaxis after Intravitreal Injections

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Patients and Methods

Results

Discussion

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Lancet Infect Dis

Surv Ophthalmol

Am J Ophthalmol

Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection

Retina

Reducing the risk of endophthalmitis following intravitreal injections

Retina

The International Intravitreal Bevacizumab Safety Survey: using the internet to assess drug safety worldwide

Br J Ophthalmol

Ranibizumab versus verteporfin for neovascular age-related macular degeneration

N Engl J Med

Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required: the Diabetic Retinopathy Clinical Research Network Laser-Ranibizumab-Triamcinolone Clinical Trials

Arch Ophthalmol

Prophylactic antibiotic use after intravitreal injection: effect on endophthalmitis rate

Retina

Original article
Incidence of Endophthalmitis and Use of Antibiotic Prophylaxis after Intravitreal Injections