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Intracameral AB


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Intracameral AB

  1. 1. T O R K R Y T H A 2 N D Y E A R R E S I D E N T INTRACAMERAL ANTIBIOTICS 1 University of Health and Sciences
  2. 2. INTRACAMERAL ANTIBIOTICS Intracameral injection delivers antibiotic directly to aqueous humor in concentrations far grater than are achieve after either topical drops or subconjunctival injection For endophthalmitis prophylaxis The most common use of intracameral prophylaxis Cephalosporin Vancomycin Moxifloxacin 2
  3. 3. ENDOPHTHALMITIS VITRECTOMY STUDY 94.2% of culture-positive endophthalmitis cases involved gram-positive bacteria Staphylococcus epidermidis (70%) Staphylococcus aureus (9.9%) Streptococcus (9.0%) Other gram positive (3%) Enterococcus (2.2%) Gram negative (5.9%) 3
  4. 4. MOXIFLOXACIN An improved spectrum of coverage, higher potency, delayed antibiotic resistance, better tissue penetration, and excellent efficacy, especially against gram-positive bacteria Good activity against gram-negative bacteria and improved coverage of gram-positive cocci and atypical pathogens. 4
  5. 5. CEPHALOSPORINS Cephalosporins are divided into 4 generations. First: gram-positive bacteria Third- and fourth: gram-negative Second: has a broad-spectrum antibiotic that covers most gram-positive and gram-negative organisms, with the exception of methicillin-resistant Staphylococcus aureus (MRSA). 5
  6. 6. CEPHALOSPORINS Cefuroxime is a second-generation cephalosporin Similar to other beta-lactam antibiotics, it inhibits cell- wall synthesis. Cefuroxime's bactericidal activity is concentration- dependent and occurs at concentrations that are 4 to 5 times higher than the minimum inhibitory concentrations (MICs). 6
  7. 7. CEPHALOSPORINS Cefuroxime less potent against S aureus and more potent against S pneumoniae and S pyogenes than first- generation cephalosporins. Cefuroxime is active against Haemophilus influenzae; Moraxella catarrhalis; Escherichia coli ; Proteus mirabilis ; Klebsiella ; b -lactamase-producing penicillinase- positive and -negative strains of Neisseria gonorrhoeae ; and the Enterobacteriaceae Salmonella , Citrobacter , Enterobacter , and Shigella species 7
  8. 8. VANCOMYCIN Vancomycin is a bactericidal antibiotic with virtually 100% coverage of gram-positive endophthalmitis- causing organisms. In vitro studies have reported that vancomycin was bacteriostatic for the first 6 hours and became bactericidal only after 8 hours, a finding that is consistent with its mechanism of action that blocks cell-wall synthesis Ferro JF, de-Pablos M, Logro~no MJ, Guisasola L, Aizpuru F. Postoperative contamination after using vancomycin and gentamicin during phacoemulsification. Arch Ophthalmol 1997; 115:165–170 8
  9. 9. VANCOMYCIN Choice for serious gram-positive cocci infections when their is resistant to multiple drugs. Active against S epidermidis , S aureus (methicillin sensitive and resistant), and most strains of Streptococcus . Also effective against the anaerobes, diphtheroids, and the Clostridium species, including C difficile 9
  11. 11. EFFICACY Espiritu et al.9 Intracameral dose for moxifloxacin 100mcg – 500mcg; in comparison, the dose of Intracameral cefuroxime shown to be safe and effective is 1mg, at least two times higher than moxifloxacin. ESCRS study confirm the clinical efficacy of Intracameral cefuroxime against most commonly encourntered bacterial strains in postoperative endophthalmitis 11
  12. 12. COMPLICATIONS Corneal endothelial toxicity Toxic anterior segment syndrome (TASS): acute sterile postoperative inflammation that can follow anterior segment surgery. Dilution errors are more likely when multiple steps are required to prepare the antibiotic solution. Both anterior and posterior segment inflammation 12
  13. 13. Vigamox eyedrops (moxifloxacin 0.5%) are preservative- free and isotonic, with a 6.8 pH and an osmolality of approximately 290 mOsm/kg. Because these values are similar to those of aqueous (pH 7.4, osmolality 305 mOsm./Kg.) using this topical solution has not been associated with ocular toxicity at full strength or with a 50:50 dilution in balanced salt solution for intracameral injection 13
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  15. 15. Kowalski et al.31 also found that intracameral injection of commercial Vigamox was nontoxic and effective in preventing endophthalmitis from S aureus in a large trials that evaluate the clinical efficacy of antibiotic prophylaxis with moxifloxacin or vancomycin. 15
  16. 16. REFERENCE ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery: Data, Dilemmas and Conclusions 2013 Intracameral antibiotics: Safety, efficacy, and preparation Rosa Braga-Mele, MD, David F. Chang, MD, Bonnie An Henderson, MD, Nick Mamalis, MD, Audrey Talley-Rostov, MD, Abhay Vasavada, MD, for the ASCRS Clinical Cataract Committee 16