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S. D. Cassard, E. W. Gower, D. E. Stare, J. M. Tielsch, O. D. Schein; Treatment for Endophthalmitis: Pathogens, Antibiotics, and Final Visual Acuity. Invest. Ophthalmol. Vis. Sci. 2010;51(13):2513.
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Endophthalmitis is a relatively rare but severe infection that can occur following cataract surgery. We report population-based results related to pathogens and treatment patterns.
Post-cataract surgery endophthalmitis cases were identified using 2003-2004 Medicare billing claims. Cases were then limited to individuals diagnosed in California, Florida, Illinois, Michigan and Texas. Treating physicians were contacted via telephone and requested to complete a questionnaire on clinical and microbiological data and to submit any relevant chart information. Materials were reviewed by two independent observers for confirmation of culture proven endophthalmitis.
507 cases of presumed endophthalmitis were confirmed. Among these, 447 (88%) had culture results available, and 268 (60%) of this subset were culture positive. 92% cultured gram-positive organisms, and 16 specimens cultured MRSA. 3 fungal cases were reported.The distribution of pathogens differed by age group. Among the 85+ age group, MRSA accounted for 15% of organisms versus 5% in the younger populations (p=.04). MRSA was more common among non-whites, accounting for 14% of all culture positive organisms compared to 5% within the white population (p=0.08). No differences in pathogen distribution were seen between men and women.Presenting visual acuity was 20/200 or worse for 92% of culture positive cases and for 79% of culture negative cases (p=0.0002). Culture positive compared to culture negative cases were more likely to undergo vitrectomy (64% vs. 44%, respectively; p<0.0001). 99% of both culture positive and culture negative cases received intravitreal vancomycin, usually in combination with ceftazidime (70%), amikacin (22%) or another antibiotic. 25% also received a systemic antibiotic. Final visual acuity was 20/200 or worse for 40% of culture positive cases compared to 29% of culture negative cases (p=0.02). Among culture positive cases, those treated with intravitreal vancomycin and amikacin were less likely to have poor visual acuity (20/200 or worse) at follow-up compared to other regimens (p=0.06).
Intravitreal injection with vancomycin, combined with either ceftazidime or amikacin, is the most common treatment regimen for post-cataract surgery endophthalmitis. Culture positive cases had poorer visual outcomes compared to culture negative cases. A trend towards better visual outcomes was found for culture positive cases treated with vancomycin combined with amikacin.
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