Causative Pathogens of Endophthalmitis after Intravitreal Anti-VEGF Injection: An International Multicenter Study

Abstract

Purpose: The main objective of this study was to investigate the microbiological spectrum of endophthalmitis after anti-VEGF injections and to compare streptococcal with non-streptococcus-associated cases with regard to baseline characteristics and injection procedure. Methods: Retrospective, international multicenter study of patients with culture-positive endophthalmitis after intravitreal anti-VEGF injection at 17 different retina referral centers. Results: Eighty-three cases with 87 identified pathogens were included. Coagulase-negative staphylococci (59%) and viridans streptococci (15%) were the most frequent pathogens found. The use of postoperative antibiotics and performance of injections in an operating room setting significantly reduced the rate of streptococcus-induced endophthalmitis cases (p = 0.01 for both). Conclusion: We found a statistically significant lower rate of postinjectional local antibiotic therapy and operating room-based procedures among the streptococcus-induced cases compared to cases caused by other organisms.

The Effect of Syringe-Filling Technique on the Risk for Endophthalmitis after Intravitreal Injection of Anti-VEGF Agents

“…This is according to the policy of the national health system in Israel, in which bevacizumab is the mandated first-line anti-VEGF agent used for all indications, and switching to other agents is approved only for cases with inadequate response. The distribution of cultured bacteria in this study is also compatible with the current literature, as other works have reported the majority of post-injection endophthalmitis to be caused by staphylococci and streptococci [20,21].…”

“…A large study that included 1,095,305 injections reported significantly lower rates of endophthalmitis following bevacizumab injections that were performed with a pharmacy-prepared prefilled syringe than following ranibizumab and aflibercept injections in which the drug was directly drawn by the physician [22]. Additionally, there was no difference in risk of endophthalmitis between ranibizumab and bevacizumab [21]. These studies indicate that the reduction in risk of endophthalmitis should be attributed to the use of prefilled syringes and not to the injected drugs.…”

Management Patterns and Outcomes for Intravitreal Injection–Related Endophthalmitis

“…In our cohort, 30% of cases were culture positive, which was consistent with the range of 30% to 60% described in previous reports. 22,[24][25][26][27] Although culture-positive and culture-negative cases in our study did not significantly differ in VA at presentation or at 6 months, Xu et al have found in a larger cohort that culture-positive cases are more likely to have worse VA. 27 As in other studies, 3,27,28 the most commonly isolated organism in our cohort was coagulase-negative Staphylococcus, with other cases growing S viridans, S maltophilia, and P acnes. Other studies have suggested that S viridans-associated endophthalmitis may be due to aerosol contamination from oral or respiratory flora during intravitreal injection and is often associated with a more severe clinical course.…”

Endophthalmitis Caused by <b><i>Agrobacterium radiobacter</i></b> following Intravitreal Aflibercept for Diabetic Retinopathy

“…Although rare, endophthalmitis is a feared complication of anti-VEGF treatment, with an incidence ranging from 0.013% to 0.061% [2][3][4]. The most frequently identified pathogens causing endophthalmitis after intravitreal anti-VEGF treatment are coagulase-negative staphylococci, Streptococcus viridans, and Staphylococcus aureus [2,5], with significant vision loss often associated with streptococcus infection [2]. The most significant risk factor for endophthalmitis is violation of aseptic technique during injection [6][7][8][9].…”