Intracameral cefuroxime and moxifloxacin used as endophthalmitis prophylaxis after cataract surgery: systematic review of effectiveness and cost-effectiveness

Abstract

Postoperative endophthalmitis is one of the most serious potential complications of ocular lens surgery. Its incidence can be reduced by means of antibiotic prophylaxis. Although the prophylactic use of intracameral cefuroxime has been extended, other drugs, such as moxifloxacin, have arisen as alternatives. We performed a systematic literature review on the effectiveness and efficiency of intracameral cefuroxime and moxifloxacin for the prophylaxis of postoperative endophthalmitis after cataract surgery. Several bibliographic databases were searched up to October 2010 and were updated up to January 2013. Outcomes were the onset of endophthalmitis after surgery and the cost-effectiveness ratio of using both antibiotic prophylaxis alternatives. The following were included: a clinical trial reported in two papers, six observational studies, and an economic evaluation. All studies assessed cefuroxime compared with another antibiotic prophylaxis or no prophylaxis. The only randomized controlled trial performed by the European Society of Cataract and Refractive Surgery found that intracameral cefuroxime is significantly more effective than not using prophylaxis or the use of a topical antibiotic. The observational studies support these results. The economic evaluation compared different prophylaxis regimens and concluded that intracameral cefuroxime showed the best cost-effectiveness ratio. Both the observational studies and the economic evaluation have methodological limits that reduce their validity. This review confirmed that cefuroxime can prevent endophthalmitis after cataract surgery. Further randomized controlled trials, with large sample sizes, are required to compare different antibiotic prophylaxis regimens.

An updated estimate of costs of endophthalmitis following cataract surgery among Medicare patients: 2010–2014

“…The rate of endophthalmitis has remained steady over time, suggesting the use of antibiotic prophylaxis has been an important prevention protocol 18,19,21,41. Studies that have empirically explored costs associated with prophylactic antibiotic treatment have consistently identified benefits, although most of these studies and cost analyses were conducted outside the United States 21,42,43.…”

“…Studies that have empirically explored costs associated with prophylactic antibiotic treatment have consistently identified benefits, although most of these studies and cost analyses were conducted outside the United States 21,42,43. Perhaps the most challenging aspect of understanding the effectiveness of antibiotic prophylaxis is that, as Gower et al point out,44 few studies have been powered sufficiently to detect differences in this fairly uncommon infection.…”

“…Rates have decreased from 0.31%–1.24% to as low as 0.01%–0.08% with intracameral cefuroxime use 46. Studies that have considered cost-effectiveness in other countries suggest that prophylaxis may be cost-effective 21,47. The low cost associated with a topical antibiotic administered before and/or after surgery, which may be decreasing as products that do not require compounding become available,48 may be a reasonable trade-off for avoiding the substantial costs associated with postoperative endophthalmitis in a United States Medicare population 21,47…”

“…Based on the findings from the Endophthalmitis Vitrectomy Study (EVS),13 the American Academy of Ophthalmology now recommends prophylactic treatment with antibiotic agents for individuals undergoing ophthalmic surgery 20. Studies have even started to compare the cost-effectiveness among prophylactic treatments, with the underlying assumption that prophylaxis is economically defensible and the question is simply which treatment to offer 21–23…”

Intracameral Antibiotics in the Shadow of Hemorrhagic Occlusive Retinal Vasculitis

“…Systematic reviews and meta-analyses have corroborated the cumulative evidence supporting the efficacy of ICAs in preventing POE. 25–28 …”