Ophthalmic surgery prophylaxis - Guideline for antimicrobial prophylaxis and prevention of infection following

Publication: 30/03/2011  
Last review: 12/12/2017  
Next review: 16/10/2020  
Clinical Guideline
CURRENT 
ID: 2335 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Guideline for antimicrobial prophylaxis and prevention of infection following ophthalmic surgery in adults

  1. Summary table of routine recommendations
  2. Background information
  3. General preventative measures
  4. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

Procedure

Antimicrobial prophylaxis recommended?

Evidence level

Prophylaxis aims to reduce

NNT

Antimicrobial dose/route

Routine

MRSA risk* or true cephalosporin allergy

Cataract surgery

YES

A1

endophthalmitis

451

Intra-cameral injection of Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime1mg in 0.1ml at the end of surgery.

Topical Chloramphenicol 0.5 % qds 3/7 (for patients with blepharitis, significant epithelial damage or sub-tenons local anaesthetic injection)

intra cameral injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin 1mg in 0.1ml at the end of surgery.

Topical Chloramphenicol 0.5% qds 3/7 (for patients with blepharitis, significant epithelial damage or sub-tenons local anaesthetic injection)

Penetrating corneal surgery

YES

B1

endophthalmitis

NK

As above

As above

Lacrimal Surgery

YES

C1

Wound infection

9

Chloramphenicol ointment single application post operation

Chloramphenicol ointment single application post operation

Penetrating eye injury (posterior segment)

YES

C1

endophthalmitis

18

intra vitreal injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin1mg in 0.1ml PLUS Ceftazidime Description: electronic Medicines Compendium information on Ceftazidime 2mg in 0.1ml at the end of surgery.

intra vitreal injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin1mg in 0.1ml PLUS amikacin 0.4mg in 0.1ml at the end of surgery.

Penetrating ocular injury (anterior segment)

YES

D

Hypopyon-anterior segment infection.

 

intra cameral injection of Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime1mg in 0.1ml

intra cameral injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin1mg in 0.1ml

Squint surgery

NO

 

 

 

 

 

Trabeculectomy and other glaucoma surgery

YES

D

endophthalmitis

 

Intra-cameral injection of Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime 1mg in 0.1ml at the end of surgery.
Topical chloramphenicol 0.5% 1 drop 6 hourly for 1 week

intra cameral injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin1mg in 0.1ml at the end of surgery.

Topical chloramphenicol 0.5% 1 drop 6 hourly for 1 week

Pars plana vitrectomy

YES

D

endophthalmitis

 

As above

As above

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2. Background information

Endophthalmitis is one of the most serious and feared complications of cataract surgery and its prevention is the main aim of prophylaxis during ophthalmic surgery. Although the incidence is low the morbidity is significant and return of sight is uncertain. The British Ophthalmological Surveillance Unit (BOSU) study estimated the incidence in the UK to be 0.14% and the outcome for one third of the patients was worse than 6/60. Most cases of postoperative endophthalmitis are caused by patient’s own bacterial flora, including Staphylococcus epidermidis, Streptococcus species and Staphylococcus aureus 2 3. Local wound infections may also occur following ocular surgery and the general measures in this guideline are aimed at reducing the risk of all types of infection.

Evidence based practice is difficult because the low incidence of endophthalmitis makes it difficult to assess accurately the efficacy of preventative measures. Many studies either have low statistical power in assessing the influence of a change in procedure on the incidence of postoperative endophthalmitis or measure surrogate outcomes such as change in conjunctival flora or aqueous bacterial counts. 1

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3. General preventative measures.

Recommendation: Whenever possible, treat conditions likely to increase the risk of endophthalmitis prior to ophthalmic surgery. e.g. blepharitis, conjunctivitis (see LTHT conjunctivitis guidelines).
[Evidence level C]

Recommendation: Prior to all ophthalmic surgery disinfect conjunctiva and cornea with povidone-iodine 5% and leave to act for 3 minutes prior to operation.
[Evidence level B]

Recommendation: Ensure correct placement of the surgical drape to cover the lashes and meibomian glands in both lids.
[Evidence level C]

Recommendation: Surgical masks should be worn by the surgical team during all ophthalmic surgery 4
[Evidence level C]

Justification
The Royal College of Ophthalmology recommends that preventative measures should include1:-

  • Treatment of patients with belpharitis, conjunctivitis and nasolacrimal infections prior to surgery.
  • Povidone iodine solution 5% instilled into the conjunctival sac prior to surgery
  • Perfect draping technique to isolate the lid margins and lashes from the surgical field avoiding contamination of the surgical gloves and instruments in the process.
  • Non-touch technique as far as possible and rigorous theatre procedures.

In the European society of cataract and refractive surgery (ESCRS) guidelines it states that for peri-orbital antisepsis a 5-10% povidone-iodine solution is recommended which should be allowed to act for a minimum of 3 minutes as the skin contains many sebaceous glands. If contra-indicated, an aqueous solution of chorhexidine 0.05% should be used 5.

For antisepsis of the conjunctiva and cornea, povidone-iodine 5% is the chemical preparation of choice as the number of bacteria on the conjunctiva and cornea can be reduced by 1 log 10 count to a maximum of 2 log 10 count if it is left in place for 3 minutes before being rinsed off 5.

For patients allergic to povidone iodine a peri-operative conjunctival irrigation with 0.05% chlorhexidine diacetate solution has been found satisfactory by some ophthalmologists 5.

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4. Special antimicrobial prophylaxis recommendations

Recommendation: Patients undergoing cataract surgery should receive an intra cameral injection of 1-2mg of Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime in 0.1 ml 0.9% sodium chloride solution at the end of surgery.
[Evidence level A]

Recommendation: Patients undergoing cataract surgery who have a history of anaphylaxis, laryngeal oedema, bronchospasm, hypotension or urticaria immediately (<1 hour) after administration of a cephalosporin should NOT receive Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime and should be given an intra cameral injection of 1mg of vancomycin in 0.1ml 0.9% BSS at the end of surgery instead.
[Evidence level D]

Recommendation: Patients undergoing routine sutureless cataract surgery do not require topical antimicrobials post operatively.
[Evidence level D]

Recommendation: Patients undergoing pars plana vitrectomy and trabeculectomy require topical chloramphenicol 0.5% 1 drop 6-hourly for one week post operatively.
[Evidence level D]

Justification
The ESCRS guidelines recommend the administration of 1mg of Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime in 0.9% sodium chloride solution at the end of surgery 5. Intra cameral Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime has been widely used in Sweden and data from over 400,000 operations indicated that it was effective. To confirm, this a prospective randomised controlled multi-centre trial was undertaken with approximately 14 000 patients. This confirmed that intra cameral cefuroxime 1mg in 0.1ml reduced the incidence of proven infective endophthalmitis by odd ratio 5.32 (95% confidence limits 1.55 to 18.62 and P < 0.008)5 6.

For penicillin allergic patients the guidelines state that the risk of an allergic reaction to Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime in patients with a known allergy to penicillin is present but small and must be weighed up against the increased risk of endophthalmitis if the injection is withheld in these patients. There is a single case report of severe anaphylactic reaction attributed to intra-cameral cefuroxime 5.

NB SIGN guidelines are explicit in the recommendation not to give beta-lactams to patients reporting anaphylaxis to penicillins 1

For patients allergic to cephalosporins intra cameral Cefuroxime Description: electronic Medicines Compendium information on Cefuroxime should not be given. As an exception it is recommended that an intra-cameral injection of Vancomycin Description: electronic Medicines Compendium information on Vancomycin1mg in 0.1ml should be given. There is no scientific study to support the use of intra cameral vancomycin as prophylaxis 5, however options are limited and Vancomycin Description: electronic Medicines Compendium information on Vancomycinis an effective therapy for endophthalmitis. At LTHT vancomycin is recommended for patients with a true cephalosporin allergy. Intra-vitreal amikacin is used for therapy of endophthalmitis in certain circumstances but its use by the intra-cameral routine has not been described, for penetrating eye injuries involving only the anterior chamber it has been decided to provide only Gram positive cover for patient who cannot be given cephalosporins. [Evidence level D]

On the premise of minimizing the risk of infection, until wound healing is secure, topical antibiotic are often used after cataract surgery but the effectiveness of this approach is unproven and only betamethasone was used post-op but due to a cluster of complications this policy has been reviewed. Antibiotics that have been used include quinolones, neomycin, or chloramphenicol 5. At LTHT betamethasone alone is considered appropriate.

Post trabeculectomy and pars plana vitrectomy, there is LTHT consensus that topical chloramphenicol (with betamethasone) should be used for one week post operation.

Penetrating eye injury is a risk factor for endophthalmitis with a range of pathogens and prophylaxis is therefore recommended.

In lachrymal surgery either chloramphenicol 1% eye ointment or fusidic acid 2% can be used. Chloramphenicol is the preferred option but in patients with a history or family history of blood dyscrasias or an allergy to chloramphenicol then fusidic acid 2% should be used.

Provenance

Record: 2335
Objective:
Clinical condition:

Ophthalmic conditions

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

  1. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh, 2008.
  2. Speaker MG, Milch FA, Shah MK, Eisner W, Kreiswirth BN. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology 1991;98(5):639-49; discussion 50.
  3. Benz MS, Scott IU, Flynn HW, Jr., Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of culture-proven cases. Am J Ophthalmol 2004;137(1):38-42.
  4. Kamalarajah S, Ling R, Silvestri G, Sharma NK, Cole MD, Cran G, et al. Presumed infectious endophthalmitis following cataract surgery in the UK: a case-control study of risk factors. Eye (Lond) 2007;21(5):580-6.
  5. Barry P, Behrens-Baumann W, Pleyer U, Seal D. European Society of cataract and refractive surgery Guidelines on prevention, investigation and management of post-operative endophthalmitis. 2007.
  6. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg 2006;32(3):407-10.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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