The Role of Systemic Antimicrobials in the Treatment of Endophthalmitis: A Review and an International Perspective.

BACKGROUND: The optimal management of patients with endophthalmitis is challenging and includes both intravitreal and, in some cases, systemic antimicrobials. Systemic antimicrobials may be administered either intravenously or orally. In this article we review systemic antimicrobial options currently available for the treatment of types of endophthalmitis and the role of systemic antimicrobials (antibiotics and antifungals) in these treatments. REVIEW: While systemic antimicrobials are not universally utilized in the management of endophthalmitis, they may be helpful in some circumstances. The blood-retinal barrier affects the penetration of systemic medications into the posterior segment of the eye differently; for example, moxifloxacin and imipenem cross the blood-retinal barrier relatively easily while vancomycin and amikacin do not. However, inflammation, including endophthalmitis, may disrupt the blood-retinal barrier, enhancing the penetration of systemic agents into the eye. CONCLUSION: Systemic antimicrobials may be particularly beneficial in patients with certain types of endophthalmitis; as such, they are standard treatment in the management of endogenous endophthalmitis (fungal and bacterial) and also widely used for prophylaxis and treatment of open-globe injuries. Although systemic antimicrobials are used in some patients with acute-onset postoperative endophthalmitis following cataract surgery, the literature generally does not support this practice. It is noted that there are currently no randomized clinical trials demonstrating a benefit of systemic antibiotics for any category of endophthalmitis.

The treatment of postoperative endophthalmitis: should we still follow the endophthalmitis vitrectomy study more than two decades after its publication?

Conducted in the early 1990s Endophthalmitis Vitrectomy Study (EVS) have helped in establishing reasonable guidelines for the management of infectious postoperative endophthalmitis. However at present, more than 20 years after its publication, tremendous progress has been introduced in vitrectomy technology, which now permits the vitreoretinal surgeon to perform surgery more safely, and with better outcomes. Moerover, performing a complete vitreous removal, along with the moving up of the surgical intervention to as early as possible allows the prevention of complications that would limit the functional improvement postoperatively. Thus, it is now highly needed to re-evaluate the conclusions of the EVS study.

More Antisepsis, Less Antibiotics Whenever Possible.

Increasing bacterial resistance to antibiotics has recently become an important medical challenge. In ophthalmology antibiotics are widely used for treatment and prophylaxis of ocular infections. In many cases antiseptics may be a valuable adjunct and sometimes even an alternative to antibiotics for the prevention and treatment of infections, reducing the overuse of antibiotics. This review aims to highlight the available literature on the subject of antibiotic resistance in ophthalmology. Full understanding of this growing problem is necessary for tailoring effective pre-, intra-, and postoperative management to improve antibiotic stewardship programs.