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Disclosures: Mearza reports no relevant financial disclosures.
December 23, 2020
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Ophthalmologists called to join global antibiotic awareness campaign

The Re-SOLVE Antibiotic Resistance initiative aims to make practitioners aware of global health issues related to antibiotic resistance.

Source:
Disclosures: Mearza reports no relevant financial disclosures.
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In the fight against antibiotic resistance, ophthalmologists play an important role and are called to join the Re-SOLVE Antibiotic Resistance initiative launched by Santen.

“We perform on average 4.5 million cataract surgeries per year, and up to 97% of us use postoperative antibiotics. That comes out to several million days per year of antibiotic exposure to bugs, which can then develop resistance,” Ali Mearza, MBBS, FRCOphth, consultant ophthalmic surgeon and director of Ophthalmic Consultants of London, said.

In a campaign launched in October, Santen joined forces with ophthalmologists in the fight against antibiotic resistance to raise awareness about this global health priority and to promote actions for the sustainable and effective use of antibiotics.

Ali Mearza

“Resistance develops naturally because organisms evolve and mutate. However, overuse and misuse of antibiotics have accelerated this problem,” Mearza said.

According to the European Centre for Disease Prevention and Control, antimicrobial-resistant infections are the cause of at least 50,000 deaths each year across Europe and the United States, with hundreds of thousands more dying in other areas of the world. If the way antibiotics are prescribed does not radically change, that figure could increase to 10 million per year by 2050.

“There are actions we can take specifically as ophthalmologists,” Mearza said.

First, stop misusing antibiotics for viral infections such as viral conjunctivitis.

“It may seem obvious, but this is not an uncommon practice,” he said.

Second, stop using them for prolonged periods unnecessarily, and third, stop using them prophylactically.

“With cataract surgery, we give prophylactic antibiotics all the time, which is a huge contribution to the increased resistance of bacteria. In addition, we taper antibiotic usage during prophylaxis, which is also a way of inducing resistance,” Mearza said.

Better approach to prophylaxis

Antibiotics are used in cataract surgery to prevent infection, primarily endophthalmitis. However, several studies have shown that the best prophylaxis against endophthalmitis is a combination of povidone-iodine instilled into the conjunctival sac before surgery and cefuroxime or moxifloxacin delivered intracamerally during surgery.

“The Swedish experience and the ESCRS study have shown that intracameral antibiotic prophylaxis has superior efficacy as compared to postoperative antibiotics, particularly against gram-negative bacteria,” Mearza said.

Intracameral cefuroxime has become the standard for preventing infection during cataract surgery in the United Kingdom and in other countries in Europe. In Sweden, where it was first adopted as a routine practice, no postoperative antibiotics are used in addition to it. According to Mearza, if they are not completely eliminated, postoperative antibiotics should be administered for no more than 1 week.

“The usual practice is to give antibiotics for 4 weeks together with steroids. We should switch our practice to 1 week four times a day and then stop without tapering. This is a sufficient dosage to kill the known pathogens at a prophylactic rather than therapeutic dosage,” he said.

Call for action

The Re-SOLVE Antibiotic Resistance initiative aims to make ophthalmologists aware of the important role they play in the mitigation of the global health issues related to antibiotic resistance, encouraging them to grow out of old habits.

“Giving antibiotics for 3 or 4 weeks is an established practice pattern without much of a rationale behind it, but changing is not easy. We need the support of a big study, showing that 1 week is equally protective, and we do not have it yet. However, quite a few of my colleagues in the U.K. are doing 1 week and no taper,” Mearza said.

Ophthalmologists globally are asked “to join the revolution” and play their part in antibiotic stewardship through a set of actions that promote the sustainable and effective use of antibiotics.

“In terms of action, we are trying to promote the message that there is good evidence to support the use of povidone-iodine and intracameral antibiotics. That is the key thing for endophthalmitis prevention rather than a prolonged postoperative course. The other message is that a short-term therapy is more than adequate postoperatively. There are cheap and effective options, such as chloramphenicol 0.5%. The last message is to work closely with microbiologists to develop guidelines for the most appropriate use of antibiotics for conditions we treat, in line with the changes due to antibiotic resistance,” Mearza said.

New and more powerful antibiotics may be developed in the future, but research is currently at a standstill, and few of the agents in development have reached phase 3 studies.

“The golden age of antibiotics, which saw the discovery of penicillin, cephalosporins and quinolones, is over. There is not so much in the pipeline at present, and we should try to make the most of the antibiotics we have, making them last as long as possible,” Mearza said.

For more information:

Ali Mearza, MBBS, FRCOphth, can be reached at Ophthalmic Consultants of London, 55 New Cavendish St., Marylebone, London W1G 9TF; email: ali@oclvision.com; website: www.oclvision.com.