Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery.
Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery.
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DOI：
10.1002/14651858.cd006364.pub3
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发表时间：
2017-02-13
期刊：
影响因子：
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通讯作者：
McDonnell PJ
中科院分区：
文献类型：
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作者：
Gower EW;Lindsley K;Tulenko SE;Nanji AA;Leyngold I;McDonnell PJ
眼内炎是眼前腔或后腔（或两腔）的严重炎症，可能是无菌的或与感染有关。这是白内障手术中一种潜在的威胁视力的并发症。预防眼内炎的措施是针对各种感染源。目的：评价白内障术后围手术期抗生素预防与不预防或其他形式预防的效果。我们检索了CENTRAL（包含Cochrane Eyes and Vision Trials Register）（2016，第12期）、Ovid MEDLINE、Epub Ahead of Print、In-Process &其他非索引引文、Ovid MEDLINE Daily（1946年1月至2016年12月）、Embase（1980年1月至2016年12月）、拉丁美洲和加勒比健康科学文献数据库（LILACS）（1982年至2016年12月）、ISRCTN注册（www.isrctn.com/editAdvancedSearch）、ClinicalTrials.gov （www.clinicaltrials.gov）、世界卫生组织（世卫组织）国际临床试验注册平台（ICTRP） （www.who.int/ictrp/search/en）。我们在电子检索中没有使用日期或语言限制。我们最后一次检索电子数据库是在2016年12月6日。我们还使用科学引文索引检索了引用任何纳入试验的其他研究。我们纳入了随机对照试验，纳入了因任何原因而接受白内障手术（任何方法和切口类型）的成年人。我们纳入了评估术前抗生素、术中（眼内、结膜下或全身）或术后抗生素预防急性眼内炎的试验。我们排除了评估使用聚维酮碘或抗生素等药物治疗白内障手术后急性眼内炎的抗菌术前准备的研究。两名综述作者独立审查摘要和全文文章的合格性，评估每个纳入研究的偏倚风险，并提取数据。5项研究符合本综述的纳入标准，包括101005名成人和132例眼内炎病例。虽然样本量非常大，但研究设计和抗生素给药模式的异质性使得无法进行正式的荟萃分析。调查的干预措施包括在冲洗液中加入万古霉素和庆大霉素与单独使用标准平衡盐水溶液冲洗的比较，围手术期使用头孢呋辛加或不加左氧氟沙星，眼周注射青霉素和外用氯霉素-磺胺滴剂与单独使用外用抗生素的比较，以及抗生素的给药方式(结膜下注射与球后注射；固定与单独滴注加替沙星和强的松龙)。由于信息未被报道，研究间的偏倚风险低至不清楚。我们确定了一项正在进行的研究。两项研究比较了有抗生素和没有抗生素。一项比较平衡盐溶液（BSS）中抗生素冲洗与单独BSS冲洗的研究，没有足够的证据来检测组间眼内炎的差异（非常低确定性的证据）。一项研究发现，头孢呋辛与左氧氟沙星联合应用可降低眼内炎的风险(风险比（RR） 0.14, 95%可信区间（CI） 0.03 ~ 0.63；8106名参与者;高确定性证据)或单独使用头孢呋辛（RR 0.21, CI 0.06至0.74；8110名受试者；高确定性证据）与安慰剂相比，单独使用左氧氟沙星与安慰剂相比效果不确定（RR 0.72, CI 0.32至1.61；8103名受试者；中等确定性证据）。两项研究发现，与单独使用外用抗生素相比，手术中联合使用抗生素注射和外用抗生素可降低眼内炎的风险（风险比（RR） 0.33, 95%可信区间（CI） 0.12至0.92）（眼周青霉素和外用氯霉素-磺胺嘧啶；6618名参与者；中等确定性证据）；RR 0.20, 95% CI 0.04 - 0.91（头孢呋辛和左氧氟沙星内服；8101名受试者；高确定性证据）。一项比较固定注射加替沙星和泼尼松龙与单独注射加替沙星和泼尼松龙的研究，没有足够的证据来检测两组之间眼内炎的差异（非常低确定性的证据）。另一项研究发现结膜下和球后抗生素注射在眼内炎方面没有差异（RR 0.85, 95% CI 0.55 - 1.32; 77,015名受试者；中等确定性证据）。两项研究报告了任何视力结果；一项比较固定注射加替沙星和泼尼松龙与单独注射加替沙星和泼尼松龙的研究仅报告两组术后20天的平均视力相同。在另一项研究中，在眼内炎后接受或不接受左氧氟沙星的眼内注射头孢呋辛组与不接受头孢呋辛的眼内炎组之间，最终视力大于20/40的眼睛比例的差异是不确定的（RR 0.69, 95% CI 0.22至2.11；29名受试者；中等确定性证据）。只有一项研究报告了不良事件（129只眼中有1只眼在人工晶状体前出现瞳孔膜，8只眼出现后囊膜混浊）。没有研究报告与生活质量或经济结果相关的结果。预防白内障手术后眼内炎的多种措施已被研究。高确定性证据表明，注射头孢呋辛加或不加局部左氧氟沙星可降低手术后眼内炎的发生几率，中等确定性证据表明，与单独使用注射或滴眼液相比，在注射抗生素的同时使用抗生素滴眼液可能降低眼内炎的发生几率。结果罕见的临床试验需要非常大的样本量，而且进行起来成本很高；因此，不太可能进行许多额外的临床试验来评估目前可用的预防措施。从业人员应依靠现有的证据，就预防选择作出明智的决定。
Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection. To evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery compared with no prophylaxis or other form of prophylaxis. We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to December 2016),the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 6 December 2016. We also searched for additional studies that cited any included trials using the Science Citation Index. We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. We included trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic), or postoperative antibiotic prophylaxis for acute endophthalmitis. We excluded studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine or antibiotics for treating acute endophthalmitis after cataract surgery. Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data. Five studies met the inclusion criteria for this review, including 101,005 adults and 132 endophthalmitis cases. While the sample size was very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime with or without topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulfadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections; fixed versus separate instillation of gatifloxacin and prednisolone). The risk of bias among studies was low to unclear due to information not being reported. We identified one ongoing study. Two studies compared any antibiotic with no antibiotic. One study, which compared irrigation with antibiotics in balanced salt solution (BSS) versus BSS alone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). One study found reduced risk of endophthalmitis when combining intracameral cefuroxime and topical levofloxacin (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.63; 8106 participants; high-certainty evidence) or using intracameral cefuroxime alone (RR 0.21, CI 0.06 to 0.74; 8110 participants; high-certainty evidence) compared with placebo, and an uncertain effect when using topical levofloxacin alone compared with placebo (RR 0.72, CI 0.32 to 1.61; 8103 participants; moderate-certainty evidence). Two studies found reduced risk of endophthalmitis when combining antibiotic injections during surgery and topical antibiotics compared with topical antibiotics alone (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin and topical chloramphenicol-sulfadimidine; 6618 participants; moderate-certainty evidence); and RR 0.20, 95% CI 0.04 to 0.91 (intracameral cefuroxime and topical levofloxacin; 8101 participants; high-certainty evidence)). One study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). Another study found no evidence of a difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32; 77,015 participants; moderate-certainty evidence). Two studies reported any visual acuity outcome; one study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, reported only that mean visual acuity was the same for both groups at 20 days postoperation. In the other study, the difference in the proportion of eyes with final visual acuity greater than 20/40 following endophthalmitis between groups receiving intracameral cefuroxime with or without topical levofloxacin compared with no intracameral cefuroxime was uncertain (RR 0.69, 95% CI 0.22 to 2.11; 29 participants; moderate-certainty evidence). Only one study reported adverse events (1 of 129 eyes had pupillary membrane in front of the intraocular lens and 8 eyes showed posterior capsule opacity). No study reported outcomes related to quality of life or economic outcomes. Multiple measures for preventing endophthalmitis following cataract surgery have been studied. High-certainty evidence shows that injection with cefuroxime with or without topical levofloxacin lowers the chance of endophthalmitis after surgery, and there is moderate-certainty evidence to suggest that using antibiotic eye drops in addition to antibiotic injection probably lowers the chance of endophthalmitis compared with using injections or eye drops alone. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that many additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.