Persistent concerns regarding intracameral cefuroxime Chris H.L. Lim, BSc(Med)Hons, BMed, MD, Sarah C. Williams, MB BCh, Steven T.H. Yun, MB BS, BSc, Felicia A. Aulia, BMed, Zachary E. McPherson, BSc, Dinuksha De Silva, BMed, Simon Irvine, FRANZCO, Ian C. Francis, FASOPRS, PhD Ophthalmic surgeons should be grateful to Mois- seiev and Levinger 1 for illuminating the serious issue of anaphylaxis secondary to the administration of intracameral cefuroxime. A large body of literature supports the incorporation of intracameral cefuroxime toward the conclusion of phacoemulsification cataract surgery, typified by the 2006 European Society of Cataract and Refractive Surgeons report. 2 However, surprisingly or otherwise, there has not been world- wide unanimous adoption of this practice. This correspondence presents an opportunity to highlight some of the persisting concerns surrounding the use of intracameral cefuroxime. Cefuroxime is a second-generation cephalosporin that exerts its bactericidal effect by acting on penicillin-binding protein, thereby disrupting bacterial cell wall synthesis. It could therefore be expected to be useful in preventing many cases of endophthalmitis. The lack of a commercially available preparation of intracameral cefuroxime had led to concerns about contamination and dilution errors. These concerns have been addressed, in part, through the introduction of a purpose-specific preparation (Aprokam), elimi- nating the 2-step dilution process previously required. However, concerns about the antibacterial characteris- tics of cefuroxime remain. Although classified as a broad-spectrum antibacterial agent, cefuroxime offers poor coverage against gram-negative organisms such as Pseudomonas spp., 3 which are regularly isolated in endophthalmitis. Furthermore, there exist major gaps in its bactericidal activity against gram-positive organ- isms including methicillin-resistant Staphylococci, penicillin-resistant S Pneumoniae, and multiresistant Enterococci. There are also pharmacokinetic considerations in evaluating the efficacy of intracameral cefuroxime. With rapid physiological turnover of aqueous humor in the anterior chamber, cefuroxime concentrations reach subtherapeutic levels rapidly. It has been sug- gested that intracameral cefuroxime concentrations decrease fourfold within an hour of administration. 4 Ocular toxicity of intracameral antibiotics has been established in small studies, exemplified by the toxic anterior segment syndrome. 5 Elevated oxidative stress markers within the cornea following intracameral cefuroxime administration have been reported in animal studies. 6 The intraocular environment rarely harbors colonizing organisms, and it is therefore thought that the use of intracameral antibiotics is unlikely to cause bacterial resistance. 7,8 However, it has been docu- mented that bacterial resistance emerges at the con- junctiva, cornea, and lids with topical antibiotic use. 9 The onset of life-threatening anaphylaxis following the administration of intracameral cefuroxime has been reported by Moisseiev and Levinger 1 and Villada et al. 10 In the former case, no anesthetist was present. Although cefuroxime, among other cephalosporins, does not present an increased risk of cross- allergenicity with penicillins, 11 these case reports have nevertheless demonstrated the importance of prompt recognition and effective treatment of anaphy- laxis by ophthalmic surgeons. This must be carried out to prevent possible catastrophic consequences. In light of these considerations, our group is convinced that further research is required before widespread recommendations for adoption of intra- cameral cefuroxime following cataract surgery can be legitimately made. We therefore recommend that cataract surgeons evaluate the risks and benefits of in- tracameral cefuroxime. It may be pertinent to consider whether intracameral antibiotics are needed at all. For instance, only 1 case of endophthalmitis has occurred in 5004 single-surgeon phacoemulsification cataract cases studied and operated on prospectively and consecutively, with 100% follow-up, without the administration of intracameral cefuroxime over 19 years in Sydney, Australia. The single endophthal- mitis case occurred in 2004, when surgeons were switching to sutureless clear corneal incisions. The sur- geon has not left a clear corneal wound unsutured since that case. REFERENCES 1. Moisseiev E, Levinger E. Anaphylactic reaction following intracameral cefuroxime injection during cataract surgery. J Cataract Refract Surg 2013; 39:1432–1434 2. Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW, for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract sur- gery; preliminary report of principal results from a European multicenter study; the ESCRS Endophthalmitis Study Group. J Cataract Refract Surg 2006; 32:407–410; erratum, 709 3. Scott LJ, Ormrod D, Goa KL. Cefuroxime axetil; an updated re- view of its use in the management of bacterial infections. Drugs 2001; 61:1455–1500 4. Montan PG, Wejde G, Setterquist H, Rylander M, Zetterstr€ om C. Prophylactic intracameral cefuroxime; evaluation of safety and kinetics in cataract surgery. J Cataract Refract Surg 2002; 28:982–987 Q 2014 ASCRS and ESCRS 0886-3350/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2014.05.015 1236 CORRESPONDENCE