Analysis of clinical and risk factors of positive conjunctival sac culture before intravitreal injection_Chinese Journal of Ocular Fundus Diseases

Authors：

Sun Lina , Li Yongtao , Xu Meiqi , Hou Guanghua , Ke Yifeng , Zheng Yue , Xin Xina , Emmanuel Eric Pazo ,  Ren Xinjun

Tianjin Medical University Eye Hospital, Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Centerfor Ocular Disease, Eye Institute and School of Optometry, Tianjin 300384, China;

Corresponding?author：

Ren Xinjun, Email: Xin2023Ren@tmu.edu.cn

Keywords：

Intravitreal injection; Conjunctival sac culture; Infectious endophthalmitis; Perioperation

DOI：

10.3760/cma.j.cn511434-20240626-00242

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Objective To observe and analyze the risk factors of positive conjunctival capsule microbial culture in patients with intravitreal injection treatment (IVT) before treatment. Methods A prospective study. A total of 1 092 patients who received IVT at the Vitreous Injection Center of Tianjin Medical University Eye Hospital from February 2021 to February 2024 were included in the study. Among them, 539 were males and 553 were females. The age was (62.29±13.61) years. Hypertension and diabetes were 661 and 576 cases, respectively. There were 742 cases of urban residence and 350 cases of rural residence. Three and one days before IVT, 364 patients received antibiotics and 364 patients did not receive antibiotics. Patients' gender, age, history of hypertension and diabetes, pre-IVT antibiotic eye drops use history, and differences in residence (town/country) were collected in detail. Samples were collected after the conjunctival sac was rinsed, and microbial culture was performed. The differences in conjunctival microbial culture positivity rates was compared between those who did not use antibiotic eye drops before IVT, those who used them 1 day before IVT, and those who used them 3 days before IVT. The positive rate of conjunctival sac microbial culture were compared among individuals of different ages, genders, with/without hypertension, with/without diabetes, with different IVT times, and from different living areas (urban/rural). The clinical baseline of positive conjunctival capsule bacterial culture was compared and observed. χ² test was used to compare the positive rate of conjunctival capsule microbial culture among different clinical baselines. Logistic binary regression analysis was used to analyze the influencing factors. Results Among the 1 092 patients, 54 cases (4.95%, 54/1 092) were positive for microbial culture of conjunctival sac. There was no significant difference (P＞0.05) in the positive rate of conjunctival sac microbial culture among patients of different ages (χ²=5.599), gender (χ²=0.549), residence (χ²=0.153), with or without hypertension and diabetes (χ²=3.545, 0.044), and with or without diabetic macular edema (χ²=0.180). There was no significant difference (P＞0.05) in the positive rate of conjunctival sac microbial culture between patients with different numbers of IVT (χ²=0.961) or between those who received antibiotic eye drops before IVT and those who did not (χ²=5.600). Logistic binary regression analysis showed that none of the above factors were risk factors for positive conjunctival capsule microbial culture (P＞0.05). No infective endophthalmitis occurred in all patients during the observation period. Conclusion The use of antibiotics before IVT is not the decisive factor for positive microbial culture in conjunctival sac.

Citation： Sun Lina, Li Yongtao, Xu Meiqi, Hou Guanghua, Ke Yifeng, Zheng Yue, Xin Xina, Emmanuel Eric Pazo, Ren Xinjun. Analysis of clinical and risk factors of positive conjunctival sac culture before intravitreal injection. Chinese Journal of Ocular Fundus Diseases, 2024, 40(12): 919-923. doi: 10.3760/cma.j.cn511434-20240626-00242 Copy

1.	Sigford DK, Reddy S, Mollineaux C, et al. Global reported endophthalmitis risk following intravitreal injections of anti-VEGF: a literature review and analysis[J]. Clin Ophthalmol, 2015, 9: 773-781. DOI: 10.2147/OPTH.S77067.
2.	Ma H, Wei H, Zou C, et al. Anti-VEGF drugs in age-related macular degeneration: a focus on dosing regimen-related safety and efficacy[J]. Drugs Aging, 2023, 40(11): 991-1007. DOI: 10.1007/s40266-023-01068-8.
3.	Davidov B, Ohayon A, Trivizki O, et al. Postintravitreal injection endophthalmitis: incidence, characteristics, management, and outcome[J/OL]. J Ophthalmol, 2023, 2023: 9212524[2023-11-06]. https://pubmed.ncbi.nlm.nih.gov/37965437/. DOI: 10.1155/2023/9212524.
4.	Simina DS, Larisa I, Otilia C, et al. The ocular surface bacterial contamination and its management in the prophylaxis of post cataract surgery endophthalmitis[J]. Rom J Ophthalmol, 2021, 65(1): 2-9. DOI: 10.22336/rjo.2021.2.
5.	Lundstr?m M, Friling E, Montan P. Risk factors for endophthalmitis after cataract surgery: predictors for causative organisms and visual outcomes[J]. J Cataract Refract Surg, 2015, 41(11): 2410-2416. DOI: 10.1016/j.jcrs.2015.05.027.
6.	Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents[J]. Ophthalmic Surg Lasers Imaging Retina, 2014, 45(2): 143-149. DOI: 10.3928/23258160-20140306-08.
7.	李筱榮, 黎曉新, 許迅. 一站式玻璃體腔注藥模式的建立與管理專家共識[J]. 中華眼底病雜志, 2023, 39(3): 187-193. DOI: 10.3760/cma.j.cn511434-20230211-00041.Li XR, Li XX, Xu X. One-stop intravitreal injection model: expert consensus on establishment and management[J]. Chin J Ocul Fundus Dis, 2023, 39(3): 187-193. DOI: 10.3760/cma.j.cn511434-20230211-00041.
8.	譚亮章, 任新軍, 柯屹峰, 等. 一站式玻璃體腔注藥模式成立前后真實世界研究大數據對比[J]. 中華眼底病雜志, 2023, 39(6): 451-458. DOI: 10.3760/cma.j.cn511434-20230518-00226.Tan LZ, Ren XJ, Ke YF, et al. Comparison of big data before and after the establishment of one-stop intravitreal injection mode in the real-world research[J]. Chin J Ocul Fundus Dis, 2023, 39(6): 451-458. DOI: 10.3760/cma.j.cn511434-20230518-00226.
9.	Bergamo VC, Nakayama LF, Moraes NSB, et al. Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series[J]. Int J Retina Vitreous, 2023, 9(1): 58. DOI: 10.1186/s40942-023-00490-9.
10.	中華醫學會眼科學分會眼底病學組, 中華醫學會眼科學分會白內障及屈光手術學組, 中華醫學會眼科學分會眼外傷學組, 等. 中國眼科手術后感染性眼內炎診療專家共識(2022年)[J]. 中華眼科雜志, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.Chinese Vitreo-Retina Society of Chinese Medical Association, Chinese Cataract and Refractive Surgery Society, China Ocular Trauma Society of Ophthalmology Branch of Chinese Medical Association, et al. Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)[J]. Chin J Ophthalmol, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.
11.	Spaide RF. Method of povidone-iodine application and endophthalmitis risk[J]. Retin Cases Brief Rep, 2024, 18(2): 141-144. DOI: 10.1097/ICB.0000000000001367.
12.	Casemiro JH, Oguido A, Casella AMB. Using 2% PVPI topical solution for serial intravitreous injections and ocular surface findings: a case control study[J]. Int J Retina Vitreous, 2024, 10(1): 41. DOI: 10.1186/s40942-024-00557-1.
13.	Gower EW, Lindsley K, Tulenko SE, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery[J/OL]. Cochrane Database Syst Rev, 2017, 2(2): CD006364[2017-02-13]. https://pubmed.ncbi.nlm.nih.gov/28192644/. DOI: 10.1002/14651858.CD006364.pub3.
14.	Lyall DA, Tey A, Foot B, et al. Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes[J]. Eye (Lond), 2012, 26(12): 1517-1526. DOI: 10.1038/eye.2012.199.
15.	Halachmi-Eyal O, Lang Y, Keness Y, et al. Preoperative topical moxifloxacin 0.5% and povidone-iodine 5.0% versus povidone-iodine 5.0% alone to reduce bacterial colonization in the conjunctival sac[J]. J Cataract Refract Surg, 2009, 35(12): 2109-2114. DOI: 10.1016/j.jcrs.2009.06.038.
16.	Schimel AM, Miller D, Flynn HW. Evolving fluoroquinolone resistance among coagulase-negative Staphylococcus isolates causing endophthalmitis[J]. Arch Ophthalmol, 2012, 130(12): 1617-1618. DOI: 10.1001/archophthalmol.2012.2348.
17.	Mino De Kaspar H, Hoepfner AS, Engelbert M, et al. Antibiotic resistance pattern and visual outcome in experimentally-induced Staphylococcus epidermidis endophthalmitis in a rabbit model[J]. Ophthalmology, 2001, 108(3): 470-478. DOI: 10.1016/s0161-6420(00)00545-5.
18.	Hou CH, Lee JS, Lin KK, et al. Risk and dose-response relationship of diabetes mellitus for endophthalmitis after cataract surgery in a nationwide cohort study in Taiwan[J]. Clin Exp Ophthalmol, 2023, 51(7): 692-703. DOI: 10.1111/ceo.14288.
19.	Israilevich RN, Mansour H, Patel SN, et al. Risk of endophthalmitis based on cumulative number of anti-vascular endothelial growth factor intravitreal injections[J]. Ophthalmology, 2024, 131(6): 667-673. DOI: 10.1016/j.ophtha.2023.12.033.
20.	Seong HJ, Park YM, Kim J, et al. Incidence of acute endophthalmitis after intravitreal antivascular endothelial growth factor injection in age-related macular degeneration[J]. Korean J Ophthalmol, 2022, 36(5): 435-442. DOI: 10.3341/kjo.2022.0088.

1. Sigford DK, Reddy S, Mollineaux C, et al. Global reported endophthalmitis risk following intravitreal injections of anti-VEGF: a literature review and analysis[J]. Clin Ophthalmol, 2015, 9: 773-781. DOI: 10.2147/OPTH.S77067.
2. Ma H, Wei H, Zou C, et al. Anti-VEGF drugs in age-related macular degeneration: a focus on dosing regimen-related safety and efficacy[J]. Drugs Aging, 2023, 40(11): 991-1007. DOI: 10.1007/s40266-023-01068-8.
3. Davidov B, Ohayon A, Trivizki O, et al. Postintravitreal injection endophthalmitis: incidence, characteristics, management, and outcome[J/OL]. J Ophthalmol, 2023, 2023: 9212524[2023-11-06]. https://pubmed.ncbi.nlm.nih.gov/37965437/. DOI: 10.1155/2023/9212524.
4. Simina DS, Larisa I, Otilia C, et al. The ocular surface bacterial contamination and its management in the prophylaxis of post cataract surgery endophthalmitis[J]. Rom J Ophthalmol, 2021, 65(1): 2-9. DOI: 10.22336/rjo.2021.2.
5. Lundstr?m M, Friling E, Montan P. Risk factors for endophthalmitis after cataract surgery: predictors for causative organisms and visual outcomes[J]. J Cataract Refract Surg, 2015, 41(11): 2410-2416. DOI: 10.1016/j.jcrs.2015.05.027.
6. Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents[J]. Ophthalmic Surg Lasers Imaging Retina, 2014, 45(2): 143-149. DOI: 10.3928/23258160-20140306-08.
7. 李筱榮, 黎曉新, 許迅. 一站式玻璃體腔注藥模式的建立與管理專家共識[J]. 中華眼底病雜志, 2023, 39(3): 187-193. DOI: 10.3760/cma.j.cn511434-20230211-00041.Li XR, Li XX, Xu X. One-stop intravitreal injection model: expert consensus on establishment and management[J]. Chin J Ocul Fundus Dis, 2023, 39(3): 187-193. DOI: 10.3760/cma.j.cn511434-20230211-00041.
8. 譚亮章, 任新軍, 柯屹峰, 等. 一站式玻璃體腔注藥模式成立前后真實世界研究大數據對比[J]. 中華眼底病雜志, 2023, 39(6): 451-458. DOI: 10.3760/cma.j.cn511434-20230518-00226.Tan LZ, Ren XJ, Ke YF, et al. Comparison of big data before and after the establishment of one-stop intravitreal injection mode in the real-world research[J]. Chin J Ocul Fundus Dis, 2023, 39(6): 451-458. DOI: 10.3760/cma.j.cn511434-20230518-00226.
9. Bergamo VC, Nakayama LF, Moraes NSB, et al. Bacterial endophthalmitis following anti-VEGF intravitreal injections: a retrospective case series[J]. Int J Retina Vitreous, 2023, 9(1): 58. DOI: 10.1186/s40942-023-00490-9.
10. 中華醫學會眼科學分會眼底病學組, 中華醫學會眼科學分會白內障及屈光手術學組, 中華醫學會眼科學分會眼外傷學組, 等. 中國眼科手術后感染性眼內炎診療專家共識(2022年)[J]. 中華眼科雜志, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.Chinese Vitreo-Retina Society of Chinese Medical Association, Chinese Cataract and Refractive Surgery Society, China Ocular Trauma Society of Ophthalmology Branch of Chinese Medical Association, et al. Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)[J]. Chin J Ophthalmol, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.
11. Spaide RF. Method of povidone-iodine application and endophthalmitis risk[J]. Retin Cases Brief Rep, 2024, 18(2): 141-144. DOI: 10.1097/ICB.0000000000001367.
12. Casemiro JH, Oguido A, Casella AMB. Using 2% PVPI topical solution for serial intravitreous injections and ocular surface findings: a case control study[J]. Int J Retina Vitreous, 2024, 10(1): 41. DOI: 10.1186/s40942-024-00557-1.
13. Gower EW, Lindsley K, Tulenko SE, et al. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery[J/OL]. Cochrane Database Syst Rev, 2017, 2(2): CD006364[2017-02-13]. https://pubmed.ncbi.nlm.nih.gov/28192644/. DOI: 10.1002/14651858.CD006364.pub3.
14. Lyall DA, Tey A, Foot B, et al. Post-intravitreal anti-VEGF endophthalmitis in the United Kingdom: incidence, features, risk factors, and outcomes[J]. Eye (Lond), 2012, 26(12): 1517-1526. DOI: 10.1038/eye.2012.199.
15. Halachmi-Eyal O, Lang Y, Keness Y, et al. Preoperative topical moxifloxacin 0.5% and povidone-iodine 5.0% versus povidone-iodine 5.0% alone to reduce bacterial colonization in the conjunctival sac[J]. J Cataract Refract Surg, 2009, 35(12): 2109-2114. DOI: 10.1016/j.jcrs.2009.06.038.
16. Schimel AM, Miller D, Flynn HW. Evolving fluoroquinolone resistance among coagulase-negative Staphylococcus isolates causing endophthalmitis[J]. Arch Ophthalmol, 2012, 130(12): 1617-1618. DOI: 10.1001/archophthalmol.2012.2348.
17. Mino De Kaspar H, Hoepfner AS, Engelbert M, et al. Antibiotic resistance pattern and visual outcome in experimentally-induced Staphylococcus epidermidis endophthalmitis in a rabbit model[J]. Ophthalmology, 2001, 108(3): 470-478. DOI: 10.1016/s0161-6420(00)00545-5.
18. Hou CH, Lee JS, Lin KK, et al. Risk and dose-response relationship of diabetes mellitus for endophthalmitis after cataract surgery in a nationwide cohort study in Taiwan[J]. Clin Exp Ophthalmol, 2023, 51(7): 692-703. DOI: 10.1111/ceo.14288.
19. Israilevich RN, Mansour H, Patel SN, et al. Risk of endophthalmitis based on cumulative number of anti-vascular endothelial growth factor intravitreal injections[J]. Ophthalmology, 2024, 131(6): 667-673. DOI: 10.1016/j.ophtha.2023.12.033.
20. Seong HJ, Park YM, Kim J, et al. Incidence of acute endophthalmitis after intravitreal antivascular endothelial growth factor injection in age-related macular degeneration[J]. Korean J Ophthalmol, 2022, 36(5): 435-442. DOI: 10.3341/kjo.2022.0088.

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Analysis of clinical and risk factors of positive conjunctival sac culture before intravitreal injection

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