Antibiotic resistance of ocular surface flora with repeated use of a topical antibiotic after intravitreal injection

JAMA Ophthalmol. 2013 Apr;131(4):456-61. doi: 10.1001/jamaophthalmol.2013.2379.


Importance: Treatment with intravitreal (IVT) injections has increased during the last several years as evidence has accumulated demonstrating the efficacy of anti-vascular endothelial growth factor agents in the treatment of neovascular age-related macular degeneration (AMD) and various retinal vascular diseases. Although IVT injections are generally safe, infectious endophthalmitis is a rare but devastating complication, and the risk of morbidity and vision loss from endophthalmitis is high.

Objective: To examine the change in antibiotic resistance of ocular surface flora with repeated prophylactic use of antibiotics after IVT injection for AMD.

Design and setting: Prospective, nonrandomized cohort study in 2 tertiary academic hospitals.

Participants: Patients 65 years and older with newly diagnosed AMD were recruited by 7 retinal specialists from July 1, 2010, through December 31, 2011.

Intervention: The study group received topical moxifloxacin hydrochloride for 3 days after each monthly IVT injection.

Main outcome measure: Resistance to moxifloxacin and ceftazidime in cultured isolates at baseline and monthly for 3 months by change in minimal inhibitory concentration (MIC) of culture isolates was studied.

Results: The study group consisted of 84 patients, and the control group had 94 patients. In the study group, the baseline adjusted MIC increased (from 1.04 to 1.25 μg/mL; P = .01) as did the MIC for 50% of isolates (MIC50) (from 0.64 to 1.00 μg/mL) and the MIC for 90% of isolates (MIC90) (from 0.94 to 4.00 μg/mL). In both groups, the culture-positive rate did not change significantly when adjusted for baseline. No significant change was found in the MIC level, culture-positive rate, MIC50 level, and MIC90 level in the control group. Subgroup analysis found diabetes mellitus to be noncontributory to both the MIC and culture-positive rate. No endophthalmitis or adverse events were reported.

Conclusions and relevance: Repeated use of topical moxifloxacin after IVT injection significantly increases antibiotic resistance of ocular surface flora. We recommend that routine use of prophylactic antibiotics after IVT injection be discouraged. TRIAL REGISTRATION Identifier: NCT01181713.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Topical
  • Aged
  • Aged, 80 and over
  • Angiogenesis Inhibitors / administration & dosage
  • Angiogenesis Inhibitors / therapeutic use*
  • Anti-Bacterial Agents / administration & dosage*
  • Antibiotic Prophylaxis
  • Antibodies, Monoclonal, Humanized / administration & dosage
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Aza Compounds / administration & dosage
  • Bacteria / drug effects*
  • Ceftazidime / administration & dosage
  • Cohort Studies
  • Conjunctiva / microbiology*
  • Drug Resistance, Multiple, Bacterial*
  • Endophthalmitis / prevention & control*
  • Female
  • Fluoroquinolones
  • Hospitals, Teaching
  • Humans
  • Intravitreal Injections
  • Male
  • Microbial Sensitivity Tests
  • Moxifloxacin
  • Prospective Studies
  • Quinolines / administration & dosage
  • Ranibizumab
  • Wet Macular Degeneration / drug therapy*


  • Angiogenesis Inhibitors
  • Anti-Bacterial Agents
  • Antibodies, Monoclonal, Humanized
  • Aza Compounds
  • Fluoroquinolones
  • Quinolines
  • Ceftazidime
  • Moxifloxacin
  • Ranibizumab

Associated data