Two-thirds of postcataract endophthalmitis isolates are now cefuroxime resistant

Design

Retrospective comparative cohort, two French tertiary referral centres, two eras

Population

234 eyes with acute postcataract endophthalmitis (126 from 2002-2007, 108 from 2016-2025)

Primary outcome

Pathogen distribution, cefuroxime susceptibility, methicillin resistance and severity at presentation

Effect

Cefuroxime resistance 26.0 to 66.1 per cent (adjusted OR 3.75, 95 per cent CI 1.59 to 8.82); methicillin resistance 30.3 to 75.0 per cent (OR 6.75, 1.99 to 22.83)

Two French tertiary referral centres compared 126 eyes with acute postcataract endophthalmitis managed from 2002 through 2007 with 108 managed from 2016 through 2025, all presenting within six weeks of surgery, using conventional culture plus 16S polymerase chain reaction on aqueous or vitreous. Bacterial identification succeeded in 67.5 per cent of the historical cohort and 58.3 per cent of the recent one.

The spectrum has moved. Coagulase-negative staphylococci fell from 38 per cent of isolates to 25 per cent, Enterococcus faecalis rose from 2 per cent to 10 per cent, and Gram-negative organisms from 3.1 per cent to 7.3 per cent. Resistance moved further. Cefuroxime resistance among tested isolates rose from 26.0 per cent to 66.1 per cent, adjusted odds ratio 3.75 (95 per cent CI 1.59 to 8.82, P = 0.003). Methicillin resistance among staphylococci rose from 30.3 per cent to 75.0 per cent, adjusted OR 6.75 (1.99 to 22.83), and multidrug-resistant phenotypes from 3.0 per cent to 37.5 per cent.

Against that, presentations were milder: 29.0 per cent of recent eyes presented at 20/400 or better against 11.2 per cent historically, the fundus was visible in 24.1 versus 9.6 per cent, and vitrectomy was needed in 51.9 versus 63.5 per cent. The two findings are not contradictory - a less virulent organism spectrum can present more gently while being harder to kill - but they should not be read as reassurance. The empiric intravitreal combination of vancomycin and ceftazidime still covers most of this, and nothing here argues for abandoning intracameral prophylaxis. What it argues for is that your own centre's isolates and susceptibilities need to be known rather than assumed, particularly where Enterococcus is turning up.

• Ask your microbiology laboratory for a five-year local endophthalmitis isolate and susceptibility summary rather than relying on published series.
• Send both culture and 16S polymerase chain reaction; identification still failed in over 40 per cent of recent cases.
• Keep vancomycin in the empiric intravitreal combination, given methicillin resistance at three-quarters of staphylococcal isolates.
• Flag Enterococcus faecalis growth to the team immediately; it behaves differently from a coagulase-negative staphylococcus and is now five times as common here.
• Do not read a milder presentation as a milder infection when deciding on early vitrectomy.

The statistics, in plain English

The odds ratios are adjusted for the confounders the authors could measure, and their confidence intervals sit clear of 1.0, so the direction of change is solid even if the exact size is not. The denominators are small - 50 tested isolates historically - so a percentage moving by twenty points can rest on a handful of organisms. This is also two French tertiary centres over two non-adjacent periods, with incomplete susceptibility data acknowledged by the authors, so the trend is a warning to check your own data, not a number to quote as national.

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