- Design
- Retrospective comparative cohort study across two time periods, culture plus 16S PCR
- Population
- 234 eyes with acute postcataract endophthalmitis at two French tertiary centres; 126 (2002-2007) and 108 (2016-2025)
- Primary outcome
- Pathogen distribution, cefuroxime susceptibility, methicillin resistance among staphylococci, and clinical severity at presentation
- Effect
- Cefuroxime resistance 26.0% to 66.1% (adjusted OR 3.75, 95% CI 1.59-8.82); methicillin resistance 30.3% to 75.0% (adjusted OR 6.75, 1.99-22.83); Enterococcus faecalis 2% to 10%
Intracameral cefuroxime became standard prophylaxis on the strength of trials run against a bacterial spectrum dominated by coagulase-negative staphylococci. This retrospective comparison asks what that spectrum looks like now, across 234 eyes presenting within six weeks of cataract surgery at two French tertiary centres: 126 from 2002 to 2007 and 108 from 2016 to 2025, with conventional culture plus 16S PCR on aqueous or vitreous.
The spectrum shifted. Coagulase-negative staphylococci fell from 38% to 25% of isolates. Enterococcus faecalis rose from 2% to 10%. Gram-negative organisms rose from 3.1% to 7.3%.
The resistance figures are starker. Cefuroxime resistance rose from 26.0% (13 of 50) to 66.1% of tested isolates (adjusted OR 3.75, 95% CI 1.59-8.82, P=.003). Among staphylococci, methicillin resistance rose from 30.3% to 75.0% (adjusted OR 6.75, 95% CI 1.99-22.83, P=.002) and multidrug-resistant phenotypes from 3.0% to 37.5% (P=.003).
One reading of the Enterococcus rise is that cefuroxime prophylaxis is doing its job — selecting for the organisms it does not cover. Presentations were milder in the recent cohort, with acuity of 20/400 or better in 29.0% against 11.2% and a visible fundus in 24.1% against 9.6%, and fewer needed vitrectomy. That is a real improvement, and it sits alongside a resistance profile that makes the empirical regimen matter more, not less.
- Intravitreal vancomycin plus ceftazidime remains the empirical standard — this reinforces it rather than changing it
- Enterococcus faecalis is not covered by cefuroxime prophylaxis and is rising
- Send a sample before injecting; culture yield was under 60% even here, and 16S PCR adds to it
- Know your own unit's isolates and susceptibilities — resistance patterns are local
- Milder presentation does not mean milder organism; it may mean earlier detection
Why it matters
The prophylaxis that is now standard may be selecting the organisms that cause the infections it does not prevent.
Don't overread it
Retrospective, two centres, incomplete susceptibility data — the direction is convincing, the exact percentages are not transferable to another country.
The statistics, in plain English
The resistance comparison rests on tested isolates, and only 50 were tested for cefuroxime in the historical cohort — so 26.0% is 13 of 50, a small denominator. Susceptibility data were incomplete, which the authors state. Two centres over two non-adjacent periods also means testing methods and referral patterns changed alongside the bacteria, and some of the apparent shift will be that rather than true ecological change.
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