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    At issue: Is MRSA testing and prophylaxis a worthwhile approach?

    Surgeons also weigh costs, merits, and limitations of alternative approaches

     

    TAKE HOME:

    Although infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are a prominent concern for cataract surgeons, leading ophthalmologists discuss the pros and cons of performing universal MRSA screening to guide targeted prophylaxis.

     

    Dr. McDonnell

    Given the increase in prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization and in levels of MRSA antimicrobial resistance, the question arises whether preoperative testing for MRSA to guide targeted prophylaxis should be done routinely in patients undergoing cataract surgery.

    Two leading ophthalmologists—Peter J. McDonnell, MD, William Holland Wilmer Professor and director, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and Stephen D. McLeod, MD, Theresa M. and Wayne M. Caygill, MD Endowed Chair and professor, Department of Ophthalmology, University of California–San Francisco—agreed universal testing is not cost-effective.

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    Both physicians also concluded that available evidence does not support a selective testing approach in which patients would be screened based on certain history factors.

    Speaking in favor of MRSA testing and targeted prophylaxis, Dr. McLeod suggested that selective empiric prophylaxis, i.e., use of intracameral vancomycin (rather than intracameral cefuroxime) in certain individuals considered to be at particularly high risk for MRSA colonization based on history (previous history of colonization or residence in an extended-care facility) might be reasonable considering the effectiveness and relative safety of intracameral vacomycin.

    Taking the opponent’s position, Dr. McDonnell underscored the current low rates of postoperative endophthalmitis, the potential for topical antibiotic delivery to achieve target site concentrations exceeding MRSA minimum inhibitory concentrations, and the activity of host defense mechanisms in addition to the lack of adequate criteria for identifying carriers of methicillin-resistant organisms. Based on those considerations, Dr. McDonnell advocated for a universal precautions approach in which every patient should be considered as a potential carrier of MRSA and treated using povidone-iodine lid scrubs, topical antibiotic drops, and draping to isolate the lashes.

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