Vancomycin prophylaxis and emerging resistance: Are ophthalmologists the villains? The heroes?

PURPOSE: To determine whether the routine use of vancomycin prophylaxis in elective cataract surgery promotes emerging resistance and provides effecti ve protection against post-operative endophthalmitis. METHODS: Critical review of the current scientific and clinical literature was undertaken including appropriate statistical analyses of published data . RESULTS: Public health concerns for emergent vancomycin-resistant life-thre atening "super bugs" are legitimate. Evaluation of the risk factors that ar e known to promote emerging vancomycin resistance (sick patients, hospital intensive care unit setting, methicillin-resistant Staphylococcus aureus (M RSA) clonal infections, prolonged systemic therapy, sub-therapeutic dosing, indwelling intravascular and drainage catheters, total kilogram usage and agricultural use) suggest that ophthalmic usage in routine cataract surgery is unlikely to be a significant factor in promoting emerging worldwide res istance. Clinical and scientific studies purporting to prove the value of v ancomycin prophylaxis in cataract surgery contain substantial biases and de sign flaws that seriously undermine their validity. Issues of potential int raocular toxicity, increased costs, absence of medical-legal protection, an d compliance with current Centers for Disease Control and Prevention (CDC) and American Academy of Ophthalmology guidelines (in hospital) mitigate aga inst this practice. CONCLUSIONS: Ophthalmologists who use vancomycin prophylaxis in routine cat aract surgery are neither the villains nor heroes according to my interpret ation of the currently available scientific data. Personal conscience and a n ongoing critical review of the literature should guide each ophthalmologi st's choice in this controversy. (Am J Ophthalmol 2001;131:371-376. Publish ed by Elsevier Science Inc.).