deoxyribonucleic acid supercoiling.
This synergy, and the thalmitis isolates were sensitive to ciprofloxacin in 1997;
resultant greater bactericidal activity, would be all the
more important considering that there is no assistance
from the body’s immune system in combating the intraoc-
ular infection. This substitution of ceftazidime with cipro-
floxacin would, of course, be more appropriate in India
than in the United States
VASUMATHY VEDANTHAM, MS, DNB, FRCS
Madurai, TamilNadu, India
REFERENCES
1. Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D.
Endophthalmitis isolates and antibiotic sensitivities: A 6-year
review of culture-proven cases. Am J Ophthalmol 2004;137:
38 –42.
2. Hodge WG, Bui DP, Cevallos V, Dang SB, Moore T, Hwang
DG. Frequency of recovery of ciprofloxacin-resistant ocular
isolates following topical ciprofloxacin therapy. Invest Oph-
thal Vis Sci 1995;36:s155.
3. Anand AR, Therese KL, Madhavan HN. Spectrum of aetio-
logical agents of postoperative endophthalmitis and antibiotic
susceptibility of bacterial isolates. Indian J Ophthalmol 2000;
48:123–128.
4. Kunimoto DY, Das T, Sharma S, et al, and the Endophthalmi-
tis Research Group. Microbiologic spectrum and susceptibility
of isolates: Part I. Post operative endophthalmitis. Am J
Ophthalmol 1999;128:240 –242.
5. Hui M, Kwok AKH, Pang CP, et al. An in vitro study on the
compatibility and precipitation of a combination of cipro-
floxacin and vancomycin in human vitreous. Br J Ophthalmol
2004;88:218 –222.
AUTHOR REPLY
OUR THANKS TO DR VEDANTHAM FOR HIS INTERESTING
points regarding our article.1 Dr Vedantham makes a case
for use of intravitreal ciprofloxacin instead of ceftazidime
in conjunction with vancomycin for treatment of endoph-
thalmitis.
One of the original intents of our article was to point out
to other ophthalmologists the steady decline in sensitivi-
ties of gram-positive, endophthalmitis-causing to third-
generation fluoroquinolones such as ciprofloxacin at our
institution. This declining sensitivity has been the case for
other institutions and other types of ocular infections, such
as keratitis, as well.2,3
The Indian experience reported by Anand and associ-
ates4 was very different with respect to sensitivities to the
third-generation fluoroquinolones. We referred to this
publication in our article because his sensitivities were
closer to those reported by Dr Vedantham. It would be
interesting to know whether the Indian experience will
follow that which has taken place at our institution over 5
years. Of note, in our series, 91% of gram-positive endoph-
1168 AMERICAN JOURNAL
by 2001, only 36% of gram-positive endophthalmitis iso-
lates were sensitive to ciprofloxacin. Regional variability in
sensitivities of infectious agents to particular antibiotics
should encourage us all to perform periodic reviews of local
sensitivities on a regular basis. Doing so enables us to treat
infections with the most appropriate antibiotics.
We believe Dr Vedantham’s data on the poor rate (only
three of 39) of sensitivities of traumatic endophthalmitis
isolates to vancomycin at his institution to be peculiar. It
would be worthwhile to know the microbiologic spectrum
of these 39 cases. Was there a particularly high rate of
gram-negative or fungal infections? In our series of post-
traumatic endophthalmitis, we found 80% of isolates were
gram positive, 8% were gram negative, and 12% were
fungal. This may once again underscore the importance in
regional variability not only in antibiotic sensitivities but
also in microbiologic spectra of endophthalmitis-causing
organisms. Among approximately 700 gram-positive en-
dophthalmitis-causing isolates at the Bascom Palmer Eye
Institute from 1990 to 2003, we have not yet found one
resistant to vancomycin.
Dr Vedantham suggests that ciprofloxacin may be useful
as an alternative to ceftazidime for gram-negative coverage
when treating endophthalmitis with intravitreal injec-
tions. Given the rather steady decline in antibiotic sensi-
tivities to ciprofloxacin over the past few years, we would
not advocate this approach. Fourth-generation fluoro-
quinolones, such as gatifloxacin and moxifloxacin, may be
better alternatives to ciprofloxacin. We will be presenting
at the Association for Research in Vision and Ophthal-
mology (ARVO) our data from the Bascom Palmer Eye
Institute on the sensitivities of endophthalmitis-causing
isolates to the fourth-generation fluoroquinolones.
MATTHEW S. BENZ, MD
Houston, Texas
HARRY W. FLYNN, JR, MD
INGRID U. SCOTT, MD, MPH
DARLENE MILLER, MPH, MA
Miami, Florida
REFERENCES
1. Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D.
Endophthalmitis isolates and antibiotic sensitivities: A 6-year
review of culture-proven cases. Am J Ophthalmol 2004;137:
38 –42.
2. Alexandrakis G, Alfonso EC, Miller D. Shifting trends in
bacterial keratitis in south Florida and emerging resistance to
fluoroquinolones. Ophthalmology 2000;107:1497–1502.
3. Goldstein MH, Kowalski RP, Gordon YJ. Emerging fluoro-
quinolone resistance in bacterial keratitis: A 5-year review.
Ophthalmology 1999;106:1313–1318.
4. Anand AR, Therese KL, Madhavan HN. Spectrum of aetio-
logical agents of postoperative endophthalmitis and antibiotic
susceptibility of bacterial isolates. Indian J Ophthalmol 2000;
48:123–128.
OF OPHTHALMOLOGY JUNE 2004