Antimicrobial resistance in post-cataract endophthalmitis: a systematic review on resistance pattern and treatment...

To systematically review the microbiological spectrum, antimicrobial resistance (AMR) patterns, management strategies, and outcomes in culture-positive endophthalmitis, a rare vision-threatening complication of cataract surgery increasingly challenged by resistance.

A comprehensive literature search was conducted in PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 1 January 1990 to 30 June 2025. Eligible studies included culture-positive cases of acute Post-Cataract Endophthalmitis reporting antimicrobial susceptibility and outcomes. Data were extracted on organisms, resistance profiles, treatment strategies and visual acuity. Risk of bias was assessed using the ROBINS-I tool.

Six studies (five retrospective, one prospective) from Europe, Asia, and North America met inclusion criteria. Coagulase-negative staphylococci predominated, with frequent methicillin and fluoroquinolone resistance; Staphylococcus, Streptococcus, and Pseudomonas were less common. An Indian cohort described multidrug-resistant Pseudomonas with near-universal resistance to fluoroquinolones, aminoglycosides, and cephalosporins but susceptibility to colistin, piperacillin, and imipenem. While vancomycin remained active against Gram-positive organisms, emerging resistance was reported in the United Kingdom. Visual outcomes varied: tap-and-inject was comparable to early pars plana vitrectomy (PPV), except in Gram-negative infections where PPV conferred benefit. Amikacin resistance correlated with poorer outcomes, whereas vancomycin or moxifloxacin resistance did not. Systemic antibiotics and intravitreal corticosteroids showed no consistent benefit.

AMR in Post-Cataract Endophthalmitis is an escalating concern with marked geographic variation. Prompt intravitreal therapy remains the key determinant of prognosis, but empiric regimens must reflect local resistance trends, particularly for Gram-negative coverage. Current evidence is limited by retrospective design and regional variability; multicentre prospective studies are needed to refine prophylaxis and treatment protocols, reducing visual and economic burden.