title: An outbreak of streptococcus endophthalmitis after intravitreal injection of bevacizumab.
abstract: OBJECTIVE
  To report a series of patients with Streptococcus endophthalmitis after injection with intravitreal bevacizumab prepared by the same compounding pharmacy.
  
  
  METHODS
  Noncomparative consecutive case series.
  
  
  METHODS
  Medical records and microbiology results of patients who presented with endophthalmitis after injection with intravitreal bevacizumab between July 5 and July 8, 2011, were reviewed.
  
  
  RESULTS
  Twelve patients were identified with endophthalmitis, presenting 1 to 6 days after receiving an intravitreal injection of bevacizumab. The injections occurred at 4 different locations in south Florida. All patients received bevacizumab prepared by the same compounding pharmacy. None of the infections originated at the Bascom Palmer Eye Institute, Miami, Florida, although 9 patients presented to its tertiary-care ophthalmic emergency room for treatment, and 3 additional patients were seen in consultation. All patients were treated initially with a vitreous tap and injection; 8 patients subsequently received a vitrectomy. Microbiology cultures for 10 patients were positive for Streptococcus mitis/oralis. Seven unused syringes of bevacizumab prepared by the compounding pharmacy at the same time as those prepared for the affected patients also were positive for S. mitis/oralis. After 4 months of follow-up, all but 1 patient had count fingers or worse visual acuity, and 3 required evisceration or enucleation. Local, state, and federal health department officials have been investigating the source of the contamination.
  
  
  CONCLUSIONS
  In this outbreak of endophthalmitis after intravitreal bevacizumab injection, Streptococcus mitis/oralis was cultured from the majority of patients and from all unused syringes. Visual outcomes were generally poor. The most likely cause of this outbreak was contamination during syringe preparation by the compounding pharmacy.
authors.affiliation: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida 33136, USA. rgoldberg.eyemd@gmail.com
authors.forename: Roger A
authors.initials: RA
authors.lastname: Goldberg
authors.forename: Harry W
authors.initials: HW
authors.lastname: Flynn
authors.forename: Ryan F
authors.initials: RF
authors.lastname: Isom
authors.forename: Darlene
authors.initials: D
authors.lastname: Miller
authors.forename: Serafin
authors.initials: S
authors.lastname: Gonzalez
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000009:adverse effects*; D000068258:Bevacizumab; D003131:Combined Modality Therapy; D004196:Disease Outbreaks; D004339:Drug Compounding; D004340:Drug Contamination; D009877:Endophthalmitis / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D015818:Eye Infections, Bacterial / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D005260:Female; D005431:Florida / Q000453:epidemiology; D006801:Humans; D058449:Intravitreal Injections; D008297:Male; D013290:Streptococcal Infections / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D034361:Streptococcus mitis / Q000302:isolation & purification; D019533:Streptococcus oralis / Q000302:isolation & purification; D014640:Vancomycin / Q000627:therapeutic use; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors; D014792:Visual Acuity; D014821:Vitrectomy; D014822:Vitreous Body / Q000382:microbiology
chemical_list: D020533:Angiogenesis Inhibitors; D000900:Anti-Bacterial Agents; D061067:Antibodies, Monoclonal, Humanized; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D014640:Vancomycin