title: An outbreak of fungal endophthalmitis after intravitreal injection of compounded combined bevacizumab and triamcinolone.
abstract: OBJECTIVE
  Our experience may be useful to other practitioners using compounded intravitreal agents, those suspecting infectious outbreaks, and those managing fungal endophthalmitis.
  
  
  OBJECTIVE
  To describe a series of patients with fungal endophthalmitis following intravitreal injection of combined bevacizumab and triamcinolone acetonide prepared by the same compounding pharmacy.
  
  
  METHODS
  Noncomparative case series.
  
  
  METHODS
  Eight eyes of 8 patients who received an intravitreal injection of compounded combined bevacizumab-triamcinolone in a period of 3 weeks had subtle, nonspecific findings that were later diagnosed as fungal endophthalmitis.
  
  
  METHODS
  Visual acuity, response to antimicrobial therapy, and number of vitreoretinal surgical operations after diagnosis of fungal endophthalmitis.
  
  
  RESULTS
  Eight patients developed endophthalmitis 41 to 97 days after receiving the intravitreal injection, which was prepared by the same compounding pharmacy. The injections occurred at the same location in New York. Treatment was based on clinical examination findings and knowledge of the etiology of the endophthalmitis. Eventually, all patients were treated with oral voriconazole. Five of 8 patients were initially treated with intravitreal antimicrobial agents. After 3 months of follow-up, visual acuities ranged from 20/50 to hand motions. Local, state, and federal health department officials were involved in investigating the source of the outbreak.
  
  
  CONCLUSIONS
  In the current study, we report a fungal endophthalmitis outbreak after intravitreal injection of contaminated, compounded combined bevacizumab-triamcinolone. In this series, Bipolaris hawaiiensis was the identified causative agent. The challenge of medical diagnosis, identification of the source of the outbreak, and management experience are highlighted in our series. Our experience may be useful to other practitioners using compounded intravitreal agents, those suspecting infectious outbreaks, and those managing fungal endophthalmitis.
authors: Department of Ophthalmology, Mount Sinai School of Medicine, New York, NY 10029, USA.
authors: Alan T
authors: AT
authors: Sheyman
authors: Ben Z
authors: BZ
authors: Cohen
authors: Alan H
authors: AH
authors: Friedman
authors: Jessica M
authors: JM
authors: Ackert
mesh_terms: D000368:Aged; D020533:Angiogenesis Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000627:therapeutic use*; D001203:Ascomycota / Q000302:isolation & purification*; D000068258:Bevacizumab; D003131:Combined Modality Therapy; D004196:Disease Outbreaks; D004339:Drug Compounding; D004340:Drug Contamination; D004359:Drug Therapy, Combination; D009877:Endophthalmitis / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D015821:Eye Infections, Fungal / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D058449:Intravitreal Injections; D008269:Macular Edema / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology* / Q000382:microbiology / Q000628:therapy; D009518:New York / Q000453:epidemiology; D014222:Triamcinolone Acetonide / Q000008:administration & dosage / Q000627:therapeutic use*; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors; D014792:Visual Acuity / Q000502:physiology; D014821:Vitrectomy; D014822:Vitreous Body / Q000382:microbiology
chemical_list: D020533:Angiogenesis Inhibitors; D000900:Anti-Bacterial Agents; D061067:Antibodies, Monoclonal, Humanized; D005938:Glucocorticoids; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D014222:Triamcinolone Acetonide