Failure of systemic antibiotic in preventing sequential endogenous endophthalmitis of a bronchiectasis patient

Gram-Negative Endogenous Endophthalmitis: A Systematic Review

Background: Gram-negative bacteria are causative agents of endogenous endophthalmitis (EBE). We aim to systematically review the current literature to assess the aetiologies, risk factors, and early ocular lesions in cases of Gram-negative EBE. Methods: All peer-reviewed articles between January 2002 and August 2022 regarding Gram-negative EBE were included. We conducted a literature search on PubMed and Cochrane Controlled Trials. Results: A total of 115 studies and 591 patients were included, prevalently Asian (98; 81.7%) and male (302; 62.9%). The most common comorbidity was diabetes (231; 55%). The main aetiologies were Klebsiella pneumoniae (510; 66.1%), Pseudomonas aeruginosa (111; 14.4%), and Escherichia coli (60; 7.8%). Liver abscesses (266; 54.5%) were the predominant source of infection. The most frequent ocular lesions were vitreal opacity (134; 49.6%) and hypopyon (95; 35.2%). Ceftriaxone (76; 30.9%), fluoroquinolones (14; 14.4%), and ceftazidime (213; 78.0%) were the most widely used as systemic, topical, and intravitreal anti-Gram-negative agents, respectively. The most reported surgical approaches were vitrectomy (130; 24.1%) and evisceration/exenteration (60; 11.1%). Frequently, visual acuity at discharge was no light perception (301; 55.2%). Conclusions: Gram-negative EBEs are associated with poor outcomes. Our systematic review is mainly based on case reports and case series with significant heterogeneity. The main strength is the large sample spanning over 20 years. Our findings underscore the importance of considering ocular involvement in Gram-negative infections.

Systematic review of 342 cases of endogenous bacterial endophthalmitis

We review a total of 342 cases of endogenous bacterial endophthalmitis reported between 1986 and 2012. Predisposing conditions were present in 60%, most commonly diabetes, intravenous drug use, and malignancy. The most common sources of infection were liver, lung, endocardium, urinary tract, and meninges. Systemic features such as fever were present in 74%, hypopyon in 35%, and an absent fundal view in 40%. Diagnostic delay occurred in 26%. Blood cultures were positive in 56%, and at least one intraocular sample was positive in 58% (comprising 26% anterior chamber samples, 59% vitreous taps, and 41% vitrectomy specimens). Worldwide, Gram negative infections (55%) were more frequent than Gram positive (45%) infections, particularly in Asia. Over the last decade, 11% of eyes were treated with systemic antibiotics alone, 10% intravitreal antibiotics alone, 36% systemic plus intravitreal antibiotics, and 20% systemic plus intravitreal antibiotics plus pars plana vitrectomy. The most commonly used intravitreal antibiotics were vancomycin (for Gram positive infection) and ceftazidime (Gram negative). The median final visual acuity was 20/100, with 44% worse than 20/200. Among all cases, 24% required evisceration or enucleation, and mortality was 4%. Both intravitreal dexamethasone and vitrectomy were each associated with a significantly greater chance of retaining 20/200 or better and significantly fewer eviscerations or enucleations-these warrant further study. For most patients, treatment should include a thorough systemic evaluation and prompt intravitreal and systemic antibiotics.

Endogenous Pseudomonas endophthalmitis in an immunocompetent patient

PURPOSE

To report an unusual case of community-acquired Pseudomonas aeruginosa pneumonia in an immunocompetent host complicated by orbital cellulitis, panophthalmitis, and subcutaneous nodules.

METHODS

An otherwise healthy 47-year-old woman presented with a 24-hour history of fever, cutaneous nodules, right sided pleuritic chest pain, and eyelid edema with severe vision loss in her right eye. A chest X-ray demonstrated a homogeneous infiltrate in the right upper lobe. Ophthalmic examination revealed signs of metastatic orbital cellulitis and panophthalmitis. Culture specimens from blood, sputum, skin, and vitreous showed a significant growth of P. aeruginosa species.

RESULTS

Intravenous antibiotic therapy led to resolution of the pneumonia, cutaneous nodules, and orbital cellulitis. Despite intravitreal and topical antibiotics, the patient finally required enucleation.

CONCLUSION

This case represents a rare combination of manifestations in an immunocompetent patient with P. aeruginosa infection. It highlights the accelerated course that may result from P. aeruginosa infection, the difficulties of treatment, and the poor prognosis in the case of eye involvement.