Bilateral hematogenous Pseudomonas aeruginosa endophthalmitis after lung transplantation

Regional Variation of Infectious Agents Causing Endogenous Endophthalmitis in the United States: A National Database Analysis

OBJECTIVE

To describe regional variation in microbes causing infectious endogenous endophthalmitis (EE) in the United States.

DESIGN

This is a retrospective, national database analysis utilizing the 2002-2014 National Inpatient Sample database.

SUBJECTS

Using the International Classification of Disease 9 codes, we identified cases with EE. Cases were stratified regionally into Northeast, South, West, or Midwest.

METHODS

Unadjusted chi-square analysis followed by adjusted multivariate logistic regression was performed to evaluate variation in demographic factors, comorbidities using the Elixhauser Comorbidity Index (ECI), microbial variation, mortality, and use of vitrectomy or enucleation by region.

MAIN OUTCOME MEASURES

Proportion of microbes, mortality, and vitrectomy by region in addition to factors with significant odds ratios for mortality and for in-hospital vitrectomy.

RESULTS

A total of 10 912 patients with infectious EE were identified, with 2063 cases in the Northeast (18.9%), 2145 cases in the Midwest (19.7%), 4134 cases in the South (37.9%), and 2570 cases in the West (23.6%). Chi-square analysis indicated significant regional variation in patient demographics, microbes causing the infection, ECI, mortality, and surgical intervention. The 4 most common microbes for all regions were methicillin-sensitive Staphylococcus aureus (MSSA), Streptococcus, Candida, and methicillin-resistant Staphylococcus aureus. Methicillin-sensitive S. aureus was the most common cause of EE in all regions, although the proportion of MSSA infection did not significantly vary by region (P = 0.03). Further, there was significant regional variation in the proportion of other microbes causing the infection (P < 0.001). Higher rates of vitrectomies were seen in the South and Midwest regions than that in the Northeast and West (P = 0.04).

CONCLUSIONS

Regional variation exists in the infectious microbes causing EE. Further studies are needed to elucidate the etiology of these variations.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Successful non-surgical treatment of pseudomonas choroidal abscess in cystic fibrosis with previous double lung transplantation

Pseudomonas aeruginosa choroidal abscess is a rare condition which tends to affect patients with cystic fibrosis (CF) who have undergone double lung transplantation. Various surgical treatment strategies have been described but almost universally have had a dismal prognosis. We present a case of pseudomonas choroidal abscess in a CF patient with previous double lung transplantation who was managed with medical treatment, with intravitreal and systemic antibiotics, without surgical intervention, which led to successful resolution of the choroidal abscess, preservation of the eye and retention of vision.

The Impact of Resistant Bacterial Pathogens including Pseudomonas aeruginosa and Burkholderia on Lung Transplant Outcomes

Pseudomonas and Burkholderia are gram-negative organisms that achieve colonization within the lungs of patients with cystic fibrosis, and are associated with accelerated pulmonary function decline. Multidrug resistance is a hallmark of these organisms, which makes eradication efforts difficult. Furthermore, the literature has outlined increased morbidity and mortality for lung transplant (LTx) recipients infected with these bacterial genera. Indeed, many treatment centers have considered Burkholderia cepacia infection an absolute contraindication to LTx. Ongoing research has delineated different species within the B. cepacia complex (BCC), with significantly varied morbidity and survival profiles. This review considers the current evidence for LTx outcomes between the different subspecies encompassed within these genera as well as prophylactic and management options. The availability of meta-genomic tools will make differentiation between species within these groups easier in the future, and will allow more evidence-based decisions to be made regarding suitability of candidates colonized with these resistant bacteria for LTx. This review suggests that based on the current evidence, not all species of BCC should be considered contraindications to LTx, going forward.

[Bilateral 4MRGN Pseudomonas aeruginosa-associated choroidal abscesses in cystic fibrosis : Bilateral enucleation of the eyes as a last resort in a life-threatening situation]

We present a case of bilateral choroidal abscesses due to a multidrug-resistant gram negative (4MRGN) Pseudomonas aeruginosa lung colonization in a patient with cystic fibrosis under immunosuppression after lung transplantation. Bilateral choroidal and subretinal abscesses were detected by funduscopy, ultrasound, magnetic resonance imaging (MRI) and phacovitrectomy and were accompanied by bilateral acute vision loss. The diagnosis was confirmed by intraoperative subretinal biopsy. Due to therapy resistance a bilateral enucleation for life-saving purposes was performed.

Endogenous endophthalmitis: diagnosis, management, and prognosis

Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. Microorganisms associated with this condition vary along a broad spectrum. Depending upon the severity of the disease, both medical and surgical interventions may be employed. Due to rarity of the disease, there are no guidelines in literature for optimal management of these patients. In this review, treatment guidelines based on clinical data and microorganism profile have been proposed.

Endogenous endophthalmitis after carotid endarterectomy due to exudative macular degeneration

A 78-year-old male patient with unilateral exudative macular degeneration developed endogenous endophthalmitis 11 days after carotid endarterectomy. The endophthalmitis could not be treated by intravitreal application of antibiotics. The patient underwent vitrectomy and systemic application of vancomycin. Six days later, the eye was quiet and the patient was discharged with a visual acuity of 0.9 logMAR.Patients with exudative macular degeneration have a higher risk for developing endogenous endophthalmitis after vascular surgery of the carotid arteries and prolonged postoperative application of systemic antibiotics might be considered in these patients.

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.

Early surgical debridement in the management of infectious scleritis after pterygium excision

PURPOSE

The purpose of this study was to report outcomes of infectious scleritis after pterygium surgery, managed with antibiotic therapies and early scleral debridement.

METHODS

Retrospective chart review of 13 consecutive cases of infectious scleritis after pterygium excision between 1999 and 2009 was conducted. Collected data included prior medical and surgical history, latency period between pterygium surgery and presentation of infectious scleritis, culture and histopathologic findings, antibiotic regimen, length of hospital stay, visual acuity before and after treatment, and complications.

RESULTS

Median follow-up was at 14 months. Twelve patients underwent prompt surgical debridement after infectious scleritis diagnosis (median, 2.5 days). Debridement was delayed in one patient. Median hospital stay was 3 days. Best-corrected visual acuity improved in ten patients, remained stable in one patient, and decreased in two patients following treatment. Complications included scleral thinning requiring scleral patch graft (1/13), glaucoma (3/13), and progression to phthisis bulbi (1/13). No patients required enucleation.

CONCLUSIONS

In contrast to the generally poor outcomes in the literature, early surgical debridement of pterygium-associated infectious scleritis appears to offer improved prognosis.

Differential roles of OxyR-controlled antioxidant enzymes alkyl hydroperoxide reductase (AhpCF) and catalase (KatB) in the protection of Pseudomonas aeruginosa against hydrogen peroxide in biofilm vs. planktonic culture

The role of the Pseudomonas aeruginosa OxyR-controlled antioxidants alkyl hydroperoxide reductase CF (AhpCF) and catalase B (KatB) was evaluated in biofilm vs. planktonic culture upon exposure to hydrogen peroxide. AhpCF was found to be critical for survival of biofilm bacteria while KatB was more important for survival of planktonic free-swimming organisms.

The peptidoglycan-associated lipoprotein OprL helps protect a Pseudomonas aeruginosa mutant devoid of the transactivator OxyR from hydrogen peroxide-mediated killing during planktonic and biofilm culture

OxyR controls H(2)O(2)-dependent gene expression in Pseudomonas aeruginosa. Without OxyR, diluted (<10(7)/ml) organisms are easily killed by micromolar H(2)O(2). The goal of this study was to define proteins that contribute to oxyR mutant survival in the presence of H(2)O(2). We identified proteins in an oxyR mutant that were oxidized by using 2,4-dinitrophenylhydrazine for protein carbonyl detection, followed by identification using a two-dimensional gel/matrix-assisted laser desorption ionization-time of flight approach. Among these was the peptidoglycan-associated lipoprotein, OprL. A double oxyR oprL mutant was constructed and was found to be more sensitive to H(2)O(2) than the oxyR mutant. Provision of the OxyR-regulated alkyl hydroperoxide reductase, AhpCF, but not AhpB or the catalase, KatB, helped protect this strain against H(2)O(2). Given the sensitivity of oxyR oprL bacteria to planktonic H(2)O(2), we next tested the hypothesis that the biofilm mode of growth might protect such organisms from H(2)O(2)-mediated killing. Surprisingly, biofilm-grown oxyR oprL mutants, which (in contrast to planktonic cells) possessed no differences in catalase activity compared to the oxyR mutant, were sensitive to killing by as little as 0.5 mM H(2)O(2). Transmission electron microscopy studies revealed that the integrity of both cytoplasmic and outer membranes of oxyR and oxyR oprL mutants were compromised. These studies suggest that sensitivity to the important physiological oxidant H(2)O(2) in the exquisitely sensitive oxyR mutant bacteria is based not only upon the presence and location of OxyR-controlled antioxidant enzymes such as AhpCF but also on structural reinforcement by the peptidoglycan-associated lipoprotein OprL, especially during growth in biofilms.

Endogenous endophthalmitis following ipsilateral carotid endarterectomy

We report a case involving a 75-year-old lady who presented to our department of ophthalmology complaining of a 1 day history of ocular pain and reduced vision in the right eye, associated with rigors and diarrhoea. This patient, who had undergone a right carotid endarterectomy (CEA) 4 days previously, was subsequently confirmed to have developed endogenous endophthalmitis. To our knowledge, endogenous endopthalmitis has not previously been described as a postoperative complication of CEA, and should be considered in patients presenting with ocular complaints after this type of surgery.