Bacterial endophthalmitis in neonates

Primary evisceration for neonatal endogenous endophthalmitis: A report of two cases

Purpose

To present two cases of neonatal endophthalmitis with poor prognosis that were managed with primary evisceration.

Observations

Case 1 is a 27-weeks’ gestation neonate who developed Pseudomonas aeruginosa endophthalmitis complicated by globe rupture. Case 2 describes a 34-weeks’ gestation neonate with Serratia marcescens endophthalmitis. Both patients had poor prognosis and thus underwent primary evisceration with good long-term cosmetic outcomes at 15 years and 17 months, respectively.

Conclusions and Importance

Primary evisceration should be considered in neonates with endophthalmitis with a poor prognosis and can result in good long-term cosmesis.

Trends in Infantile Endogenous Endophthalmitis Hospitalizations in the United States: An Analysis from 2007 through 2014 Using the National Inpatient Sample

PURPOSE

To determine the annual change in incidence of neonatal and infantile endogenous endophthalmitis in the United States between 2007 and 2014 and identify associated risk factors for development of endophthalmitis and mortality.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Neonates (<28 days; n = 1650) hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants (age range, 28 days-1 year; n = 1850) hospitalized between 2007 and 2014 across United States community hospitals were analyzed.

METHODS

The Nationwide Inpatient Sample database was queried to identify neonates hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants hospitalized between 2007 and 2014 across the United States. National and regional incidence of neonatal and infantile endogenous endophthalmitis and comorbidities as well as risk factors in the development of the disease and predictive factors for mortality from the years 2007 through 2014 were calculated.

MAIN OUTCOMES AND MEASURES

National incidence, regional incidence, and risk factors for development of neonatal and infantile endogenous endophthalmitis.

RESULTS

The rate of decline in incidence of neonatal endogenous endophthalmitis was 4% from 2003 through 2014. The rate of decline in the infantile population was 7% from 2007 through 2014. In 2007, an estimated 291 total cases of infantile endophthalmitis were identified, in comparison with 140 cases in 2014. Comorbidities prevalent in the endophthalmitis population included prematurity, respiratory disorders, perinatal infections, and retinopathy of prematurity (ROP). Significant positive predictors for the development of endogenous endophthalmitis based on multivariate logistic regression were perinatal infections, candidemia, bacteremia, very low birth weight, prematurity, respiratory disorders, and ROP. Descriptive analyses showed that the in-hospital mortality rate for patients identified with endophthalmitis was 1.55% in comparison with infants without endophthalmitis.

CONCLUSIONS

The incidence of endogenous endophthalmitis declined in both the neonatal and infantile population from 2007 through 2014. Odds of endogenous endophthalmitis were higher for premature and low-birthweight infants and those identified with perinatal infections, candidemia, bacteremia, respiratory disorders, or ROP. These findings are consistent with the decline observed in pediatric infectious disease-related hospitalizations in general.

Post-Ranibizumab injection endophthalmitis in aggressive posterior retinopathy of prematurity

A preterm infant with zone 1 aggressive posterior retinopathy of prematurity developed infectious endophthalmitis after intravitreal injection of ranibizumab. Urgent empirical intravitreal therapy with vancomycin, ceftazidime, and dexamethasone along with intravenous therapy with amikacin and meropenem helped in early resolution. Vascularization/activity of disease subsided on follow-up, media cleared, and laser photocoagulation was completed. Later the disease reactivated, developed vitreous membranes and central retinal traction, for which 25-gauge lens-sparing vitrectomy was performed. Emergent treatment helped in salvaging the eye from both aggressive ROP disease and devastating endophthalmitis. Rationale approach to such a case is being discussed.

Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis

PURPOSE

To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis.

METHODS

This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible.

RESULTS

Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged.

CONCLUSIONS

Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.

Neonatal endogenous endophthalmitis: a report of six cases

Endogenous endophthalmitis is a rare but potentially blinding complication of neonatal sepsis. Early diagnosis and aggressive treatment are essential to avoid vision loss. Therapeutic options include systemic and intravitreal antibiotics, as well as vitrectomy in selected cases. We report a series of 6 premature very low birth weight neonates who developed endogenous endophthalmitis in our NICU over the past 3 years. Endophthalmitis was part of early-onset sepsis in 2 newborns, both of whom died, and late-onset sepsis in 4 newborns, of which 1 infant died. None of the neonates had any history of previous trauma or intervention to the eye. Maternal screening for congenital infections, including HIV, was negative in all. Causative organisms included Klebsiella pneumoniae (2 cases), Pseudomonas aeruginosa (2 cases), Methicillin-resistant Staphylococcus aureus (1 case), and Candida albicans (1 case). All bacterial isolates showed resistance to first-line antibiotics. Of the 3 survivors, 2 infants had normal vision in the affected eye, and 1 developed phthisis bulbi after corneal perforation and required enucleation. This report draws attention to the emergence of endophthalmitis as a complication of neonatal sepsis in places where, although survival of very low birth weight newborns has increased significantly due to improved care, the burden of infection continues to be high. We emphasize the importance of daily examination of eyes as a part of routine clinical care in septic newborns for early diagnosis of endophthalmitis and prompt intervention in consultation with an ophthalmologist to optimize the outcome.

Declining incidence of neonatal endophthalmitis in the United States

PURPOSE

To determine the incidence of neonatal endogenous endophthalmitis in the United States between 1998 and 2006 and to identify associated risk factors.

DESIGN

Retrospective cohort study.

METHODS

We used the Nationwide Inpatient Sample database, a 20% representative sample of all hospital discharges in the United States, to help refine our understanding of this condition. International Classification of Diseases, ninth edition, codes for endophthalmitis, sepsis, and suspected endophthalmitis risk factors in hospitalized infants and neonates were searched in the database and were tracked over time. The main outcome measure was incidence of neonatal endophthalmitis over the study period.

RESULTS

Of 3.64 million live births in 1998, 317 newborns were identified with endophthalmitis (8.71 cases per 100 000 live births). Of 4.14 million live births in 2006, only 183 newborns were identified with endophthalmitis (4.42 cases per 100 000 live births) by comparison. The incidence of endophthalmitis decreased at a rate of 6% per year (P = .01130) between 1998 and 2006. Neonates with endophthalmitis were more likely to have systemic bacteremia (odds ratio, 21.114; P < .0001), Candidemia (odds ratio, 2.356; P < .0001), a birth weight of less than 1500 g (odds ratio, 1.215; P < .0001), and retinopathy of prematurity (odds ratio, 2.052; P < .0001).

CONCLUSIONS

We objectively validated the commonly held belief that Candidemia, bacteremia, retinopathy of prematurity, and low birth weight are significant risk factors for endophthalmitis development in infants, which seems to have had a decreasing incidence in recent years.

Pseudomonas aeruginosa endophthalmitis in a preterm infant

Bacterial endophthalmitis is rare in the neonatal period. It occurs in susceptible individuals such as preterm infants. Pseudomonas aeruginosa, a Gram-negative bacillus, has been identified as the causative organism in more than 75% of invasive neonatal eye infections. The source may be endogenous; secondary to septicemia or exogenous, including reports of nosocomial infections and those infections arising from the birth canal. We report the case of a preterm infant who developed pseudomonas endophthalmitis, septicemia, and meningitis after a corneal abrasion.

Pseudomonas aeruginosa infections in a neonatal intensive care unit

This report describes a cluster of nosocomial infections with Pseudomonas aeruginosa in a neonatal intensive care nursery. All 5 cases of P aeruginosa infection were clustered in September 1999. Aggressive infection control measures were instituted, including installation of a user-friendly handwashing soap and environmental cleaning. On the basis of the finding of persistent dirty equipment, a new full-time position was created that was dedicated to equipment cleaning. These measures were effective in eliminating the cluster. The nursery has remained free of P aeruginosa infection for more than 2 years, attesting to the success of our program.

Pseudomonas-induced bilateral endophthalmitis with corneal perforation in a neonate

Neonatal endophthalmitis is a rare entity that may be exogenous or endogenous. Pseudomonas aeruginosa is a ubiquitous gram-negative rod that may appear as a nosocomial source of infection in the neonatal intensive care unit. A case of bilateral Pseudomonas-induced endophthalmitis is presented, and a discussion of the case and of the relevant literature follows.

Neonatal infections with Pseudomonas aeruginosa associated with a water-bath used to thaw fresh frozen plasma

In our 15-bed neonatal intensive care unit (NICU), four new-borns were found to be colonized or infected with Pseudomonas aeruginosa within a period of one week. To identify the outbreak source, three independent studies were performed: epidemiological investigation, environmental surveillance and genotypic typing of isolates. Although epidemiological investigation by a case-control study revealed no conclusive results, the transfusion of fresh frozen plasma (FFP) and human albumin (HA) appeared to be the factor with highest risk. Environmental surveillance and random amplification of polymorphic DNA (RAPD) of isolates identified a water-bath used to warm FFP and HA as the likely reservoir for the outbreak. Further spread of the organism did not occur after elimination of this water-bath from the NICU. RAPD identified in addition an isolate from an infant hospitalized in the NICU five months before the outbreak with a pattern matching the one of the outbreak cluster.

Complications of conjunctivitis caused by Pseudomonas aeruginosa in a newborn intensive care unit

BACKGROUND

In infancy Pseudomonas aeruginosa conjunctivitis may lead to a rapidly progressive invasive eye infection. In some cases this destructive eye disease is associated with or followed by infection at other sites. We observed seven hospitalized infants with P. aeruginosa conjunctivitis who developed systemic complications of P. aeruginosa infection without evidence of invasive eye disease, prompting us to examine the characteristics of this infection and its associated systemic complications in hospitalized infants.

METHODS

We reviewed retrospectively the course, treatment and outcome of infants with nonepidemic P. aeruginosa conjunctivitis in the Newborn Special Care Unit at Yale-New Haven Hospital during a 10-year period from November 1, 1986, to October 31, 1996.

RESULTS

Eighteen infants with P. aeruginosa conjunctivitis had mean birth weights and gestational ages of 29.3 weeks and 1380 g, respectively. The average postnatal age at onset of P. aeruginosa conjunctivitis was 17 days. No infant had invasive eye disease. Systemic complications occurred in seven (39%) infants and included bacteremia, meningitis, brain abscess and death. Infants who developed systemic complications had lower mean birth weights (850 g vs. 1716 g, P = 0.04) and lower mean gestational ages (26.4 vs. 31.2 weeks, P = 0.02) than infants who did not. Six of seven infants weighing < 1000 g developed systemic complications; two of these infants died.

CONCLUSIONS

In hospitalized infants P. aeruginosa conjunctivitis may be associated with systemic complications with or without invasive eye infection, emphasizing the need for early detection and treatment of this infection in this population.