Stenotrophomonas maltophilia Induced Post-Cataract-Surgery Endophthalmitis: Outbreak Investigation and Clinical Courses of 26 Patients

Ochrobactrum anthropi: A Rare Cause of Culture-Proven Acute Post-Operative Cluster Endophthalmitis

AIM

To report the clinical presentation and management outcomes of an outbreak of culture-proven post-operative endophthalmitis (POE) secondary to Ochrobactrum anthropi.

METHODS

This study was conducted at a tertiary-care eye hospital in South India.

RESULTS

Fifty-five patients underwent cataract surgery by six surgeons on three consecutive days in the same surgical facility in September 2020. Four patients developed POE after a mean interval of 12.0 ± 4.8 days and underwent immediate vitreous tap and intravitreal antibiotic injections (Vancomycin and Ceftazidime). All patients required a core vitrectomy (culture positive, n = 4/4). Two patients underwent an additional intraocular lens explantation, 2 and 4 months after presentation. All the four patients showed good anatomical and functional recoveries (mean follow-up, 5.75 ± 1.5 months). Two other patients had an exaggerated post-operative inflammation, which was successfully treated with topical medications.

CONCLUSIONS

O. anthropi is a rare cause of acute POE. Although the isolated organism was multi-drug resistant, the outcome was good in all the patients.

Conjunctival sac bacterial culture of patients using levofloxacin eye drops before cataract surgery: a real-world, retrospective study

Background

The use of antibiotics preoperatively is effective to decrease the incidence of ocular bacterial infections but may lead to high resistance rate, especially on patients with multi-risk clinical factors. This study systematically analyzed real-world data (RWD) of patients to reveal the association between clinical factors and conjunctival sac bacterial load and offer prophylaxis suggestions.

Methods

We retrieved RWD of patients using levofloxacin eye drops (5 mL: 24.4 mg, 4 times a day for 3 days) preoperatively. Retrieved data included information on the conjunctival sac bacterial culture, sex, presence of hypertension and diabetes mellitus (DM), and history of hospital-based surgeries. Data was analyzed using SPSS 24.0.

Results

RWD of 15,415 cases (patients) were retrieved. Among these patients, 5,866 (38.1%) were males and 9,549 (61.9%) females. 5,960 (38.7%) patients had a history of hypertension, and 3,493 (22.7%) patients had a history of DM. 7,555 (49.0%) patients had a history of hospital-based operations. There were 274 (1.8%) positive bacterial cultures. Male patients with hypertension and DM may be at increased risk of having positive bacterial cultures (P < 0.05). Staphylococcus epidermidis (n = 56, 20.4%), Kocuria rosea (n = 37, 13.5%), and Micrococcus luteus (n = 32, 11.7%) were the top 3 isolated strains. Most bacterial strains were resistant to various antibiotics except rifampin, and 82.5% (33 of 40 isolates) of Staphylococcus epidermidis isolates had multidrug antibiotic resistance. Numbers of culture-positive Staphylococcus epidermidis isolates in the male group and non-DM group were greater than those in the female and DM groups, respectively. Micrococcus luteus (n = 11, 8.8%) was found less frequently in non-hypertension group than in hypertension group.

Conclusion

Sex (Male) and the presence of hypertension and DM are risk factors for greater conjunctival sac bacterial loads. We offer a prophylactic suggestion based on the combined use of levofloxacin and rifampin. However, this approach may aggravate risk of multidrug resistance.

Clinical features of endophthalmitis clusters after cataract surgery and practical recommendations to mitigate risk: systematic review

Intraocular transmission of exogenous pathogens in cataract surgery can lead to endophthalmitis. This review evaluates the features of endophthalmitis clusters secondary to pathogen transmission in cataract surgery. Articles reporting on pathogen transmission in cataract surgery were identified via searches of Ovid MEDLINE, EMBASE, and Cochrane CENTRAL, and a total of 268 eyes from 24 studies were included. The most common source of infectious transmission was attributed to a contaminated intraocular solution (ie, irrigation solution, viscoelastic, or diluted antibiotic; n = 10). Visual acuity at presentation with infectious features was 1.89 logMAR (range: 1.35 to 2.58; ∼counting fingers) and 1.33 logMAR (range: 0.04 to 3.00; Snellen: ∼20/430) at last follow-up. Patients with diabetes had worse outcomes compared with patients without diabetes. The most frequently isolated pathogen from the infectious sources was Pseudomonas sp. (50.0%). This review highlights the various routes of pathogen transmission during cataract surgery and summarizes recommendations for the detection, prevention, and management of endophthalmitis clusters.

Antimicrobial Susceptibility, Minimum Inhibitory Concentrations, and Clinical Profiles of Stenotrophomonas maltophilia Endophthalmitis

Stenotrophomonas maltophilia has been reported in various ocular infections, including keratitis, conjunctivitis, preseptal cellulitis, and endophthalmitis, all of which may lead to vision loss. However, the S. maltophilia strain is resistant to a wide variety of antibiotics, including penicillins, third-generation cephalosporins, aminoglycosides, and imipenem. In this study, we retrospectively reviewed the clinical characteristics, antibiotic susceptibility, antimicrobial minimum inhibitory concentrations (MICs), and visual outcomes for S. maltophilia endophthalmitis. The data of 9 patients with positive S. maltophilia cultures in a tertiary referral center from 2010 to 2019 were reviewed. Cataract surgery (n  =  8, 89%) was the most common etiology, followed by intravitreal injection (n  =  1, 11%). S. maltophilia’s susceptibility to levofloxacin and moxifloxacin was observed in 6 cases (67%). Seven isolates were resistant to sulfamethoxazole-trimethoprim (78%). The MIC₉₀ for S. maltophilia was 256, 256, 256, 8, 12, 12, 12, and 8 μg/mL for amikacin, cefuroxime, ceftazidime, tigecycline, sulfamethoxazole-trimethoprim, levofloxacin, galtifloxacin, and moxifloxacin, respectively. Final visual acuity was 20/200 or better in 5 patients (56%). Fluoroquinolones and tigecycline exhibited low antibiotic MIC₉₀. Therefore, the results suggest that fluoroquinolones can be used as first-line antibiotics for S. maltophilia endophthalmitis.

Clinical and Optical Coherence Tomography Angiographic Features in Patients with Postcataract Stenotrophomonas maltophilia Endophthalmitis

Purpose

To report the clinical presentations and optical coherence tomography (OCT) angiographic features of patients with postcataract surgery endophthalmitis due to Stenotrophomonas maltophilia. Methods. A retrospective observational study of 4 patients who developed S. maltophilia endophthalmitis after cataract surgery. Pars plana vitrectomy (PPV) was performed to control the infection. Patients were followed up for six months. Complete ophthalmological examination results were collected before and after PPV.

Results

Patients' response to PPV therapy was excellent and the infection was cured in all cases. OCTA showed that, at the one-month follow-up, the vascular density (VD) and perfusion density (PD) in the superficial capillary plexus (SCP) were significantly lower than those in healthy collateral eyes. As time went on, the SCP-VD and SCP-PD values gradually improved.

Conclusions

With early PPV, the infection caused by S. maltophilia can be cured. OCTA provides a quantitative noninvasive assessment to evaluate the severity and prognosis of patients with S. maltophilia endophthalmitis.

Treatment outcomes of post cataract surgery endophthalmitis in a tertiary referral center in Iran

Purpose

To evaluate the treatment outcomes of patients with post cataract surgery endophthalmitis in our tertiary referral center.

Methods

In this prospective study, patients with presumed post cataract surgery endophthalmitis were treated based on the modified endophthalmitis vitrectomy study (EVS) guidelines and followed for at least three months. Visual and anatomical outcomes were assessed in the last follow-up visit.

Results

A total of 46 eyes with presumed post cataract surgery endophthalmitis were admitted to our hospital, of which 3 eyes with initial visual acuity of no light perception (NLP) and severe inflammation underwent primary evisceration. Forty-three patients were included to this study and followed up for at least three months. Culture results were positive in 51.2% of cases and streptococcus viridans was the most frequent isolated organism. Pars plana vitrectomy was performed in 16 eyes as primary treatment, and intravitreal antibiotic injection was done in 27 eyes. Re-treatment with pars plana vitrectomy was required in 15 eyes (34.9%). Best corrected visual acuity (BCVA) at final visit was 20/40 or better in 12 eyes (27.9%), between 20/200 to 20/40 in 17 eyes (39.5%), and worse than 20/200 in 14 eyes (32.6%). Evisceration was done in one eye (2.3%), and retinal detachment happened in 4 eyes (9.3%).

Conclusions

The visual outcomes of post cataract surgery endophthalmitis are generally poor. Our results in this study were comparable with many previous studies from other referral centers, however, unlike many reports, streptococcus viridans was the most common isolate in our study.

Stenotrophomonas maltophilia: An emerging entity for cluster endophthalmitis

PURPOSE

This was a study of acute cluster endophthalmitis along with clinical features, culture results, and visual outcomes of 10 eyes of 10 patients after intravitreal injection of Avastin (bevacizumab) in one sitting from a single vial.

METHODS

Retrospective review of intravitreal injection of 1.25 mg/0.05 ml bevacizumab that was given to 10 eyes of 10 patients on the same day from a freshly opened vial. All patients manifested with endophthalmitis the next day. Vitreous tap for direct smear and culture was done. Intravitreal antibiotics and steroids were injected and appropriate treatment begun. The injection vial of the same batch was sent for VITEKTM identification and antimicrobial susceptibility of isolates.

RESULTS

Endophthalmitis presented within 24 h of intravitreal injection. There was a remarkable absence of posterior pupillary synechia. Two cases were culture-positive (20%), showing pseudomonoid growth. The vial of the same batch revealed a pseudomonoid bacilli Stenotrophomonas maltophilia using VITEKTM, which was resistant to multiple drugs. Hence, the contaminated vial was identified as the source of infection in our case. Among 10 patients, two underwent pars plana vitrectomy. Visual acuity returned to preendophthalmitis levels in 9/10 eyes after 1 month. One patient was lost to follow-up. Late complications included retinal detachment in one case and neovascular glaucoma in another.

CONCLUSION

Early recognition and treatment are key factors in improving outcomes. Causative etiology could be microbial contamination of the drug vial. S. maltophilia should be considered a pathogenic organism of postintravitreal endophthalmitis.

Prophylactic removal and microbiological evaluation of calcified plaques after pterygium surgery

PURPOSE

The aim of this study was to investigate microbiological characteristics of prophylactically removed calcified plaques developed after pterygium excision, and to evaluate risk factors for the growth of microorganisms.

METHODS

Only exposed calcified plaques developed at the same site of previous pterygium excision were prospectively removed in 15 eyes of 14 patients. Plaques were completely removed, divided into small pieces and evaluated for microbiological identification. Underlying scleral defects were reconstructed using a conjunctival autograft, amniotic membranes and scleral patch grafts according to the size and depth of the defects. Based on the results of microbiologic cultures, eyes were divided into two groups and risk factors for microbial growth were analyzed.

RESULTS

At surgery, the mean age of the patients was 71.2 ± 5.8 years and 71.4 % were females. The mean time interval between pterygium excision and calcified plaque removal was 19.3 ± 13.8 years. Six of 15 (40 %) removed plaques showed bacterial growth, and Stenotrophomonas maltophilia was the most frequently isolated microorganism. The size of calcified plaques was the only risk factor for culture-positive results (p = 0.045). Underlying scleral defects were successfully repaired without any serious complication.

CONCLUSIONS

Microorganisms can be isolated from calcified plaques developed at the site of previous pterygium excision, and the size of plaques is the only risk factor for culture-positive results. To remove potential source of infection, prophylactic removal of calcified plaques and scleral surface reconstruction should be considered, especially when the plaques are exposed and large.

Stenotrophomonas maltophilia endophthalmitis caused by surgical equipment contamination: an emerging nosocomial infection

PURPOSE

We report three cases of Stenotrophomonas maltophilia endophthalmitis after uneventful extracapsular cataract extraction with intraocular lens implantation-related to surgical equipment contamination.

CASE REPORT

All patients developed acute, culture-positive endophthalmitis in a period ranging from 2 to 13 days. Cultures from vitreous tap, as well as those obtained from the hand-piece of the irrigation-aspiration system, revealed S. maltophilia as the causing infectious agent. All patients received intravitreal antibiotic treatment as initial therapy, nevertheless, visual disturbance continued to be present, hence pars plana vitrectomy was required.

CONCLUSION

Contamination of surgical-reusable equipment should be considered in addition to the well-known risk factors associated with development of endophthalmitis by S. maltophilia.

Post-cataract endophthalmitis caused by multidrug-resistant Stenotrophomonas maltophilia: clinical features and risk factors

Background

To report clinical features and risk factors of post-cataract surgery endophthalmitis (PE) due to Stenotrophomonas maltophilia.

Methods

A retrospective case review from December 10, 2010 to April 7, 2011 was performed at the Eye & ENT Hospital, Fudan University. Data were collected for surgical details, disease characteristics, antibiotic sensitivity of the pathogen, and treatment response. Visual outcomes were examined with a minimum follow-up of 12 months.

Results

Fourteen cases of S. maltophilia endophthalmitis were identified. The onset of infection occurred from 1–56 days postoperatively (median, 13.5 days). Obvious cellular reactions were found in all patients in the anterior chamber, along with the absence of pupil synechia. Retinal periphlebitis was an early sign of PE. S. maltophilia was positive in eight patients (57.1%). The fluids from aspiration tubes revealed the same bacteria, which were resistant to multiple drugs (e.g., amino glycosides, most of the β-lactams, aztreonam, imipenem, and ciprofloxacin), except levofloxacin. Compared with the culture-negative group, the infection was more rapid, more severe, and more difficult to control in the culture-positive group. Among 14 patients, 11 patients (78.6%) underwent pars plana vitrectomy (PPV) with intravitreal injection. Three patients had PPV twice, and three patients had intraocular lens and capsular bag removal. A final visual acuity of ≥20/100 was achieved by 13/14 patients (92.9%). Complications included retinal detachment in three cases (21.4%) and recurrence of infection in two cases (14.8%). Statistical analysis showed that age over 90 years and posterior capsule rupture were risk factors of infection (P = 0.034 and P = 0.034, respectively). The phacoemulsifier allowed potential contamination between the aspiration and irrigation tubes.

Conclusions

S. maltophilia should be considered a pathogenic organism of PE. The infection often occurs in older patients with posterior capsule rupture. Intravitreal or systemic administration of effective antibiotics and earlier initial PPV may contribute to better clinical outcomes. Tubes with connections between aspiration and irrigation should be avoided during surgery.

Stenotrophomonas maltophilia Pseudo-outbreak at a University Hospital Bronchoscopy Unit in Turkey

OBJECTIVE

Stenotrophomonas maltophilia is an opportunistic pathogen found predominantly in the environment and hospital setting. Invasive procedures and treatment methods, instruments used for diagnosis and irrational antibiotic use play major roles in the spread of this pathogen. The study aimed to evaluate consecutive S maltophilia isolation from bronchoalveolar lavage samples during bronchoscopy procedure during a week.

METHODS

Four patients consecutively had S maltophilia isolated during bronchoscopy between September 8 and 15, 2012. The identification of the isolates and their antibiotic susceptibility were studied by automated Vitek version 2.0 (Biomerieux, France) system. The clonal relationship between the isolates was studied by enterobacterial repetitive intergenic consensus (ERIC) polymerase chain reaction (PCR).

RESULTS

Four consecutive S maltophilia isolates had identical band patterns and showed clonal relatedness.

CONCLUSION

Bronchoscopy is a common invasive procedure that is utilized in chest diseases departments and intensive care units (ICUs). Contamination may take place due to inappropriate use and cause spread of infectious pathogens. In the current study, we detected consecutive S maltophilia strains with identical band patterns isolated within a week. After appropriate disinfection and cleaning procedures, no further isolation was detected.

Clinical characteristics and outcomes of patients with pleural infections due to Stenotrophomonas maltophilia at a medical center in Taiwan, 2004-2012

Stenotrophomonas maltophilia can cause various clinical diseases; however, pleural infections due to S. maltophilia are rare. We evaluated the clinical characteristics and outcomes of patients with pleural infections (complicated parapneumonic effusion or empyema) due to S. maltophilia who were treated at a medical center in Taiwan from 2004 to 2012. During the study period, 40 patients were treated for pleural infections due to S. maltophilia. The incidence of S. maltophilia pleural infections ranged from 2.66 per 1,000,000 patient-days in 2009 to 12.44 per 1,000,000 patient-days in 2011. Most of the patients with S. maltophilia pleural infections were immunocompromised male adults and all of the infections were acquired in healthcare settings. The majority of patients had polymicrobial pleural infections (n = 31, 77.5 %) and the most common pathogen was Pseudomonas aeruginosa (n = 12). The causes of pleural infections due to S. maltophilia were pneumonia due to S. maltophilia in two patients (5 %), post-surgical/tube thoracostomy in 26 (65 %) patients, and fistula (bronchopleural, esophagopleural and biliopleural) in 12 (30 %) patients. The 14-day and 30-day mortality rates were 32.5 % and 42.5 %, respectively. Pleural infections due to S. maltophilia are most commonly the result of surgical procedures, thoracostomy, and underlying fistulas. These infections are associated with a high mortality rate, especially among immunocompromised patients.

Stenotrophomonas maltophilia endophthalmitis following cataract surgery: clinical and microbiological results

Background

Stenotrophomonas maltophilia is a Gram-negative organism known to cause opportunistic infections. It is a rare source of endophthalmitis, often in the setting of trauma, but has been reported following cataract extraction. The purpose of this study was to evaluate antimicrobial sensitivities, clinical characteristics, and treatment outcomes in patients with endophthalmitis caused by S. maltophilia following cataract extraction.

Methods

A retrospective case review of records from January 1, 1990 to June 30, 2010 was performed at the Bascom Palmer Eye Institute.

Results

Eight cases of S. maltophilia endophthalmitis were identified following cataract surgery. Initial visual acuity ranged from 20/200 to light perception. Time to diagnosis with cultures was 2–118 days. Patients received either intravitreal tap and inject (n = 5) or pars plana vitrectomy with intravitreal antibiotic injections (n = 3). All patients had vitreous or anterior chamber cultures positive for S. maltophilia. Seven of seven isolates tested were found to be sensitive to ceftazidime. Seven of eight isolates were sensitive to polymyxin B, six of eight isolates were sensitive to amikacin, and five of the seven isolates tested were sensitive to ciprofloxacin. Two of four tested isolates were sensitive to trimethoprim-sulbactam. All eight isolates were resistant to gentamicin and seven of the seven tested isolates were resistant to imipenem. All patients received intravitreal ceftazidime as part of the initial treatment regimen. Final visual acuity ranged from 20/25 to 4/200.

Conclusion

S. maltophilia endophthalmitis is a rare source of endophthalmitis following cataract surgery. A case series of eight independent patients is reported, along with antibiotic resistance profiles and clinical outcomes. Isolates showed sensitivity to ceftazidime, amikacin, and polymyxin, with variable sensitivity to other antibiotics, therefore differing from previous reports.

Anterior vitrectomy and partial capsulectomy via anterior approach to treat chronic postoperative endophthalmitis

AIM

To describe the results of vitrectomy and partial capsulectomy via anterior approach surgical technique in treatment of chronic postoperative endophthalmitis (CPE).

METHODS

Clinical records of 9 patients treated for CPE between 2006 and 2010 were reviewed retrospectively. All of these patients were treated with vitrectomy and partial capsulectomy via anterior approach.

RESULTS

Six of 9 patients were male. The average patients' age was (60±8.1) years. The average period between cataract extraction and onset of signs and symptoms was (3.6±1.3) weeks. The average presenting visual acuity was 0.3±0.1 and the average final post operative visual acuity was 0.7±0.2. The mean follow-up period was (28.1±8.9) weeks. In all patients, the inflammation subsided after surgery.

CONCLUSION

Our results suggest that anterior vitrectomy and partial capsulectomy via anterior approach may be considered as potentially useful and relatively less invasive technique to treat CPE.

Post‒cataract surgery endophthalmitis outbreak caused by multidrug-resistant Pseudomonas aeruginosa

In June 2010, a severe outbreak of 13 cases of post-cataract surgery endophthalmitis caused by multidrug-resistant Pseudomonas aeruginosa occurred. Pulse-field gel electrophoresis in eye isolates found 95% genetic similarity; however, extensive environmental and carriage investigation revealed no source of infection.

Stenotrophomonas maltophilia: emerging disease patterns and challenges for treatment

Stenotrophomonas maltophilia is a ubiquitous organism associated with opportunistic infections. In the immunocompromised host, increasing prevalence and severity of illness is observed, particularly opportunistic bloodstream infections and pneumonia syndromes. In this article, the classification and microbiology are outlined, together with clinical presentation, outcomes and management of infections due to S. maltophilia. Although virulence mechanisms and the genetic basis of antibiotic resistance have been identified, a role for standardized and uniform reporting of antibiotic sensitivity is not defined. Infections due to S. maltophilia have traditionally been treated with trimethoprim-sulfamethoxazole, ticarcillin-clavulanic acid, or fluoroquinolone agents. The use of combination therapies, newer fluoroquinolone agents and tetracycline derivatives is discussed. Finally, measures to prevent transmission of S. maltophilia within healthcare facilities are reported, especially in at-risk patient populations.

Outcomes of post-cataract surgery endophthalmitis referred to a tertiary center from local hospitals in the south of China

BACKGROUND

Endophthalmitis after cataract surgery is an uncommon but devastating complication. Prophylactic intracameral injection of cefuroxime 1 mg at the end of surgery decreases the incidence five-fold. The visual outcome can be good (53% of cases having a visual acuity [VA] of better than 20/40) if treatment is initiated rapidly and follows the Endophthalmitis Vitrectomy Study (EVS) guidelines; but even with the best treatment, some patients end up with a poor visual outcome. Previous studies on postoperative endophthalmitis mainly focus on the cases performed in metropolitan tertiary hospitals; however, little information is available on the cases performed in local hospitals in rural areas.

METHODS

We retrospectively reviewed the medical records of patients with acute endophthalmitis following cataract surgery, which were performed in local hospitals and later treated at the Zhongshan Ophthalmic Center between 1 January 1998 and 31 December 2009. Details of each case, including the interval from symptoms to presentation, initial treatment in local hospitals, microorganisms isolated, treatment, and visual outcome, were recorded. Cross-tabulations were conducted in order to identify the prognostic factors of final visual outcome.

RESULTS

Forty-six patients referred from 36 local hospitals and later treated at the Zhongshan Ophthalmic Center were reviewed over the audit period. Most of these cases occurred in April. Gram-positive bacteria were the predominant etiology, with fungal infection accounting for 15%. Even though 54% of patients had symptoms within 3 days post-cataract surgery, they did not present to a tertiary center until a mean of 10 days. The main initial treatment in local hospitals is systemic antibiotics, instead of the intravitreal injection of antibiotics. A high proportion of cases (27/46) received immediate pars plana vitrectomy (PPV) in the tertiary center, and the antibiotic used for intravitreal injection was mainly tobramycin. The final visual outcome was poor, with only three cases having a VA ≥20/40.

CONCLUSION

A relatively high rate of fungal endophthalmitis suggests that sterilization patterns in local hospitals should be further revised. A delayed presentation, inappropriate treatment procedures, poor presenting VA, and causative organism virulence may account for the unfavorable visual outcome in this study.

Endophthalmitis caused by Stenotrophomonas maltophilia

BACKGROUND AND OBJECTIVE

The authors investigate clinical settings, antibiotic susceptibility and resistance patterns, and visual outcomes associated with endophthalmitis caused by Stenotrophomonas maltophilia.

PATIENTS AND METHODS

Records of six patients with S. maltophilia endophthalmitis between January 1, 1998, and December 31, 2007, were reviewed.

RESULTS

Clinical settings included post-trauma (2 eyes), post-cataract extraction (2 eyes), post-keratoplasty with keratitis (1 eye), and post-vitreous lavage (1 eye). Presenting visual acuity ranged from counting fingers to no light perception. Final visual acuity ranged from 10/20 to no light perception. Initial treatment included pars plana vitrectomy in 4 eyes and tap in 2 eyes. Most isolates were susceptible to fluoroquinolones (ciprofloxacin, levofloxacin, or moxifloxacin) and sulfamethoxazole-trimethoprim; however, they were resistant to ceftazidime and aminoglycosides.

CONCLUSION

S. maltophilia is an uncommon causative agent of endophthalmitis and is resistant to commonly used antibiotics, such as ceftazidime and aminoglycosides. Based on in vitro antibiotic susceptibility testing, sulfamethoxazole-trimethoprim and new-generation fluoroquinolones may be preferable in the treatment of endophthalmitis caused by S. maltophilia.