Risk Factors for Endogenous Endophthalmitis in Hospitalized Patients with Candida Fungemia

[Endogenous Candida endophthalmitis]

Endogenous Candida endophthalmitis is a rare but vision-threatening disease. In most cases, endogenous endophthalmitis caused by Candida species has a better prognosis than endogenous endophthalmitis caused by other fungal species or bacteria but the prognosis still depends heavily on the time required for diagnosis and subsequent treatment as well as the initial visual acuity. Suggestions for treatment algorithms have already been made in the past but binding guidelines in ophthalmology only exist sporadically due to the rarity of the disease. This review discusses the current knowledge on endogenous Candida endophthalmitis and draws conclusions from the current study situation.

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.

ENDOGENOUS FUNGAL ENDOPHTHALMITIS AFTER COVID-19 INFECTION: CASE REPORT AND REVIEW OF LITERATURE

PURPOSE

The purpose of this study was to describe a case of endogenous endophthalmitis (EE) after severe COVID-19 disease, review patient outcomes with EE after COVID-19 infection, and review evidence regarding risk factors for developing EE.

METHODS

This is a review of health records, imaging, intravitreal injection, and pars plana vitrectomy for bilateral fungal EE after severe COVID-19 disease, and is a literature review on outcomes in EE after COVID-19 disease.

RESULTS

Sixty-three year-old man with diabetes and hypertension was admitted to hospital for severe COVID-19 disease for 3 months. His stay required intensive care unit admission, intubation, high-dose corticosteroids, tocilizumab, and was complicated by bacteremia, empyema, and fungal esophagitis. He developed floaters and bilateral vision loss (visual acuity 20/40 in the right eye, counting fingers in the left eye) with vitritis 2.5 months into his stay that did not respond to intravitreal voriconazole. Pars plana vitrectomy was performed for both eyes, resulting in visual acuity of 20/40 in the right eye, 20/30 in the left eye. Vitreous cultures were positive for Candida albicans . Endogenous endophthalmitis after COVID-19 disease has been reported in 22 patients to date, and outcomes are poor, with 40%+ of eyes legally blind (20/200 or worse). Although influenced by availability of imaging modalities and degree of training of the evaluating physician, misdiagnosis can affect ¼ of cases, delaying treatment. Age, male sex, and diabetes increase the risk of severe COVID-19, which requires prolonged hospitalization, invasive catheterization, and immunosuppression, which in turn increases the risk of nosocomial infection.

CONCLUSION

Low threshold for suspecting EE in patients presenting with floaters and decreased vision after severe COVID-19 disease is necessary to ensure prompt recognition and treatment.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis.

DESIGN

Retrospective observational multicenter cohort study.

METHODS

We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation.

RESULTS

The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome.

CONCLUSIONS

Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Candida Biofilm Eye Infection: Main Aspects and Advance in Novel Agents as Potential Source of Treatment

Fungi represent a very important cause of microbial eye infections, especially in tropical and developing countries, as they could cause sight-threating disease, such as keratitis and ocular candidiasis, resulting in irreversible vision loss. Candida species are among the most frequent microorganisms associated with fungal infection. Although Candida albicans is still the most frequently detected organism among Candida subspecies, an important increase in non-albicans species has been reported. Mycotic infections often represent an important diagnostic-clinical problem due to the difficulties in performing the diagnosis and a therapeutic problem due to the limited availability of commercial drugs and the difficult penetration of antifungals into ocular tissues. The ability to form biofilms is another feature that makes Candida a dangerous pathogen. In this review, a summary of the state-of-the-art panorama about candida ocular pathology, diagnosis, and treatment has been conducted. Moreover, we also focused on new prospective natural compounds, including nanoparticles, micelles, and nanocarriers, as promising drug delivery systems to better cure ocular fungal and biofilm-related infections. The effect of the drug combination has also been examined from the perspective of increasing efficacy and improving the course of infections caused by Candida which are difficult to fight.

Klebsiella Endogenous Endophthalmitis During the COVID-19 Pandemic

Purpose: To describe the characteristics of Klebsiella pneumoniae endogenous endophthalmitis (KEE) encountered during the COVID-19 pandemic. Methods: This retrospective consecutive case series evaluated eyes that presented with KEE between March 2020 and July 2022. Results: Seven eyes of 5 patients developed KEE. Between January 2020 and July 2022, KEE was observed in 42% of consecutive EE cases compared with 7.8% during the preceding 13 years. COVID-19 was positive in 4 of 5 patients before they developed KEE. Only 1 patient presented with a VA better than hand motions (20/400). All eyes were treated with urgent vitrectomy and intravitreal and systemic antibiotics. No improvement in vision occurred in any patient; VA remained light perception to no light perception in 60% of eyes. Conclusions: The visual prognosis in KEE is extremely poor. The presence of a preceding COVID-19 infection in 80% of patients may signal a new risk factor for KEE. Patients with a hypervirulent Klebsiella syndrome should be routinely screened for EE.

National emergency department trends for endogenous endophthalmitis: an increasing public health challenge

BACKGROUND/OBJECTIVE

To characterize incidence rates and identify risk factors for admission and mortality in patients with endogenous endophthalmitis (EE) in the United States (US).

SUBJECTS/METHODS

Patients with EE were identified using the Nationwide Emergency Department (NEDS) Database from 2006 to 2017 in this cross-sectional study. Subjects were required to have diagnoses of both endophthalmitis and septicaemia using contemporary International Classification of Diseases diagnosis codes. Incidence rates, mortality rates and demographics were evaluated. Risk factors for admission and mortality were identified using weighted logistic regression analysis.

RESULTS

A total of 6400 patients with EE were identified. Incidence increased from 0.10 (95% confidence interval [CI]: 0.07-0.12) per 100,000 in the US population in 2006 to 0.25 (95% CI: 0.21-0.30) in 2017 (p < 0.05). Most were female (55.4%), insured with Medicare (53.5%), were in the first income quartile earnings (29.3%) [bottom 25% income bracket], lived in the South (40.5%), and presented to metropolitan teaching hospitals (66.6%). Mortality increased from 8.6% (95% CI: 3.8-18.3%) in 2006 to 13.8% (95% CI: 9.7-19.2%) in 2017 (p = 0.94). Factors predicting admission included older age (odds ratio [OR] 32.59; [95% CI 2.95-359.78]) and intravenous drug use (OR 14.90 [95% CI: 1.67-133.16]). Factors associated with increased mortality included: human immunodeficiency virus infection/immune deficiencies (OR 2.58 [95% CI: 1.26-5.28]), heart failure (OR 2.12 [95% CI: 1.47-3.05]), and hepatic infections/cirrhosis (OR 1.89 [95% CI: 1.28-2.79]). Pneumonia and renal/urinary tract infections (UTI) were associated with both increased hospital admission [(pneumonia OR 9.64 (95% CI: 1.25-74.35, p = 0.030), renal/UTI OR 4.09 (95% CI: 1.77-9.48)] and mortality [(pneumonia OR 1.64 (95% CI: 1.17-2.29, p = 0.030), renal/UTI OR 1.87 (95% CI: 1.18-2.97)]. Patients with diabetes mellitus (DM) had decreased odds ratio for mortality (OR 0.49 [95% CI: 0.33-0.73]).

CONCLUSION

EE has increased in incidence throughout US. The two systemic factors that conferred both an increase in mortality and admission were pneumonia, and renal/UTI. Additional exploration of the potential protective association of DM with decreased mortality in this context is needed.

Endogenous Fungal Endophthalmitis following COVID-19 Hospitalization: Evidence from a Year-Long Observational Study

PURPOSE

To describe cases of endogenous fungal endophthalmitis (EFE) post-recovery from or hospitalization for coronavirus disease 2019 (COVID-19).

METHODS

This prospective audit involved patients with suspected endophthalmitis referred to a tertiary eye care center over a one-year period. Comprehensive ocular examinations, laboratory studies, and imaging were performed. Confirmed cases of EFE with a recent history of COVID-19 hospitalization±intensive care unit admission were identified, documented, managed, followed up, and described.

RESULTS

Seven eyes of six patients were reported; 5/6 were male, and the mean age was 55. The mean duration of hospitalization for COVID-19 was approximately 28 days (14-45); the mean time from discharge to onset of visual symptoms was 22 days (0-35). All patients had underlying conditions (5/6 hypertension; 3/6 diabetes mellitus; 2/6 asthma) and had received dexamethasone and remdesivir during their COVID-related hospitalization. All presented with decreased vision, and 4/6 complained of floaters. Baseline visual acuity ranged from light perception (LP) to counting fingers (CF). The fundus was not visible in 3 out of 7 eyes; the other 4 had "creamy-white fluffy lesions" at the posterior pole as well as significant vitritis. Vitreous taps were positive for Candida species in six and Aspergillus species in one eye. Anti-fungal treatment included intravenous amphotericin B followed by oral voriconazole and intravitreal amphotericin B. Three eyes underwent vitrectomy; the systemic health of two patients precluded surgery. One patient (with aspergillosis) died; the others were followed for 7-10 months - the final visual outcome improved from CF to 20/200-20/50 in 4 eyes and worsened (hand motion to LP) or did not change (LP), in two others.

CONCLUSION

Ophthalmologists should maintain a high index of clinical suspicion for EFE in cases with visual symptoms and a history of recent COVID-19 hospitalization and/or systemic corticosteroid use - even without other well-known risk factors.

The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis

PURPOSE

Characterize the impact of frailty on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients.

DESIGN

Population-level, retrospective cohort study.

PARTICIPANTS

Adult inpatients within the National Inpatient Sample (years 2002-2014) diagnosed with bacterial septicemia.

METHODS

Septicemic patients were classified as frail or nonfrail using the previously validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, and diagnosis of EE was abstracted from International Classification of Diseases 9 codes. We used multivariable logistic regression to generate odds ratios (ORs) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood culture-proven organism class, inpatient length of stay, and total charges billed to insurance.

MAIN OUTCOME MEASURES

Incidence of EE among septicemic patients; rates of EE development among frail and nonfrail patients; blood culture-proven microbe type, length of stay, and total charges billed to insurance.

RESULTS

9294 of 18 470 658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition [68%]). Odds of developing EE were 16.7% higher for frail patients (OR, 1.167; 95% confidence interval, 1.108-1.229) when controlling for age, sex, race, concomitant human immunodeficiency virus/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, sex, race, and Elixhauser comorbidity score (OR, 1.279; 95% confidence interval, 1.056-1.549). Higher rates of methicillin-resistant Staphylococcus aureus bacteremia (14.3% vs. 10.9%, P = 0.000016), gram-negative bacteremia (7.6% vs. 4.9%, P = 0.000003), and concomitant candidemia (10.4% vs. 7.0%, P = 0.0000004) were associated with frailty. Hospital stays were significantly longer (median, 14 days; interquartile range, 19 days; P < 0.00001) and total charges billed to insurance were significantly greater (median, $96 398; interquartile range, $154,682; P < 0.00001) among frail EE patients.

CONCLUSIONS

Frailty syndrome is independently associated with development of EE in the setting of bacterial septicemia; frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and it predisposes to higher rates of in-hospital death and health care resource usage.

Endogenous Fungal Endophthalmitis: Causative Organisms, Treatments, and Visual Outcomes

Endogenous fungal endophthalmitis (EFE) is a vision-threatening intraocular infection and a rare complication of fungemia. Early diagnosis and prompt aggressive treatment are crucial to avoid vision loss. We retrospectively reviewed the data of 37 patients (49 eyes) with EFE who were treated at a tertiary referral hospital from January 2000 to April 2019. The most common risk factor was diabetes (24 patients; 65%), followed by recent hospitalization, urinary tract disease, liver disease, and immunosuppressive therapy. Two or more risk factors were detected in 24 patients (65%), and yeasts (29 patients; 78%) were more commonly detected than mold (8 patients; 22%). The most common fungal isolates were Candida spp. (78%), especially Candida albicans (70%). Moreover, 24 eyes in 21 patients underwent vitrectomy, and 2 eyes underwent evisceration. Retinal detachment (RD) occurred in 17 eyes (35%) in 14 patients, and eyes without RD exhibited significantly superior visual outcomes (p = 0.001). A comparison of the initial VA between the better (20/200 or better) and worse groups (worse than 20/200) revealed that better initial VA was related to a superior visual outcome (p = 0.003). Therefore, to achieve superior visual outcomes, early diagnosis and prompt treatment are necessary for patients with EFE.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.