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Das S, Murthy SI, Padhi TR, Behera HS, Jakati S, Sharma S, Das S. Ocular infections associated with atypical mycobacteria: A review. Indian J Ophthalmol 2024; 72:19-28. [PMID: 38131566 PMCID: PMC10841776 DOI: 10.4103/ijo.ijo_560_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/20/2023] [Accepted: 08/04/2023] [Indexed: 12/23/2023] Open
Abstract
Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes.
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Affiliation(s)
- Shilpa Das
- Cornea Service, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Somasheila I Murthy
- Cornea and Anterior Segment Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Tapas Ranjan Padhi
- Vitreo Retinal Service, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | | | - Saumya Jakati
- Ophthalmic Pathology Laboratory, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sujata Das
- Cornea and Anterior Segment Service, L V Prasad Eye Institute, Bhubaneswar, Odisha, India
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Liu J, Guo X, Wei Z, Zhang Y, Zhang Z, Xu X, Liang Q. Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature. Eye Contact Lens 2023; 49:275-282. [PMID: 37166228 PMCID: PMC10281179 DOI: 10.1097/icl.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery. METHODS To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article. RESULTS Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%). CONCLUSIONS Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.
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Affiliation(s)
- Jiamin Liu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xiaoyan Guo
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zhenyu Wei
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Yuheng Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Zijun Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Xizhan Xu
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
| | - Qingfeng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Key Laboratory of Ophthalmology and Visual Sciences, Beijing, China
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Ye H, Harris VC, Chiu KHY, Chen S, Xing F, Sun L, Deng C, Yang J, Chan JFW, Yuen KY. Cutaneous Mycobacterium szulgai infection in a patient with Cushing's syndrome: a case report and literature review. BMC Infect Dis 2023; 23:266. [PMID: 37101119 PMCID: PMC10134568 DOI: 10.1186/s12879-023-08253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Opportunistic infection is an under-recognized complication of Cushing's syndrome, with infection due to atypical mycobacterium rarely reported. Mycobacterium szulgai commonly presents as pulmonary infection, with cutaneous infection seldom reported in the literature. CASE PRESENTATION 48-year-old man with a newly-diagnosed Cushing's syndrome secondary to adrenal adenoma presented with a subcutaneous mass on the dorsum of his right hand, was diagnosed with cutaneous Mycobacterium szulgai infection. The most likely source of the infection was through minor unnoticed trauma and inoculation from a foreign body. The patient's Cushing's syndrome, high serum cortisol levels and secondary immune suppression facilitated mycobacterial replication and infection. The patient was successfully treated with adrenalectomy, surgical debridement of cutaneous lesion, and a combination of rifampicin, levofloxacin, clarithromycin, and ethambutol for 6 months. There were no signs of relapse one year after cessation of anti-mycobacterial treatment. A literature review on cutaneous M. szulgai infection to further characterize the clinical characteristics of this condition, identified 17 cases of cutaneous M. szulgai infection in the English literature. Cutaneous M. szulgai infections with subsequent disease dissemination are commonly reported in immunocompromised hosts (10/17, 58.8%), as well as in immunocompetent patients with a history of breached skin integrity, such as invasive medical procedures or trauma. The right upper extremity is the most commonly involved site. Cutaneous M. szulgai infection is well controlled with a combination of anti-mycobacterial therapy and surgical debridement. Disseminated infections required a longer duration of therapy than localized cutaneous infections. Surgical debridement may shorten the duration of antibiotics. CONCLUSIONS Cutaneous M. szulgai infection is a rare complication of adrenal Cushing's syndrome. Further studies are needed to provide evidence-based guidelines on the best combination of anti-mycobacterial and surgical therapy for managing this rare infective complication.
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Affiliation(s)
- Haiyan Ye
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Vanessa C Harris
- Department of Internal Medicine, Division of Infectious Diseases and Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Institute of Infection and Immunity, Infectious Diseases, Amsterdam, Netherlands
| | - Kelvin Hei-Yeung Chiu
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, Pokfulam, China
| | - Shuang Chen
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Fanfan Xing
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Linlin Sun
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Chaowen Deng
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jin Yang
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jasper Fuk-Woo Chan
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, Pokfulam, China
- State Key Laboratory of Emerging Infectious DiseasesDepartment of Microbiology, School of Clinical MedicineFaculty of Medicine, Carol Yu Centre for InfectionLi Ka ShingThe University of Hong KongHong Kong Special Administrative Region, Pokfulam, China
| | - Kwok-Yung Yuen
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, Pokfulam, China.
- State Key Laboratory of Emerging Infectious DiseasesDepartment of Microbiology, School of Clinical MedicineFaculty of Medicine, Carol Yu Centre for InfectionLi Ka ShingThe University of Hong KongHong Kong Special Administrative Region, Pokfulam, China.
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Late onset of microbial keratitis after laser in situ keratomileusis surgery: case series. J Cataract Refract Surg 2021; 47:1044-1049. [PMID: 34292889 DOI: 10.1097/j.jcrs.0000000000000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To report predisposing factors, clinical features, microbiology spectrum, antibiotic resistance, antimicrobial therapy, and outcomes of patients with a previous laser in situ keratomileusis (LASIK) surgery and diagnosed with presumed microbial keratitis. SETTING Sydney Eye Hospital, Sydney, New South Wales, Australia. DESIGN Retrospective case review. METHODS Patients were identified from pathology and hospital coding data from 2012 to 2016. Inclusion criteria were all patients with a previous LASIK surgery, a presumed diagnosis of microbial keratitis, and a corneal scrape performed and aged older than 18 years. Demographics, clinical details, and outcomes were collated from the medical records. RESULTS Sixteen patients were included, with median age of 41.5 years (range 22 to 85 years) and 56.2% of women. The median time between LASIK procedure and microbial keratitis presentation was 38.3 months (interquartile range 6.7 to 77.45 months). Cultures were positive for bacteria in 12 (75%) of 16 scrapes. Of the bacterial isolates, 12 (85.7%) were gram-positive and 2 (14.3%) gram-negative. Sensitivity profiles for the isolated bacteria were similar between fortified antibiotics (cefalotin and gentamicin) and commercial products (chloramphenicol and ofloxacin). Complications included the need for tectonic grafts, nonhealing epithelial defects, thinning, and neovascularization. CONCLUSIONS Late onset of keratitis after LASIK can occur with no positive cultures for nontuberculous mycobacteria, no interface involvement, and no other usual features reported in case series of infectious keratitis in LASIK patients. It has a similar clinical course to non-LASIK keratitis, such that the surgery may not have been a risk factor for infection.
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Das S, Garg P, Mullick R, Annavajjhala S. Keratitis following laser refractive surgery: Clinical spectrum, prevention and management. Indian J Ophthalmol 2021; 68:2813-2818. [PMID: 33229656 PMCID: PMC7856934 DOI: 10.4103/ijo.ijo_2479_20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Laser refractive surgery (LRS) is one of the most demanding areas of ophthalmic surgery and high level of precision is required to meet outcome expectations of patients. Post-operative recovery is of vital importance. Keratitis occurring after LRS can delay visual recovery. Both surface ablations [Photorefractive keratectomy (PRK)] as well as flap procedures [Laser in-situ keratomileusis (LASIK)/Small incision lenticule extraction] are prone to this complication. Reported incidence of post-LRS infectious keratitis is between 0% and 1.5%. The rate of infections after PRK seems to be higher than that after LASIK. Staphylococci, streptococci, and mycobacteria are the common etiological organisms. About 50–60% of patients present within the first week of surgery. Of the non-infectious keratitis, diffuse lamellar keratitis (DLK) is the most common with reported rates between 0.4% and 4.38%. The incidence of DLK seems to be higher with femtosecond LASIK than with microkeratome LASIK. A lot of stress is laid on prevention of this complication through proper case selection, asepsis, and use of improved protocols. Once keratitis develops, the right approach can help resolve this condition quickly. In cases of suspected microbial keratitis, laboratory identification of the organism is important. Most lesions resolve with medical management alone. Interface irrigation, flap amputation, collagen cross-linking and therapeutic penetrating keratoplasty (TPK) are reserved for severe/non-resolving cases. About 50–75% of all infectious keratitis cases post LRS resolve with a final vision of 20/40 or greater. Improved awareness, early diagnosis, and appropriate intervention can help limit the damage to cornea and preserve vision.
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Affiliation(s)
- Shilpa Das
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
| | - Prashant Garg
- Paul Dubord Chair of Cornea, L.V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Ritika Mullick
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
| | - Sriram Annavajjhala
- Cornea and Refractive Services, Narayana Nethralaya Eye Hospital, Bengaluru, Karnataka, India
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Identification of the Infection Source of an Outbreak of Mycobacterium Chelonae Keratitis After Laser in Situ Keratomileusis. Cornea 2018; 37:116-122. [PMID: 29111994 DOI: 10.1097/ico.0000000000001423] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Nontuberculous mycobacteria keratitis is a rare but challenging complication of laser in situ keratomileusis (LASIK). This study was conducted to determine the source(s) of infection in a cluster of cases of keratitis after LASIK and to describe this outbreak and patients' outcomes. METHODS In this retrospective, case series, single-center study, 86 patients were included who underwent LASIK or photorefractive keratectomy between December 2011 and February 2012. Corneal scrapes from the affected eyes, samples of tap and distilled water, water from the reservoir of the distilling equipment, steamer, and autoclave cassette; antiseptic and anesthetic solutions and surgical instrument imprints were cultivated in liquid and on solid media. Gram-negative bacteria and yeasts were identified using automated systems and mycobacteria by polymerase chain reaction-restriction enzyme analysis of the hsp65 gene (PRA-hsp65) and DNA sequencing. Mycobacterial isolates were typed by pulsed-field gel electrophoresis. The cases and outcomes are described. The main outcome measure was identification of the source(s) of the mycobacterial infections. RESULTS Eight (15 eyes) of 86 patients (172 eyes) who underwent LASIK developed infections postoperatively; no patients who underwent photorefractive keratectomy developed infections. Mycobacterium chelonae was isolated from 4 eyes. The distilled water collected in the surgical facility contained the same M. chelonae strain isolated from the patients' eyes. Different gram-negative bacteria and yeasts were isolated from samples collected at the clinic but not from the patients' eyes. CONCLUSIONS Tap water distilled locally in surgical facilities may be a source of infection after ocular surgery and its use should be avoided.
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Hung JH, Chang TC, Wu JJ, Lai CC, Huang FC, Huang YH. A cluster of Mycobacterium massiliense keratitis in foundry workers. Clin Microbiol Infect 2016; 22:386.e5-386.e8. [PMID: 26721784 DOI: 10.1016/j.cmi.2015.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/04/2015] [Accepted: 12/14/2015] [Indexed: 11/28/2022]
Abstract
Three consecutive workers from the same foundry had Mycobacterium massiliense keratitis. The strains isolated from each patient were identical. This is the first report of a non-surgery-related outbreak of non-tuberculous mycobacterial ocular infection. An investigation revealed that injured cornea with exposure to aerosolized non-tuberculous mycobacteria might account for this outbreak.
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Affiliation(s)
- J H Hung
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, Taiwan
| | - T C Chang
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - J J Wu
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - C C Lai
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, Taiwan
| | - F C Huang
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, Taiwan
| | - Y H Huang
- Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, Taiwan.
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Nontuberculous Mycobacterial Ocular Infections: A Systematic Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2015; 2015:164989. [PMID: 26106601 PMCID: PMC4461732 DOI: 10.1155/2015/164989] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 11/01/2022]
Abstract
Nontuberculous or atypical mycobacterial ocular infections have been increasing in prevalence over the past few decades. They are known to cause periocular, adnexal, ocular surface and intraocular infections and are often recalcitrant to medical therapy. These infections can potentially cause detrimental outcomes, in part due to a delay in diagnosis. We review 174 case reports and series on nontuberculous mycobacterial (NTM) ocular infections and discuss etiology, microbiology, risk factors, diagnosis, clinical presentation, and treatment of these infections. History of interventions, trauma, foreign bodies, implants, contact lenses, and steroids are linked to NTM ocular infections. Steroid use may prolong the duration of the infection and cause poorer visual outcomes. Early diagnosis and initiation of treatment with multiple antibiotics are necessary to achieve the best visual outcome.
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Abstract
We report a 17-year-old patient with inherited STAT1 deficiency, who was diagnosed with Mycobacterium szulgai chronic multifocal osteomyelitis and responded well to the therapy with ethambutol, rifampicin and azithromycin. Seven other reported cases of M. szulgai osteomyelitis are reviewed. This is the first description of M. szulgai osteomyelitis in an adolescent with a primary immunodeficiency.
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Nontuberculous mycobacterial infection after clear corneal phacoemulsification cataract surgery: a report of 13 cases. Cornea 2012. [PMID: 23187167 DOI: 10.1097/ico.0b013e31826cf840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To review the patient profile, clinical presentation, management, and outcomes of nontuberculous mycobacterial (NTM) infection after clear corneal phacoemulsification. METHODS Review of consecutive cases diagnosed with NTM infection after phacoemulsification from 2004 to 2009. Demographic data, clinical characteristics, diagnosis, treatment, and outcomes were analyzed. RESULTS Thirteen eyes of 13 patients with mean age of 61.1 years, consisting of 7 men and 6 women were included. Twelve of 13 eyes (92%) underwent uncomplicated clear cornea phacoemulsification with posterior lens implant. Mean interval from surgery to onset of symptoms was 6.3 weeks, and time to referral ranged from 2 days to 9 months. Ten eyes (77%) presented with stromal wound abscess, whereas 3 (23%) appeared as iridocyclitis with posterior capsule plaques. Five eyes were clustered while the rest were isolated cases. All cases were culture positive for NTM. Two cases were treated medically, 3 had removal of lens implant and capsule, and 8 had penetrating keratoplasty with or without removal of lens implant, iridectomy, and/or pars plana vitrectomy. After a mean follow-up of almost 22 months, best-corrected visual acuity of 20/40 or better was achieved in half of the cases (54%). One case of recurrence was noted. CONCLUSIONS NTM infection should be suspected in patients presenting with corneal stromal wound abscess or iridocyclitis with posterior capsular plaques 6 to 7 weeks after phacoemulsification. Early diagnosis and treatment can lead to good outcomes, and management should include a combination of medical and surgical therapies.
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Abstract
PURPOSE To characterize formerly designated atypical or nontuberculous mycobacteria (NTM) associated with eye infections. METHODS All clinical NTM eye isolates (112 isolates from 100 patients) submitted to a single national NTM reference laboratory between 1982 and 2009 were identified using polymerase chain reaction and restriction fragment length polymorphism of the hsp65 gene. Isolates were tested against 10 antimicrobials, including besifloxacin, a new 8-chloro-fluoroquinolone. Assessments included species of NTM recovered, year of isolation, type of eye infection, geographic location, and drug susceptibilities. RESULTS In the 1980s, the major pathogen isolated was Mycobacterium abscessus. In the 1990 s, Mycobacterium chelonae emerged as the major pathogen. By 2000, it was responsible for more than 50% of all cases. The majority of M. abscessus and Mycobacterium fortuitum were from southern coastal states and Texas, whereas M. chelonae isolates were more widespread geographically. The most active antimicrobials were amikacin and clarithromycin/azithromycin for M. abscessus and clarithromycin/azithromycin, amikacin, and tobramycin, and the quinolones for M. chelonae. CONCLUSIONS This is the largest study of NTM ophthalmic isolates to date and is the first to include susceptibilities and molecular identification for all isolates studied. This series establishes M. chelonae (44%) and M. abscessus (37%) as the NTM species most frequently associated with ophthalmic infections. Topical ophthalmic fluoroquinolones may have a role in the management of ocular infections involving M. chelonae and M. fortuitum.
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Brown-Elliott BA, Nash KA, Wallace RJ. Antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria. Clin Microbiol Rev 2012; 25:545-82. [PMID: 22763637 PMCID: PMC3416486 DOI: 10.1128/cmr.05030-11] [Citation(s) in RCA: 335] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Within the past 10 years, treatment and diagnostic guidelines for nontuberculous mycobacteria have been recommended by the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA). Moreover, the Clinical and Laboratory Standards Institute (CLSI) has published and recently (in 2011) updated recommendations including suggested antimicrobial and susceptibility breakpoints. The CLSI has also recommended the broth microdilution method as the gold standard for laboratories performing antimicrobial susceptibility testing of nontuberculous mycobacteria. This article reviews the laboratory, diagnostic, and treatment guidelines together with established and probable drug resistance mechanisms of the nontuberculous mycobacteria.
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Moorthy RS, Valluri S, Rao NA. Nontuberculous mycobacterial ocular and adnexal infections. Surv Ophthalmol 2012; 57:202-35. [PMID: 22516536 DOI: 10.1016/j.survophthal.2011.10.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 10/01/2011] [Accepted: 10/04/2011] [Indexed: 10/28/2022]
Abstract
The nontuberculous (also called "atypical") mycobacteria have become increasingly important causes of systemic as well as ocular morbidity in recent decades. All ocular tissues can become infected with these organisms, particularly in patients who are predisposed following ocular trauma, surgery, use of corticosteroids, or are immunocompromised. Because of their relative resistance to available antibiotics, multidrug parenteral therapy continues to be the mainstay of treatment of more serious ocular and adnexal infections caused by nontuberculous mycobacteria (NTM). Periocular cutaneous, adnexal, and orbital NTM infections remain rare and require surgical debridement and long-term parenteral antibiotic therapy. NTM scleritis may occur after trauma or scleral buckling and can cause chronic disease that responds only to appropriate antibiotic therapy and, in some cases, surgical debridement and explant removal. NTM infectious keratitis following trauma or refractive surgical procedures is commonly confused with other infections such as Herpes simplex keratitis and requires aggressive topical therapy and possible surgical debridement, particularly in those cases occuring after laser in situ keratomileusis. Only 18 cases of endophthalmitis due to NTM have been reported. Systemic and intraocular antibiotic therapy and multiple vitrectomies may be needed in NTM endophthalmitis; the prognosis remains poor, however. Disseminated NTM choroiditis in acquired immune deficiency syndrome patients with immune reconstitution during highly active anti-retroviral therapy is a rare infection that can present as a necrotizing chorioretinitis with dense vitritis, mimicking many other entities and needs to be recognized so that timely, life-saving treatment can be administered. Regardless of which ocular tissue is infected, all NTM ocular infections present similar challenges of recognition and of therapeutic intervention. We clarify diagnosis and delineate modern, effective therapy for these conditions.
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Affiliation(s)
- Ramana S Moorthy
- Indiana University Medical Center, Department of Ophthalmology, Vincent Hospital, Indianapolis, IN 46260, USA.
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Yamaguchi T, Bissen-Miyajima H, Hori-Komai Y, Matsumoto Y, Ebihara N, Takahashi H, Tsubota K, Shimazaki J. Infectious keratitis outbreak after laser in situ keratomileusis at a single laser center in Japan. J Cataract Refract Surg 2011; 37:894-900. [DOI: 10.1016/j.jcrs.2010.11.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 11/11/2011] [Accepted: 11/11/2011] [Indexed: 10/18/2022]
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15
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Biber JM, Kim JY. Nontuberculous Mycobacteria Keratitis. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Tappe D, Langmann P, Zilly M, Klinker H, Schmausser B, Frosch M. Osteomyelitis and skin ulcers caused by Mycobacterium szulgai in an AIDS patient. ACTA ACUST UNITED AC 2009; 36:883-5. [PMID: 15764180 DOI: 10.1080/00365540410024736] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Mycobacterium szulgai is a ubiquitious non-tuberculous mycobacterium causing infection in immunocompetent and immunocompromized patients. Clinically mimicking pulmonary tuberculosis in most cases described, rarely other manifestations occur. Here we report the case of an AIDS patient with osteomyelitis of the hand and toe, accompanied by multiple cutaneous ulcers of the chest and forearm. The case highlights the unusual combination of osteomyelitis and skin ulcers without pulmonary infection and describes the likely cutaneous route of infection in a patient who keeps tropical fish.
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Affiliation(s)
- Dennis Tappe
- Institute of Hygiene and Microbiology, University of Würzburg, Josef-Schneider-Str 2, 97080 Würzburg, Germany.
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Warwick R, Magee J, Leeming J, Graham J, Hannan M, Chadwick M, Crook D, Yearsley C, Rayner A, Parker R. Mycobacteria and allograft heart valve banking: an international survey. J Hosp Infect 2008; 68:255-61. [DOI: 10.1016/j.jhin.2007.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Accepted: 11/23/2007] [Indexed: 11/27/2022]
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Meyer JJ, Gelman SS. Multifocal osteomyelitis due to Mycobacterium szulgai in a patient with chronic lymphocytic leukemia. J Infect 2008; 56:151-4. [PMID: 18199481 DOI: 10.1016/j.jinf.2007.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 08/10/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
Abstract
Mycobacterium szulgai is a pathogenic organism that most frequently causes pulmonary infection and may rarely result in disseminated disease in immunocompromised individuals. We report a case of multifocal osteomyelitis and cutaneous lesions due to M. szulgai in a patient with chronic lymphocytic leukemia. The successful treatment of multifocal osteomyelitis was accomplished using isoniazid, rifampin, and ethambutol.
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Affiliation(s)
- Jay J Meyer
- University of Utah School of Medicine, 30 North 1900 East, 4B319, Salt Lake City, Utah 84132, USA
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Sharma A, Chandraker SK, Bharti M. Nontubercular Mycobacteria in drinking water of some educational institutes in Jabalpur (M.P.), India. Indian J Microbiol 2007; 47:233-40. [PMID: 23100671 DOI: 10.1007/s12088-007-0044-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 07/27/2007] [Accepted: 08/24/2007] [Indexed: 11/29/2022] Open
Abstract
Sixteen isolates of Nontubercular Mycobacteria species were isolated from drinking water supply of some educational institutes in Jabalpur during July 2006 and were identified by biochemical test, thin layer chromatography (TLC) and high performance liquid chromatography (HPLC) analysis and PRA ( PCR restriction enzyme analysis) of rpoB gene. Out of 21 water samples total 16 isolates of nontuberculous mycobacteria were identified, as M. terrae (6), M. szulgai (4), M. gordonae (3), and one each as M. malmoense, M. kansasii, and M. gastri.
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Affiliation(s)
- Anjana Sharma
- Bacteriology Laboratory, Department of Post Graduate Studies and Research in Biological Sciences, R.D. University, Jabalpur (M.P), 482 001 India
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Lacasse C, Terio K, Kinsel MJ, Farina LL, Travis DA, Greenwald R, Lyashchenko KP, Miller M, Gamble KC. Two cases of atypical mycobacteriosis caused by Mycobacterium szulgai associated with mortality in captive African elephants (Loxodonta africana). J Zoo Wildl Med 2007; 38:101-7. [PMID: 17469283 DOI: 10.1638/06-051.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Mycobacterium szulgai was associated with mortality in two captive African elephants (Loxodonta africana) housed at Lincoln Park Zoo. The first elephant presented with severe, acute lameness of the left rear limb. Despite extensive treatments, the animal collapsed and died 13 mo after initial presentation. Necropsy revealed osteomyelitis with loss of the femoral head and acetabulum and pulmonary granulomas with intralesional M. szulgai. The second elephant collapsed during transport to another institution with no premonitory clinical signs. This animal was euthanized because of prolonged recumbency. Granulomatous pneumonia with intralesional M. szulgai was found at necropsy. Two novel immunoassays performed on banked serum samples detected antibody responses to mycobacterial antigens in both infected elephants. It was not possible to determine when the infection was established or how the elephants were infected. When reviewing the epidemiology of this organism in humans, however, transmission between elephants seemed unlikely because human-to-human transmission of this organism has never been reported and a third elephant in the herd was not affected. In addition to Mycobacterium bovis and Mycobacterium tuberculosis, atypical mycobacterial organisms need to be considered potentially pathogenic in elephants.
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Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F, Holland SM, Horsburgh R, Huitt G, Iademarco MF, Iseman M, Olivier K, Ruoss S, von Reyn CF, Wallace RJ, Winthrop K. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med 2007; 175:367-416. [PMID: 17277290 DOI: 10.1164/rccm.200604-571st] [Citation(s) in RCA: 4002] [Impact Index Per Article: 235.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
PURPOSE To report a cluster of Nocardia asteroides keratitis cases after LASIK. METHODS Retrospective review of the history and examination of three patients (four eyes) operated on the same day at a single center who developed postoperative keratitis. All patients underwent lifting of the superficial flap for microbiologic evaluation of the corneal scrapings. The operating surgeon was contacted to identify the possible source of contamination. RESULTS Two patients underwent simultaneous bilateral LASIK; however, only one developed postoperative keratitis in both eyes. One patient had unilateral surgery and developed keratitis in the operated eye. Microscopic examination of smears from all eyes revealed thin, branching, acid-fast, filamentous bacteria that were identified as Nocardia asteroides after culture. The infiltrates resolved with topical administration of amikacin sulphate (2.5%) and topical and oral trimethoprim-sulfamethoxazole. Final visual acuity ranged between 20/25 and 20/80. The operating surgeon had used the same blade and microkeratome in all patients. CONCLUSIONS Nocardia, a relatively unusual organism, can cause an epidemic of infection after LASIK.
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Affiliation(s)
- Prashant Garg
- Cornea and Anterior Segment Service, L V Prasad Eye Institute, Hyderabad, India.
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de la Cruz J, Pineda R. LASIK-associated atypical mycobacteria keratitis: a case report and review of the literature. Int Ophthalmol Clin 2007; 47:73-84. [PMID: 17450008 DOI: 10.1097/iio.0b013e318037751b] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Jose de la Cruz
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Boston, MA 02114, USA
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Chung SH, Roh MI, Park MS, Kong YT, Lee HK, Kim EK. Mycobacterium abscessus keratitis after LASIK with IntraLase femtosecond laser. Ophthalmologica 2006; 220:277-80. [PMID: 16785761 DOI: 10.1159/000093084] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2005] [Accepted: 12/12/2005] [Indexed: 11/19/2022]
Abstract
A healthy 38-year-old woman developed 2 white spots in her left eye 2 weeks after bilateral laser in situ keratomileusis (LASIK) using the IntraLase femtosecond laser. Initial treatment included levofloxacin 0.5% but was unsuccessful. The surgeon irrigated the interface and repositioned the flap due to a worsened lesion. She was referred to us after the keratitis had not improved. The flap was lifted for collection of the specimen and irrigation of the interface. The keratitis was treated with intensive topical clarithromycin 1%, amikacin 1.25% and oral clarithromycin, which improved her clinical condition. She developed a toxic reaction to amikacin 1.25%, which was replaced by moxifloxacin 0.5%. Mycobacterium abscessus was identified. The keratitis resolved over 2 months. Five months after treatment, the patient had a visual acuity of 20/20 with correction. Nontuberculous mycobacteria should be considered as an etiologic agent, even in cases of infectious keratitis after LASIK using the femtosecond laser.
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Affiliation(s)
- So-Hyang Chung
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
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26
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Hamam RN, Noureddin B, Salti HI, Haddad R, Khoury JM. Recalcitrant Post-LASIK Mycobacterium chelonae Keratitis Eradicated after the Use of Fourth-Generation Fluoroquinolone. Ophthalmology 2006; 113:950-4. [PMID: 16647126 DOI: 10.1016/j.ophtha.2006.02.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Revised: 02/15/2006] [Accepted: 02/15/2006] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To report a patient with Mycobacterium chelonae keratitis after LASIK and discuss therapeutic measures. DESIGN Interventional case report and literature review. INTERVENTION A healthy, 25-year-old man presented 6 weeks after LASIK with infectious keratitis in the left eye. Scrapings were obtained from the central stromal bed after lifting the flap and inoculated on culture media. MAIN OUTCOME MEASURES Response to medical treatment. RESULTS Mycobacterium chelonae was identified from stromal bed scrapings. The protracted course of the infection necessitated surgical debridement and flap amputation with slow and suboptimal response to prolonged (14 weeks) treatment with topical amikacin 3.3%, clarithromycin 1%, and levofloxacin 0.5%. The substitution of levofloxacin 0.5% with gatifloxacin 0.3% resulted in closure of the epithelial defect within 1 week and resolution of the infiltrates in 3 weeks. The combined regimen of gatifloxacin 0.3%, amikacin 3.3%, and clarithromycin 1% was continued for a total of 4 months. The patient remains infection free 1 year after stopping all antibiotics. CONCLUSION Treatment of post-LASIK nontuberculous mycobacteria remains a challenge. Institution of combination therapy including fortified amikacin, clarithromycin 1%, and a fourth-generation fluoroquinolone appeared to be beneficial in this patient.
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Affiliation(s)
- Rola N Hamam
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
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Rodriguez B, Holzinger KA, Le LH, Winkle RK, Allen RD. Mycobacterium chelonae keratitis after laser-assisted subepithelial keratectomy. J Cataract Refract Surg 2006; 32:1059-61. [PMID: 16814072 DOI: 10.1016/j.jcrs.2006.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 11/09/2006] [Indexed: 11/23/2022]
Abstract
A 24-year-old man with myopic astigmatism had uncomplicated laser-assisted subepithelial keratectomy (LASEK) in October 2004. Approximately 4 weeks later, a foreign-body sensation and redness developed in the left eye. A paracentral anterior stromal infiltrate was observed, and Gram stain on the day of presentation showed branching filamentous gram-positive rods. Cultures subsequently grew Mycobacterium chelonae. Topical tobramycin 15 mg/mL, azithromycin 2 mg/mL, amikacin 25 mg/mL, and cefazolin 50 mg/mL were initiated based on Gram stain results. We believe this is the first documented case of M chelonae keratitis after LASEK.
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Affiliation(s)
- Brandon Rodriguez
- Tripler Army Medical Center, Department of Ophthalmology, Honolulu, Hawaii 96789, USA
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Caballero AR, Marquart ME, O'Callaghan RJ, Thibodeaux BA, Johnston KH, Dajcs JJ. Effectiveness of fluoroquinolones against Mycobacterium abscessus in vivo. Curr Eye Res 2006; 31:23-9. [PMID: 16421016 DOI: 10.1080/02713680500477321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine the effectiveness of fluoroquinolones against Mycobacterium abscessus in vivo. METHODS M. abscessus growth was determined quantitatively in rabbit corneas after intrastromal bacterial injection (10(4) CFU/cornea; n >or= 4 corneas per group). Eyes were treated topically with 0.3% ciprofloxacin, 0.5% levofloxacin, or 0.5% moxifloxacin by three protocols: (1) 1 drop of antibiotic applied hourly for 10 hr on day 3 postinfection (PI); (2) 1 drop applied every 2 hr for 10 hr on days 2 and 3 PI; or (3) 1 drop applied every 2 hr for 10 hr on days 1, 2, and 3 PI. Corneas were cultured 1 hr after the last topical drop. Results are expressed as the log CFU. RESULTS Bacteria in control group reached maximal numbers in vivo by day 3 PI (approximately 6 logs CFU/cornea). Treatment of infected eyes on day 3 with moxifloxacin or levofloxacin resulted in approximately 2.0 log decrease in CFU/cornea relative to the untreated control. Treatment on days 2 and 3 with moxifloxacin or levofloxacin resulted in approximately 3.0 and 2.5 log CFU/cornea decrease, respectively. Ciprofloxacin had no effect on bacterial load. Treatment on days 1, 2, and 3 with moxifloxacin resulted in a 5.5 log CFU decrease, whereas treatment with levofloxacin or ciprofloxacin resulted in a approximately 4.0 log CFU decrease. CONCLUSIONS Moxifloxacin, and to a lesser extent levofloxacin and ciprofloxacin, demonstrated significant effectiveness for reducing the number of M. abscessus in vivo, suggesting the potential usage of these agents in prevention of M. abscessus keratitis.
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Affiliation(s)
- Armando R Caballero
- Department of Microbiology, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
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Chai N, Deforges L, Sougakoff W, Truffot-Pernot C, De Luze A, Demeneix B, Clément M, Bomsel MC. MYCOBACTERIUM SZULGAI INFECTION IN A CAPTIVE POPULATION OF AFRICAN CLAWED FROGS (XENOPUS TROPICALIS). J Zoo Wildl Med 2006; 37:55-8. [PMID: 17312814 DOI: 10.1638/04-064.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A colony of captive Xenopus tropicalis became infected with Mycobacterium szulgai. Clinical signs, when observed, were lethargy, weight loss, and emaciation. Visceral granulomas were common findings at laparoscopy and necropsy. The diagnosis of mycobacteriosis was based on histologic appearance and Ziehl-Neelsen staining of tissues. The identification of M. szulgai organisms was based on comparison of the 16S rRNA gene sequence with several GenBank databases. There have been no reports of this mycobacterial species as the causative agent of naturally occurring disease in amphibians.
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Affiliation(s)
- Norin Chai
- Muséum National d'Histoire Naturelle-Menagerie du Jardin des Plantes, 57 rue Cuvier, 75005 Paris, France
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Affiliation(s)
- Lewis R Groden
- Department of Ophthalmology, University of South Florida College of Medicine, MDC Box 21, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612, USA
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Lee SB, Oliver KM, Strube YNJ, Mohan SK, Slomovic AR. Fourth-generation fluoroquinolones in the treatment of mycobacterial infectious keratitis after laser-assisted in situ keratomileusis surgery. Can J Ophthalmol 2005; 40:750-3. [PMID: 16391641 DOI: 10.1016/s0008-4182(05)80094-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
CASE REPORT Infectious keratitis after laser-assisted in situ keratomileusis (LASIK) is a rare complication that may be challenging to diagnose and treat. We discuss some of the reasons for difficulties diagnosing postoperative atypical or nontuberculous mycobacterial infection and establishing an effective treatment, with reference to reports of comparative antibacterial activity of the most commonly used antibiotics. COMMENTS To the best of our knowledge, we are the first to report the use of the fourth-generation fluoroquinolone moxifloxacin in combination therapy for the successful treatment of this condition.
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Affiliation(s)
- Sao Bing Lee
- Department of Ophthalmology and Vision Science, University of Toronto, Ontario
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Sarayba MA, Shamie N, Reiser BJ, Sweet PM, Taban M, Graff JM, Kesler-Diaz A, Osann KE, McDonnell PJ. Fluoroquinolone therapy in Mycobacterium chelonae keratitis after lamellar keratectomy. J Cataract Refract Surg 2005; 31:1396-402. [PMID: 16105613 DOI: 10.1016/j.jcrs.2004.12.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To characterize a rabbit model of Mycobacterium chelonae keratitis after lamellar keratectomy and assess the effectiveness of fluoroquinolone therapy. SETTING University Laboratory, University of California, Irvine, California, USA. METHODS Twenty-eight New Zealand white rabbits had unilateral lamellar keratectomy with placement of 2.5 x 10(5) colony-forming units of log-phase M chelonae under each flap. Eyes (7 per group) were randomized and treated with sterile balanced salt solution, gatifloxacin 0.3%, ciprofloxacin 0.3%, or levofloxacin 0.5% 4 times daily. Two masked observers examined all eyes on days 2, 5, and 7 and weekly for 4 weeks. Severity of disease and bacterial culture results were the main outcomes measured. The means and standard deviations were calculated, and differences between the groups were statistically analyzed. RESULTS All eyes developed clinical disease. At the time the rabbits were killed, eyes treated with balanced salt solution, ciprofloxacin, levofloxacin, and gatifloxacin were culture positive in 6 (85.7%), 7 (100%), 6 (85.7%), and 3 (42.9%) of 7 eyes per group, respectively. Frequency of positive culture and the severity of clinical disease in gatifloxacin-treated eyes were significantly less (P < .05) than in the other groups combined. CONCLUSIONS The rabbit model of M chelonae keratitis was successfully developed in our study. A fourth-generation quinolone (gatifloxacin) showed the best performance among the fluoroquinolones tested in our experimental approach. The fourth-generation fluoroquinolone, gatifloxacin, could be effectively used for the treatment of mycobacterial keratitis.
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Affiliation(s)
- Melvin A Sarayba
- Department of Ophthalmology, University of California, Irvine, California, USA
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Höfling-Lima AL, de Freitas D, Sampaio JLM, Leão SC, Contarini P. In Vitro Activity of Fluoroquinolones Against Mycobacterium abscessus and Mycobacterium chelonae Causing Infectious Keratitis After LASIK in Brazil. Cornea 2005; 24:730-4. [PMID: 16015094 DOI: 10.1097/01.ico.0000154411.07315.0a] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the in vitro activity of fluoroquinolones against Mycobacterium abscessus and Mycobacterium chelonae isolated from outbreaks of infectious keratitis in Brazil. MATERIAL AND METHODS Micobacterial isolates were recovered from infectious keratitis cases related outbreaks that occurred in Brazil after LASIK for myopia. Two outbreaks occurred in Rio de Janeiro in 1998 and 1999, and 3 in São Paulo between 2000 and 2003. All laboratorial analysis, including molecular identification and antibiotic susceptibility testing with determination of the minimum inhibitory concentration (MIC) levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin, were performed at Universidade Federal de São Paulo in Brazil. RESULTS Fifteen samples were identified as M. chelonae, and 3 were identified as M. abscessus. The outbreaks studied were designated SP-1 in 2000; SP-2 in 2000-2001; and SP-3 in 2003, R1 in 1988 and R2 in 1999. All but 1 of the M. chelonae were resistant to all fluoroquinolones with an MIC90 greater than 32 microg/mL. The only susceptible isolate had MIC levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin of 0.38 microg/mL, 0.032 microg/mL, 0.047 microg/mL, and 0.19 microg/mL, respectively. MIC levels for all 3 M. abscessus isolates tested were greater then 32 microg/mL for all fluoroquinolones tested. CONCLUSIONS Fluoroquinolone MICs for 17 M. abscessus and M. chelonae isolates recovered from infectious keratitis cases in Brazil indicate that they are not susceptible to these drugs in vitro. Further studies to investigate the in vivo effectiveness of fluoroquinolones against mycobacteria are required because in vitro tests do not support their use in the treatment of micobacterial keratitis in this particular geographic area.
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Abstract
PURPOSE We present a case of Mycobacterium keratitis after laser in situ keratomileusis (LASIK). METHOD A retrospective case report. RESULTS A 40-year-old woman developed Mycobacterium chelonae keratitis in the right eye 2 weeks after bilateral LASIK. The diagnosis was made by acid-fast staining of corneal scrapings on admission and confirmed by culture results 2 weeks later. Intensive treatment with topical amikacin (25 mg/mL) and ciprofloxacin and partial excision of the flap led to resolution of the infection after 2 months of therapy. In addition, topical methylprednisolone (1 mg/mL) was necessary to control inflammation and pain. No recurrence was found during the 1-year follow-up period. The final uncorrected and corrected visual acuity in the right eye was 20/25 and 20/20, respectively. CONCLUSION Mycobacterium keratitis is a potentially vision-threatening complication after LASIK. Early recognition of the organisms and aggressive treatment if infection develops may improve the outcome. When surgery is indicated, partial flap amputation, which may help to resolve the infection and preserve better vision, may be considered.
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Affiliation(s)
- Kai-Shiang Yang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China
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John T, Velotta E. Nontuberculous (atypical) mycobacterial keratitis after LASIK: current status and clinical implications. Cornea 2005; 24:245-55. [PMID: 15778593 DOI: 10.1097/01.ico.0000151565.63107.64] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Corneal infection with unfamiliar organisms such as nontuberculous (atypical) mycobacteria after laser in situ keratomileusis (LASIK) can be a significant clinical problem, and mismanagement of such corneal infection in an otherwise healthy, young individual can lead to significant medicolegal issues for the refractive surgeon. Because nontuberculous (atypical) mycobacterial keratitis is the most common infection after LASIK, the refractive surgeon should be aware of all aspects of this dreaded infection to be better prepared to manage such cases. METHODS Literature search. RESULTS/CONCLUSIONS This article provides a comprehensive compilation of all reported cases of nontuberculous (atypical) mycobacterial keratitis in the English literature and provides some useful recommendations for the clinical management of such corneal infection after LASIK.
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Affiliation(s)
- Thomas John
- Department of Ophthalmology, Loyola University at Chicago, Maywood, IL, USA.
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Tehrani M, Dick HB, Daeschlein G, Kramer A. Mikrobielle Keratitis nach Laser-in-situ-Keratomileusis. Ophthalmologe 2005; 102:514-9. [PMID: 15503051 DOI: 10.1007/s00347-004-1127-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Laser in situ keratomileusis (LASIK) is an effective option and currently one of the most commonly applied surgical techniques in the correction of refractive errors such as myopia, hyperopia, and astigmatism. In contrast to photorefractive keratectomy, it maintains the integrity of Bowman's membrane and the epithelium leading to faster visual rehabilitation as well as less pain and discomfort. Nevertheless, following LASIK the stroma is exposed to infectious organisms. Sight-threatening complications after LASIK are reported to be as rare as 1 in 1000 procedures. However, any infectious keratitis remains potentially devastating. Reports about infectious keratitis following LASIK have increasingly surfaced in recent years. We present a review of the literature on microbial keratitis and present our own cases and recommendations for possible prophylaxis and therapy.
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MESH Headings
- Adult
- Anti-Bacterial Agents/therapeutic use
- Antifungal Agents/therapeutic use
- Diagnosis, Differential
- Eye Infections/diagnosis
- Eye Infections/drug therapy
- Eye Infections/etiology
- Eye Infections/microbiology
- Eye Infections/prevention & control
- Eye Infections, Bacterial/diagnosis
- Eye Infections, Bacterial/drug therapy
- Eye Infections, Bacterial/etiology
- Eye Infections, Bacterial/microbiology
- Eye Infections, Bacterial/prevention & control
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/drug therapy
- Eye Infections, Fungal/etiology
- Eye Infections, Fungal/microbiology
- Eye Infections, Fungal/prevention & control
- Humans
- Incidence
- Keratitis/diagnosis
- Keratitis/drug therapy
- Keratitis/etiology
- Keratitis/microbiology
- Keratitis/prevention & control
- Keratitis, Herpetic/diagnosis
- Keratitis, Herpetic/etiology
- Keratomileusis, Laser In Situ/adverse effects
- Postoperative Care
- Postoperative Complications/diagnosis
- Postoperative Complications/drug therapy
- Postoperative Complications/prevention & control
- Preoperative Care
- Risk Factors
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McNabb A, Eisler D, Adie K, Amos M, Rodrigues M, Stephens G, Black WA, Isaac-Renton J. Assessment of partial sequencing of the 65-kilodalton heat shock protein gene (hsp65) for routine identification of Mycobacterium species isolated from clinical sources. J Clin Microbiol 2004; 42:3000-11. [PMID: 15243051 PMCID: PMC446301 DOI: 10.1128/jcm.42.7.3000-3011.2004] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We assessed the ability of an in-house database, consisting of 111 hsp65 sequences from putative and valid Mycobacterium species or described groups, to identify 689 mycobacterial clinical isolates from 35 species or groups. A preliminary assessment indicated that hsp65 sequencing confirmed the identification of 79.4% of the isolates from the 32 species examined, including all Mycobacterium tuberculosis complex isolates, all isolates from 13 other species, and 95.6% of all M. avium-M. intracellulare complex isolates. Identification discrepancies were most frequently encountered with isolates submitted as M. chelonae, M. fortuitum, M. gordonae, M. scrofulaceum, and M. terrae. Reexamination of isolates with discrepant identifications confirmed that hsp65 identifications were correct in a further 40 isolates. This brought the overall agreement between hsp65 sequencing and the other identification methods to 85.2%. The remaining 102 isolates had sequence matches below our acceptance criterion, had nondifferential sequence matches between two or more species, were identified by 16S rRNA sequencing as a putative taxonomic group not contained in our database, or were identified by hsp65 and 16S rRNA gene sequencing as a species not in our biochemical test database or had conflicting identifications. Therefore, to incorporate the unconfirmed isolates it was necessary to create 29 additional entries in our hsp65 identification database: 18 associated with valid species, 7 indicating unique sequences not associated with valid or putative species or groups, and 4 associated with unique, but currently described taxonomic groups. Confidence in the hsp65 sequence identification of a clinical isolate is best when sequence matches of 100% occur, but our data indicate that correct identifications can be confidently made when unambiguous matches exceeding 97% occur, but are dependent on the completeness of the database. Our study indicates that for hsp65 sequencing to be an effective means for identifying mycobacteria a comprehensive database must be constructed. hsp65 sequencing has the advantage of being more rapid and less expensive than biochemical test panels, uses a single set of reagents to identify both rapid- and slow-growing mycobacteria, and can provide a more definitive identification.
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Affiliation(s)
- Alan McNabb
- Laboratory Services, British Columbia Centre for Disease Control, 655 West 12th Ave., Vancouver, British Columbia V5Z 4R4, Canada.
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Ferrer C, Rodríguez-Prats JL, Abad JL, Alió JL. Unusual anaerobic bacteria in keratitis after laser in situ keratomileusis. J Cataract Refract Surg 2004; 30:1790-4. [PMID: 15313309 DOI: 10.1016/j.jcrs.2003.11.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2003] [Indexed: 11/28/2022]
Abstract
Laser in situ keratomileusis (LASIK) was performed in the left eye of a 57-year-old man for residual ametropia after phacoemulsification. The patient was given topical tobramycin and a corticosteroid for 1 week postoperatively. Fifteen days later, he developed 3 corneal infiltrates beneath the flap with a gas bubble, suggesting an anaerobic infection. Tobramycin and ofloxacin were administered every 2 hours, but the condition worsened. Corneal scrapings were taken from beneath the flap for microbiological cultures and a polymerase chain reaction (PCR) test. The PCR amplification was negative for fungi and mycobacteria and positive for bacterial DNA. Sequence analysis showed Propionibacterium granulosum as the causal agent, but cultures were negative. Treatment with vancomycin and cefazolin led to clinical improvement, with resolution of corneal infiltrates. Anaerobic microorganisms can cause keratitis after LASIK. Polymerase chain reaction amplification and DNA typing can help detect microorganisms involved in these ocular infections.
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Affiliation(s)
- Consuelo Ferrer
- Departmento Biología Molecular, Instituto Oftalmológico de Alicante, Avenida de Denia no 111, 03015 Alicante, Spain.
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Solomon R, Donnenfeld ED, Azar DT, Holland EJ, Palmon FR, Pflugfelder SC, Rubenstein JB. Infectious keratitis after laser in situ keratomileusis: Results of an ASCRS survey. J Cataract Refract Surg 2003; 29:2001-6. [PMID: 14604725 DOI: 10.1016/s0886-3350(03)00512-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To investigate the incidence, culture results, treatment, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) worldwide, the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) contacted 8600 United States and international ASCRS members by e-mail and asked them to respond to a questionnaire about post-LASIK infectious keratitis. One hundred sixteen infections were reported by 56 LASIK surgeons who had performed an estimated 338 550 procedures. Seventy-six cases presented in the first week after surgery, 7 during the second week, 17 between the second and fourth weeks, and 16 after 1 month. Forty-seven cases were not diagnosed on initial presentation. The most common organisms cultured were atypical mycobacteria and staphylococci. Empiric therapy is not recommended as most of the organisms are opportunistic and not responsive to conventional therapy. Flap elevation and culturing should be performed when post-LASIK infectious keratitis is suspected.
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Affiliation(s)
- Renée Solomon
- Ophthalmic Consultants of Long Island, Rockville Centre, East Meadow, New York, USA
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Abstract
PURPOSE OF REVIEW To assess the recent advances in the field of waterborne nosocomial infections. RECENT FINDINGS In the last year, many publications have confirmed the importance of well known nosocomial waterborne pathogens such as Legionella spp. or other Gram-negative bacteria, especially non-fermentative bacilli. There have also been numerous reports of outbreaks or pseudo-outbreaks caused by Mycobacteria spp. The most intriguing information relates to the possibility that some fungi causing nosocomial infections may originate from the hospital water distribution system. SUMMARY Despite progress in understanding the pathogenesis of nosocomial waterborne infections, outbreaks, pseudo-outbreaks and sporadic infections still occur. Targeted quality control of hospital water, updated procedures for the appropriate use of sterile and non-sterile water, coupled with surveillance constitute the cornerstones of prevention of these infections.
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Affiliation(s)
- Giorgio M Merlani
- Department of Infectious Diseases, Vaudois University Hospital, Lausanne, Switzerland
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Freitas D, Alvarenga L, Sampaio J, Mannis M, Sato E, Sousa L, Vieira L, Yu MC, Martins MC, Hoffling-Lima A, Belfort R. An outbreak of Mycobacterium chelonae infection after LASIK. Ophthalmology 2003; 110:276-85. [PMID: 12578767 DOI: 10.1016/s0161-6420(02)01643-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe an outbreak of mycobacterial keratitis after laser in situ keratomileusis (LASIK), including the microbiologic investigation, clinical findings, treatment response, and outcome. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Patients (n = 10) who underwent LASIK surgery between August 22 and September 4, 2000, and developed mycobacterial infection. METHODS Patients were prospectively followed in relation to microbiologic investigation, clinical findings, treatment response, and outcome. MAIN OUTCOME MEASURES Most patients underwent bilateral simultaneous LASIK. Postoperative infection was signaled by the appearance of corneal infiltrates in the third postoperative week. The microbiologic workup was performed on cultures obtained either by direct scraping of the cornea or by lifting the flap. Medical therapy was instituted based on drug susceptibility testing. Surgical interventions such as corneal debridement and flap removal were performed during recurrences or when there was no satisfactory clinical response. RESULTS Cultures revealed Mycobacterium subspecies chelonae. Patients were treated with topical clarithromycin (1%), tobramycin (1.4%), and ofloxacin (0.3%). Oral clarithromycin (500 mg twice a day) was prescribed for those patients who did not respond clinically to topical treatment. Four eyes healed on this regimen. Flap removal was necessary in seven eyes. CONCLUSIONS This report highlights mycobacteria as an etiologic infectious agent after LASIK. Diagnosis can be difficult and is often delayed. The treatment mainstay is prolonged antibiotic therapy. Surgical debridement and flap removal may shorten the disease course.
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Affiliation(s)
- Denise Freitas
- Ophthalmology Department, Federal University of São Paulo, Paulista School of Medicine, São Paulo Hospital, Rua Botucatu 822, 04023-062 São Paulo, Brazil.
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Winthrop KL, Steinberg EB, Holmes G, Kainer MA, Werner SB, Winquist A, Vugia DJ. Epidemic and sporadic cases of nontuberculous mycobacterial keratitis associated with laser in situ keratomileusis. Am J Ophthalmol 2003; 135:223-4. [PMID: 12566028 DOI: 10.1016/s0002-9394(02)01955-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To report national case-finding results for nontuberculous mycobacterial keratitis and describe its association with laser in situ keratomileusis (LASIK). DESIGN Enhanced passive disease reporting. METHODS In April 2001, we investigated a California cluster of Mycobacterium chelonae keratitis associated with hyperopic LASIK using a contact lens mask. To identify other possibly related cases, the American Academy of Ophthalmology e-mailed its members asking them to report recent cases of nontuberculous mycobacterial keratitis to the Centers for Disease Control and Prevention. RESULTS Forty-three additional cases of keratitis were reported (onsets between August 2000 and June 2001). Of these, 31 occurred as part of two unrelated LASIK-associated outbreaks. The 12 other reported cases occurred in sporadic fashion. Of the latter cases, 4 were associated with LASIK surgery. None of the reported cases were related to the M. chelonae cluster in California. CONCLUSIONS Laser in situ keratomileusis-associated keratitis with nontuberculous mycobacteria may be more common than previously known.
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Affiliation(s)
- Kevin L Winthrop
- Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Allen G. Mycobacterium szulgai; malnutrition and wounds; biological indicators; sterilizing with infrared radiation. AORN J 2002. [DOI: 10.1016/s0001-2092(06)61047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE To describe the time course, diagnosis, clinical features, and treatment of seven patients with Mycobacterium szulgai keratitis that developed from 7 to 24 weeks after laser in situ keratomileusis (LASIK). METHODS Seven of 30 eyes of 18 patients were identified with keratitis after LASIK. The first two patients presented 12 to 14 weeks after LASIK; nontuberculous mycobacteria were identified 1 month after the flaps were cultured. Patient recall identified three additional cases by culture and two cases by clinical features alone. Pulsed-field gel electrophoresis (PFGE) was used to type the isolates, and treatment was modified based on susceptibilities. RESULTS M. szulgai was identified in five patients for whom cultures were performed, but response to empiric therapy based on cultures proved unsatisfactory. The keratitis resolved in all patients with treatment including clarithromycin based on susceptibilities. Medical therapy was sufficient, although one patient required flap amputation. Six of seven patients recovered best-corrected visual acuity (BCVA), while one patient lost one line of BCVA. Two patients lost one line of postoperative uncorrected visual acuity (UCVA), two patients gained one line of UCVA, and three patients recovered postoperative UCVA. PFGE analysis revealed that the M. szulgai strains were identical, and the infection source was contaminated ice used to chill syringes for saline lavage. CONCLUSIONS Nontuberculous mycobacterial keratitis after LASIK is a diagnostic and management challenge, but outcomes can be preserved with treatment based on susceptibilities. This cluster underscores the importance of adherence to sterile protocol during LASIK.
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Affiliation(s)
- Samuel F A Fulcher
- Division of Ophthalmology, Scott & White Memorial Hospital and Clinic, 2401 South 31st Street, Temple, TX 76508, USA.
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