ENDOGENOUS KLEBSIELLA PNEUMONIAE ENDOPHTHALMITIS IN NORTHERN CALIFORNIA

Endogenous endophthalmitis: New insights from a 12-year cohort study

OBJECTIVES

To describe the clinical and microbiological characteristics of patients with endogenous endophthalmitis (EE), determine factors associated with outcome and propose a management plan for EE.

METHODS

Retrospective case series in two tertiary referral centers from 2010 to 2022.

RESULTS

Sixty-four eyes of 53 patients were included. Bilateral involvement occurred for 11/53 patients (21%). Ocular symptoms were the only first manifestation of the disease in 36/53 (68%) of cases; signs of sepsis were evident in 17/53 (32%). Imaging tests detected at least one extraocular focus of infection in 34/53 patients (64%), with contrast-enhanced thoraco-abdominopelvic computed tomography showing relevant findings in 28/50 (56%) of cases. EE was microbiologically confirmed in 43/53 patients (81%); the organisms involved were: Gram-positive bacteria (19/53, 36%), Gram-negative bacteria (13/53, 25%) and Candida sp. (11/53, 21%). Klebsiella pneumoniae was the most common bacteria (10/32, 31%). Blood cultures were positive in 28/53 patients (53%) and eye samples in 11/41 eyes (27%). All patients were treated with systemic antimicrobial therapy, 39/64 eyes (61%) received anti-infective intravitreal injection(s) and 17/64 eyes (27%) underwent vitrectomy. Four patients (8%) died due to uncontrolled systemic infection. Final visual acuity (VA) was < 20/400 in 28/57 eyes (49%) and ocular structural loss (bulbar phthisis or enucleation/evisceration) was reported in 18/64 eyes (28%). In multivariate analysis, initial VA was the only parameter associated with visual and/or structural loss of the eye (OR = 24.44 (4.33-228.09) and 5.44 (1.33-26.18) respectively).

CONCLUSIONS

EE remains a severe infection with a poor ocular outcome. We propose a standard protocol to improve diagnosis and medical management.

Klebsiella pneumoniae Endophthalmitis with Subretinal Abscess: A Case Series and Review of the Literature

This study assessed prognostic factors and the role of vitrectomy in patients with subretinal abscesses secondary to K. pneumoniae endophthalmitis. We reviewed published studies, including three cases from our cohort. Among 50 eyes, 26 had poor visual outcomes (final visual acuity <20/800, eyeball removal, or phthisis bulbi). Poor outcomes correlated with delayed ocular symptom-to-diagnosis time, initial visual acuity <20/800, severe vitritis, and macular involvement of abscesses (p < 0.001, p = 0.008, p < 0.001, and p = 0.033, respectively). Vitrectomy had a trend towards reducing eyeball removal and phthisis bulbi rates compared with non-vitrectomy (10.8% vs 30.8%, p = 0.181). However, the final visual acuity was not different and the rate of retinal detachment tended to be higher in vitrectomized eyes (45.9% vs 15.4%, p = 0.095). The study suggested that vitrectomy and drainage of K. pneumoniae subretinal abscesses could be avoided in patients with a mild degree of vitritis.

Hypervirulent Klebsiella Pneumoniae, an Emerging Cause of Endogenous Endophthalmitis in A French Center: A Comparative Cohort Study

INTRODUCTION

Klebsiella pneumoniae (KP) is the most common cause of endogenous endophthalmitis (EE) in Asia, but data in Europe are scarce. We describe eight cases of KP EE compared to a cohort of EE in a French center.

METHODS

EE cases were retrospectively studied between January 2014 and January 2021. KP EE cases were analyzed to assess clinical, microbiological features, and outcome.

RESULTS

Among the 33 EE cases identified, the first causative agent (24%, n = 8) was KP, mainly (7/8) with hypervirulent phenotype (hvKP). All but one of these cases occurred from December 2019 to January 2021. Contrary to non-KP patients, KP patients had multiple extraocular infective foci (p = .006), all presented with liver abscesses (p < .001), 50% had cerebral involvement (p = .13). Visual outcome was poor in both groups.

CONCLUSION

KP is an emerging cause of EE in a French center, consistently associated with liver abscesses, frequent cerebral involvement, and predominance of hvKP strains.

Case Series on Endogenous Klebsiella pneumoniae Endophthalmitis: More Than Meets the Eye

Endogenous endophthalmitis (EE) is a rare but potentially sight-threatening disease with an appreciable mortality rate. Diabetes mellitus remains the most frequently associated condition especially in the Asian population, which potentiates Klebsiella pneumoniae involvement. Endogenous Klebsiella pneumoniae endophthalmitis (EKE) usually has a poor final visual outcome despite treatment with intravitreal and systemic antibiotics. We report three cases of EKE with systemic involvement Klebsiella pneumoniae invasive syndrome (KPIS). KPIS was diagnosed in three patients with multiple comorbidities who presented with a blurring of vision and eye redness. Patient 1 was a 63-year-old Malay man diagnosed with left eye panophthalmitis with multifocal liver and prostate abscesses. He underwent drainage of the liver abscess and eventually evisceration of the left eye due to scleral perforation. Patient 2 was a 66-year-old Malay woman diagnosed with left eye endophthalmitis. Due to hemodynamic instability, vitrectomy was delayed and eventually sustained corneal perforation and eviscerated. The patient eventually succumbed to infection. Patient 3 was a 42-year-old Malay woman diagnosed with KPIS, renal abscess, lung abscess, and left endogenous endophthalmitis. She underwent a vitrectomy but her postoperative vision remained poor. All patients received multiple intravitreal antibiotics and systemic antibiotics. KPIS is frequently associated with catastrophic disabilities. Our cases highlight the importance of an early suspicion of systemic involvement in patients presenting with EKE. Prompt diagnosis, emergent radiographic evaluation, early adequate drainage, and appropriate treatment with antibiotics potentially improve survival and visual prognosis.

Clinical Features and Mortality of Endogenous Panophthalmitis in China: A Six-Year Study

PURPOSE

To report the clinical features, treatment strategy, and mortality of patients with endogenous panophthalmitis (EP).

METHODS

Fifteen patients (16 eyes) diagnosed with EP from December 2012 to December 2018 were investigated with a standard protocol at a tertiary medical center of the largest eye center in Northern China. Mortality was followed up.

RESULTS

All participants were Han Chinese. The mean age was 58.3, 62.5% were male, and 93.3% were unilaterally involved. The average number of predisposing factors was 3.0. The top two predisposing factors were diabetes mellitus (DM, 93.3%) and pyogenic liver abscess (PLA, 66.7%). All patients initially presented at an ophthalmic emergency due to severe ocular symptoms. All patients were co-managed by relevant specialists and were admitted to medical or surgical wards instead of the eye center unless the systemic condition was well controlled. Only four eyes were eligible for vitrectomy. The mean follow-up duration was 12.5 months. The mortality rate was 0%. The predominant causative organism was Klebsiella pneumoniae (80.0%), and there were no positive fungal cases.

CONCLUSIONS

EP is a rare, life-threatening disease. DM and PLA could predispose its development. The predominant causative organism was Klebsiella pneumoniae. The interdisciplinary cooperation system of the management of EP may reduce the mortality rate.Abbreviations :EP: endogenous panophthalmitis; EE: endogenous endophthalmitis; DM: diabetes mellitus; PLA: pyogenic liver abscess; ACI: acute cerebral infarction; UTI: urinary tract infection; ICU: intensive care unit; VA: visual acuity; LP: light perception; HM: hand motion; NLP: no light perception; K. pneumoniae: Klebsiella pneumoniae; CT: computed tomography; MRI: magnetic resonance imaging; CRP: C-reactive protein; PCT: procalcitonin; FBG: fasting blood glucose; WBC: white blood cell; NEUT: neutrophil proportion; BDG: 1,3-β-D-glucan; GM: galactomannan; IVI: intravitreal injection; PPV: pars plana vitrectomy; ILAS: invasive liver abscess syndrome; cps: capsular polysaccharide; CSF: cerebrospinal fluid; SD: standard deviation.

Hypervirulent Klebsiella pneumoniae Endogenous Endophthalmitis-A Global Emerging Disease

The review aims to document the new emerging hypervirulent Klebsiella pneumoniae (Kp) endogenous endophthalmitis (EKE) in terms of incidence, microbiological characterization of the pathogenic agent, associated risk factors, management, and outcomes. Hypervirulent (hv) strains of KP (hvKp) induce invasive liver abscesses (LA) with specific clinical features. Up to 80–90% of cases have hepatic liver abscess as a primary focus of infection, followed by renal or lung hvKp infections. However, the incidence of EKE in patients with KPLA varied between 3.4% (19) and 12.6% (13), with a total of 95 cases of endophthalmitis in 1455 cases of KPLA (6.5%). Severe visual loss was encountered in 75% of cases, with 25% bilateral involvement. Intravitreal antibiotics are the mainstay therapeutic approach. Pars plana vitrectomy is a subject of controversy. HvKp strains present mostly natural “wild-type” antibiotic resistance profile suggestive for community-acquired infections, being highly susceptive to the third and fourth generation of cephalosporins and carbapenems. Antimicrobial resistance in hypervirulent strains was recently documented via plasmid transfer and may result in extremely difficult to treat cases. Global dissemination of these strains is a major epidemiologic shift that should be considered in the diagnostic and therapeutic management of patients with endogenous endophthalmitis. Ophthalmologic screening in patients with KPLA and other hvKp infections and a multidisciplinary therapeutic approach is extremely important for early diagnosis and preservation of the visual function.

Endogenous Endophthalmitis: A Review of Case Series Published between 2011 and 2020

This is a literature review of 31 case series of endogenous endophthalmitis (EE) published in the last ten years, identified from a literature search of several databases (PubMed, EMBASE, and the Cochrane Library). While diabetes mellitus and malignancies remain the most frequently associated medical conditions, intravenous drug use is a significant risk factor (especially in the last years, in studies from Western countries). Ophthalmologic screening is recommended for candidaemia, but not in patients with sepsis of other aetiologies (however, the physician treating patients with sepsis must be well aware of EE). The most frequent Gram-positive microorganisms that cause EE are Staphylococcus and Streptococcus; the most frequent Gram-negative organism is Pseudomonas, and yeasts, probably Candida, usually cause fungal infections. In all-cause EE, prognostic factors of better visual outcomes are initial VA better than counting fingers, performing a pars plana vitrectomy (PPV), performing an intravitreal injection within the first 24 hours after clinical diagnosis, and the presence of a focal type of EE. In endogenous fungal endophthalmitis, more than 1/4 of patients have bilateral involvement. Blood samples have a low rate of positivity. Yeasts remain the most prevalent cause. Many authors report using azoles and echinocandins for systemic therapy (and voriconazole for intravitreal injections). Although PPV was performed in small proportions of eyes, the anatomical success rate is quite high. Klebsiella pneumoniae is an important cause of EE in Southeast Asia (and probably an emergent etiology in other regions), which is frequently associated with diabetes. There is a robust association with pyogenic liver abscess (PLA) (but in up to half of the cases, the diagnosis of EE precedes that of PLA). Blood cultures have a high diagnostic yield, while vitreous samples have a low yield. K. pneumoniae may carry antibiotic resistance. Anatomical and functional success rates are small, but they may be improved with PPV.

Surgery combined with antibiotics for the treatment of endogenous endophthalmitis caused by liver abscess

Backgrounds

Endogenous endophthalmitis is a serious disease caused by intraocular infection that can rapidly progress to cause blindness. This study evaluated the clinical features, surgical and antibiotics treatment strategies, and treatment outcomes in patients with endophthalmitis caused by liver abscess.

Methods

Between April 2014 and April 2019, the clinical data of 16 patients (19 eyes) with endophthalmitis associated with liver abscess who underwent surgery at Shengjing Hospital were retrospectively analyzed. Furthermore, we evaluated the final visual outcomes in the patients to determine the efficacy of surgery.

Results

Fifteen patients (18 eyes) underwent intravitreal injection followed by vitrectomy after admission. One patient (1 eye) only underwent intravitreal injection. Of the 16 patients, 3 patients (3 eyes) had recurrent intraocular inflammation and eventually underwent evisceration. Systemic antibiotics were administered for all patients based on the results of vitreous humor culture, blood culture, and antibiotic susceptibility tests. Outpatient follow-ups were performed until the patients were stable (6 months). Of the 19 eyes, 1 eye (5%) had visual acuity restored to 20/200, 6 eyes (31%) had visual acuity restored to counting fingers (CF), 2 eyes (11%) had visual acuity restored to hand motion (HM), 4 eyes (22%) showed only light perception (LP), and the remaining 6 eyes (31%) showed no light perception (NLP). Drug susceptibility tests suggested that the carbapenems exhibited significant effects in the inflammatory reaction.

Conclusion

Endogenous endophthalmitis caused by liver abscess is a very serious condition, and the final visual outcome is poor. Timely surgical intervention combined with antibiotic treatment is essential, and the primary disease must be treated to control disease progression at the earliest.

Endogenous Klebsiella endophthalmitis as the presentation of both Klebsiella liver abscess and underlying anti-IFN-3 autoimmunity

This case study is one of the first ever reported examples of infection in a patient with anti-IFN-3 autoimmunity and demonstrates how overwhelming infection can sometimes present with visual symptoms. We report the case of a previously fit middle-aged patient presenting with painless loss of vision and loss of appetite. Examination showed choroidal abscess and a pan-uveitis, leading to admission for vitreous biopsy. Klebsiella pneumoniae was isolated both in the vitreous and in blood cultures. Subsequent investigation discovered a liver abscess which was treated with percutaneous drainage. Despite the administration of intravitreal antibiotics from the time of presentation, intravenous antibiotics and vitrectomy on the same day, the patient proceeded to need enucleation 19 days later, and now has only light perception in the remaining eye. The strong association between K. pneumoniae endophthalmitis and underlying liver abscess leads to a significant mortality rate. Early diagnosis is essential, with prompt aggressive treatment with antibiotics, but sadly the visual prognosis remains poor. In cases of suspected choroidal abscess, initiation of sepsis screen and immediate empirical treatment is vital to improve this prognosis. This patient had no significant past medical history, no known immunocompromise, was not diabetic and had no recent significant foreign travel. However, further immunological analysis demonstrated the presence of anti-IFN-3 antibodies, a hitherto under-reported potential cause of increased susceptibility to infection, and so cases of sepsis in previously healthy individuals should be considered for further immunology assessment.

Endophthalmitis in HIV Infection

Purpose: The role of HIV infection in exogenous and endogenous endophthalmitis has not been clarified. We aim to assess the potential role of HIV as a risk factor or a poor prognostic feature in this sight-threatening condition. Methods: Literature review. Review of evidence: Evidence for endophthalmitis in HIV patients is based on scarce retrospective case series and case reports. Infrequency of literature on this topic is owed to the diversity of the different types of endophthalmitis as well as the rarity of the coexistence of the two conditions. Conclusions: Endophthalmitis in HIV patients are a rare but potentially devastating condition. Many forms of endophthalmitis tend to occur in severely immunosuppressed HIV patients with low CD4 counts. Therefore, the early introduction of cART with full immune reconstitution is an essential part of the prevention of endophthalmitis in the HIV population.

Hypervirulent Klebsiella pneumoniae

Hypervirulent K. pneumoniae (hvKp) is an evolving pathotype that is more virulent than classical K. pneumoniae (cKp). hvKp usually infects individuals from the community, who are often healthy. Infections are more common in the Asian Pacific Rim but are occurring globally. hvKp infection frequently presents at multiple sites or subsequently metastatically spreads, often requiring source control. hvKp has an increased ability to cause central nervous system infection and endophthalmitis, which require rapid recognition and site-specific treatment. The genetic factors that confer hvKp's hypervirulent phenotype are present on a large virulence plasmid and perhaps integrative conjugal elements. Increased capsule production and aerobactin production are established hvKp-specific virulence factors. Similar to cKp, hvKp strains are becoming increasingly resistant to antimicrobials via acquisition of mobile elements carrying resistance determinants, and new hvKp strains emerge when extensively drug-resistant cKp strains acquire hvKp-specific virulence determinants, resulting in nosocomial infection. Presently, clinical laboratories are unable to differentiate cKp from hvKp, but recently, several biomarkers and quantitative siderophore production have been shown to accurately predict hvKp strains, which could lead to the development of a diagnostic test for use by clinical laboratories for optimal patient care and for use in epidemiologic surveillance and research studies.