Endophthalmitis caused by Achromobacter xylosoxidans after cataract surgery

POSTINTRAVITREAL INJECTION AND POSTCATARACT EXTRACTION ENDOPHTHALMITIS VISUAL OUTCOMES BY ORGANISM: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

To compare visual outcomes of endophthalmitis following intravitreal injections (IVIs) and cataract extraction by causative organism.

METHODS

Searches in Cochrane Central Register of Controlled Trials, MEDLINE, and Embase identified articles reporting visual outcomes by causative organisms in post-IVI and cataract extraction endophthalmitis cases from January 2010 to February 2022. A random-effects meta-analysis compared visual improvement among endophthalmitis cases caused by causative organisms.

RESULTS

Eighty-five out of 3,317 retrieved studies were included. The highest degree of visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis was seen in cases caused by coagulase-negative staphylococci, followed by gram-negative organisms and other gram-positive organisms such as streptococci and enterococci. Culture-negative cases showed more visual acuity improvement than culture-positive cases in post-IVI endophthalmitis. These results remained consistent when accounting for endophthalmitis treatment, IVI type, condition requiring IVI treatment, follow-up period, and initial preprocedural visual acuity.

CONCLUSION

Coagulase-negative staphylococci and gram-negative organisms show the most visual acuity improvement in both post-IVI and postcataract extraction endophthalmitis. Other gram-positive organisms such as streptococci and enterococci are associated with less visual improvement. This updated systematic review and meta-analysis revealed that the results of the Endophthalmitis Vitrectomy Study are consistent decades later despite advancements in surgical practices and the evolution of microorganisms over time.

A Rare Case of Acute Post-cataract Surgery Endophthalmitis Associated With Achromobacter xylosoxidans

Achromobacter xylosoxidans is rarely reported as a causative agent of post-cataract surgery endophthalmitis. Here, we present a case where timely surgical intervention preserved the patient's vision. A 68-year-old man presented with clinical signs of endophthalmitis in his right eye three days after uneventful cataract surgery. He was initially treated with intravitreal, topical, and systemic antibiotics. After starting intravitreal, topical, and systemic antibiotics, his condition deteriorated on the second day of treatment. A prompt pars plana vitrectomy (PPV) with the removal of the posterior chamber intraocular lens (PCIOL) was performed. Culture from the intravitreal tapping yielded A. xylosoxidans, which was sensitive to ceftazidime and piperacillin. His condition was better post-PPV, and the infection was under control until day 10 post-first PPV. There was a recrudescence of infection with a recurrence of hypopyon and loculations detected on B-scan ultrasound. A second PPV with the complete removal of the lens capsule was performed. One month later, his right eye was quiet without inflammation, with a best-corrected vision of 20/30. A. xylosoxidans is a rare but serious pathogen of endophthalmitis that often necessitates multiple surgical interventions. Although it may not initially respond to intravitreal injections and vitrectomy, appropriate treatment, such as the removal of the intraocular lens and capsulectomy, can still result in favorable visual outcomes.

Delayed-onset endophthalmitis associated with Achromobacter species developed in acute form several months after cataract surgery: Three case reports

BACKGROUND

Achromobacter species-associated endophthalmitis is rare and may present as either acute or chronic postoperative endophthalmitis. Delayed-onset Achromobacter species endophthalmitis appearing in acute presentation that develops more than several months after cataract surgery is very rare. Intraocular lens (IOL) removal is commonly recommended to treat Achromobacter species endophthalmitis, which is based on previous studies. Here, we report the results of surgery without IOL removal when treating patients with delayed-onset postoperative Achromobacter species endophthalmitis that developed in an acute form.

CASE SUMMARY

Three patients visited our ophthalmology clinic due to visual impairment that began 2-3 d earlier. They had undergone cataract surgery 5-18 mo prior. Best-corrected visual acuity of the diseased eye was between counting fingers at 30 cm to non-light perception. They showed conjunctival injection, inflammation in the anterior chamber (cell reaction 4+) and hypopyon formation. The patients were diagnosed with infectious endophthalmitis and immediately underwent pars plana vitrectomy, anterior chamber irrigation and intravitreal injection of ceftazidime and vancomycin. Before fluid infusion, a vitreous specimen was obtained. In all cases, the IOLs were not removed. Achromobacter species was detected on vitreous specimen culture. After surgery, the vitreous opacity decreased gradually and there was little retinal damage. At 1 mo after treatment, the best-corrected visual acuity had improved to 20/50 and 20/40.

CONCLUSION

Delayed onset postoperative endophthalmitis caused by Achromobacter species can appear in an acute form. All patients responded well to early vitrectomy and administration of empirical antibiotics including ceftazidime. There was no need for IOL removal during surgery.

Atypical Microbiological Feature of Infectious Endophthalmitis on Jeju Island: A 10-Year Study at a Single Tertiary Referral Center

Background

To analyze the microbiological causes of infectious endophthalmitis on an isolated island over ten years.

Methods

A retrospective review of the medical records of 49 eyes clinically diagnosed with infectious endophthalmitis between January 2009 and December 2018 was done. The subjects were recruited from a single tertiary referral center on Jeju Island. The baseline characteristics of all subjects were investigated, and a culture examination was performed. The isolated pathogens were analyzed to determine how their microbiological features differed from those in regions with different geographical conditions.

Results

Of the 49 eyes, causative microorganisms were identified in 27 eyes (55.1%). Bacteria were found in 24 cases and fungi in 3 cases. Among the exogenous causes, Staphylococcus species (Staphylococcus aureus, S. epidermidis, and S. hominis) were the most common pathogens (7 cases). Achromobacter xylosoxidans was the second most common causative pathogen (4 cases) followed by Moraxella species (3 cases). The most frequent endogenous origin was due to Klebsiella pneumoniae (6 cases). The subjects were divided into two groups according to the treatment results and analyzed for predisposing factors related to visual outcomes. The presence of diabetes mellitus (P = 0.038) and initial visual acuity (P ≤ 0.001) were significant predisposing factors for visual outcomes.

Conclusion

The causative microorganisms of endogenous endophthalmitis on Jeju Island were not different from those reported previously. However, isolated exogenous microorganisms were different from those reported in other studies from inland areas. A high incidence and atypical clinical features of Achromobacter xylosoxidans and Moraxella in exogenous endophthalmitis were observed, reflective of the distinct climatic features of Jeju Island: high humidity and temperature. Therefore, considering the causative microorganisms of exogenous endophthalmitis, it may be assumed that the causative microorganisms of exogenous endophthalmitis and its clinical manifestations differ according to the region.

Characterization of Novel Lytic Bacteriophages of Achromobacter marplantensis Isolated from a Pneumonia Patient

Achromobacter spp. are becoming increasingly associated with lung infections in patients suffering from cystic fibrosis (CF). A. marplatensis, which is closely related to A. xylosoxidans, has been isolated from the lungs of CF patients and other human infections. This article describes the isolation, morphology and characterization of two lytic bacteriophages specific for an A. marplatensis strain isolated from a pneumonia patient. This host strain was the causal agent of hospital acquired pneumonia–the first clinical report of such an occurrence. Full genome sequencing revealed bacteriophage genomes ranging in size from 45901 to 46,328 bp. Transmission electron microscopy revealed that the two bacteriophages AMA1 and AMA2 belonged to the Siphoviridae family. Host range analysis showed that their host range did not extend to A. xylosoxidans. The possibility exists for future testing of such bacteriophages in the control of Achromobacter infections such as those seen in CF and other infections of the lungs. The incidence of antibiotic resistance in this genus highlights the importance of seeking adjuncts and alternatives in CF and other lung infections.

Chronic Conjunctivitis From a Retained Contact Lens

PURPOSE

To help clinicians diagnose and manage unilateral recalcitrant chronic bacterial conjunctivitis secondary to a retained soft contact lens and describe the first report of Gram-negative bacteria causing this condition.

METHODS

Chart review of successive cases presenting with unilateral chronic conjunctivitis with positive cultures and a retained contact lens.

RESULTS

Three cases were identified and described. Culturing of the retained contact lenses grew Pseudomonas aeruginosa in the first case, Achromobacter xylosoxidans in the second, and Staphylococcus epidermidis in the third. All three patients were successfully treated with removal of the retained lens and targeted antibiotic eyedrop therapy.

CONCLUSIONS

Unilateral chronic recurrent or recalcitrant purulent papillary conjunctivitis is rare, and a retained contact lens should be suspected in patients with a history of wearing contact lenses. Careful examination with double eversion of the upper eyelid and sweeping of the fornices can recover the offending lens. Although only Gram-positive organisms have been isolated in previous reports, two of our three cultures grew Gram-negative organisms, highlighting the importance of broad-spectrum antibiotic usage for these cases.

Chronic, Recurrent Bacterial Endophthalmitis Caused by Achromobacter xylosoxidans: Clinical Features and Management

A 79-year-old man presented to a tertiary referral center from the Dominican Republic with an opaque corneal graft and a diagnosis of chronic, recurrent culture-positive Achromobacter xylosoxidans endophthalmitis of the left eye. The patient had a history of penetrating keratoplasty for Fuchs' dystrophy and had undergone multiple intraocular surgeries including pars plana vitrectomy and anterior chamber wash out for the diagnosis and management of chronic endophthalmitis. After being referred, the patient underwent a third PKP, removal of his intraocular lens (IOL), capsulectomy, and injection of intravitreal antibiotics. All surgical specimens demonstrated the growth of A. xylosoxidans. Five months after surgery, the graft remained clear without evidence of infection and best-corrected visual acuity was 20/350.

Adhesion of Pseudomonas aeruginosa, Achromobacter xylosoxidans, Delftia acidovorans, Stenotrophomonas maltophilia to contact lenses under the influence of an artificial tear solution

Corneal infection is a devastating sight-threatening complication that is associated with contact lens (CL) wear, commonly caused by Pseudomonas aeruginosa. Lately, Achromobacter xylosoxidans, Delftia acidovorans, and Stenotrophomonas maltophilia have been associated with corneal infection. This study investigated the adhesion of these emerging pathogens to CLs, under the influence of an artificial tear solution (ATS) containing a variety of components commonly found in human tears. Two different CL materials, etafilcon A and senofilcon A, either soaked in an ATS or phosphate buffered saline, were exposed to the bacteria. Bacterial adhesion was investigated using a radio-labeling technique (total counts) and plate count method (viable counts). The findings from this study revealed that in addition to P. aeruginosa, among the emerging pathogens evaluated, A. xylosoxidans showed an increased propensity for adherence to both CL materials and S. maltophilia showed lower viability. ATS influenced the viable counts more than the total counts on CLs.

Achromobacter spp. healthcare associated infections in the French West Indies: a longitudinal study from 2006 to 2016

Background

Bacteria of the Achromobacter genus, more particularly xylosoxidans species, are responsible for various healthcare associated infections (HAI) which are increasingly described since the last decade. Cystic fibrosis (CF) patients are considered as potential reservoirs in hospitals. We performed a retrospective study to estimate the frequencies of Achromobacter spp. HAI among patients from French West Indies, to determine characteristics of infected patients and establish a possible link between CF and infections.

Methods

All adults with at least one Achromobacter spp. positive sample and infection criteria in accordance with European official definitions of HAI, hospitalized in University Hospital of Martinique from 2006 to 2016 for more than 48 h, were included. Patient clinical features, immune status and underlying diseases were obtained from medical files. A list of CF patients was given by clinicians.

Antibiotic-susceptibility profiles of the strains were determined using an automated method.

Results

Mean incidence density was 0.038/1000 days of hospitalization. Achromobacter spp. HAI evolved as an endemic situation with a low but pretty much stable incidence rate over the 11-year observation period. An epidemic peak was noticed in 2013. Among the 66 included patients, 56.1% were immunocompetent and no one had CF. Pneumonia and bacteraemia were the two main HAI. Among the 79 isolated strains, 92.4% were resistant to at least 1 major antibiotic and 16.4% met the definition of multidrug-resistant bacteria.

Conclusions

This microorganism, little known in our country because of the scarcity of CF patients, represents a threat for both immunosuppressed and immunocompetent patients and a therapeutic challenge because of its high resistance.

Persistently Vitreous Culture-Positive Exogenous Bacterial Endophthalmitis

PURPOSE

To report the clinical settings, bacterial isolates, antibiotic sensitivities, and visual acuity outcomes of patients with persistently positive vitreous cultures after intravitreal antibiotics.

DESIGN

Consecutive, noncomparative case series.

METHODS

setting: Tertiary care center.

PATIENT POPULATION

Thirty-six eyes of 36 patients with exogenous endophthalmitis with the same bacterial organism identified on at least 2 consecutive vitreous cultures from 1981 to 2015.

OBSERVATION PROCEDURES

Vitreous cultures with intravitreal injections of antibiotics and pars plana vitrectomies with intravitreal antibiotics.

MAIN OUTCOME MEASURES

Bacterial isolates, antibiotic sensitivities, visual outcomes.

RESULTS

Thirty-six eyes of 36 patients met the study criteria. The mean follow-up was 26.5 months. The most common clinical settings were after cataract extraction (18/36, 50%) and glaucoma surgery (11/36, 31%). The mean initial visual acuity was 2.16 ± 0.77 logMAR (Snellen equivalent ≈20/2900), and there was no statistically significant change at the final evaluation (2.08 ± 0.97 logMAR, ≈20/1900, P = .72). The most common bacteria were Staphylococcus (11/36, 31%) and Streptococcus (9/36, 25%). Gram-positive bacteria were sensitive to vancomycin (27/27, 100%); gram-negative bacteria were sensitive to amikacin (5/5, 100%). The antibiotic sensitivities were the same on repeat cultures in 34 of 36 patients (94%). The initial treatment was a vitreous culture and intravitreal injection of antibiotics in 28 of 36 patients (78%). The vision at the last follow-up was 20/200 or better in 12 patients (33%) and no light perception in 11 of 36 patients (31%).

CONCLUSIONS

The most commonly identified organisms were gram-positive bacteria. There was good concordance in the antibiotic sensitivities between initial and subsequent cultures. Patients with persistently vitreous culture-positive endophthalmitis had poor visual outcomes.