High-Dose Steroid Treatment of Bacterial Keratitis

Bacterial keratitis in a tertiary hospital in São Paulo: a 21-year review of the epidemiological, laboratory, and clinical data

Infectious keratitis is a sight-threatening condition that is usually an ocular emergency. The visual outcome depends on prompt and accurate clinical management as well as geographic and epidemiological awareness. We conducted a retrospective observational study to define the epidemiological and laboratory profile, as well as the clinical course of bacterial keratitis in a tertiary hospital in São Paulo over 21 years. Information about age, sex, predisposing factors, topical and surgical treatment, visual acuity, ulcers' classification, bacterioscopy, culture, and antibiotic sensitivity tests were collected. This study included 160 patients. The mean age was 65.1 ± 18.4 years and risk factors were identified in 83.1 % of the patients. Empirical topical fortified cephalosporin with an aminoglycoside or fourth-generation fluoroquinolone was curative for 66.2 % of the cases. The mean treatment duration was 22.5 ± 9 days. The mean variation of visual acuity was -0.25 logMAR, p < 0.001. Culture revealed 64 % of Gram-positive bacteria. All Gram-positive bacteria were sensitive to cephalothin, vancomycin, and quinolones. All Gram-negative bacteria were sensitive to gentamicin, tobramycin, amikacin, and ciprofloxacin. These findings reinforce the importance of prompt empirical treatment of severe corneal ulcers with a fortified cephalosporin and aminoglycoside or a fourth-generation fluoroquinolone as there are equally effective. Collected data was insufficient to evaluate resistance of ocular infections over time in this population.

Epidemiology and Economic Cost Analysis of Microbial Keratitis from a Tertiary Referral Hospital in Australia

Microbial keratitis is the most common cause of infective vision loss. The causative organism varies by region, and most cases require intensive antimicrobial therapy. The purpose of this study was to analyse the causative organisms of microbial keratitis, its presentation and economic burden from a tertiary referral hospital in Australia. A retrospective review of 160 cases of microbial keratitis was performed, over a 5-year period from 2015–2020. A wide variety of costs were considered to determine the economic burden, using standardized data from the Independent Hospital Pricing Authority and the cost of personal income loss. Our study showed the most commonly occurring pathogens were Herpes Simplex (16%), Staphylococcus aureus (15.1%) and Pseudomonas aeruginosa (14.3%). A total of 59.3% of patients were admitted, with a median length of admission of 7 days. Median cost for all presentations of microbial keratitis was AUD 8013 (USD 5447), with costs significantly increasing with admission. The total annual cost of microbial keratitis within Australia is estimated to be AUD 13.58 million (USD 9.23 million). Our findings demonstrate that microbial keratitis represents a significant economic burden for eye-related diseases and the key driving factor for the cost is the length of admission. Minimizing the duration of admission, or opting for outpatient management where appropriate, would significantly reduce the cost of treatment for microbial keratitis.

Practice patterns in the management of bacterial keratitis: a five-continent survey

PURPOSE

To assess the current diagnostic and therapeutic practice patterns in early management of bacterial keratitis over five continents.

METHODS

Between March and August 2019, we distributed an online survey including two clinical scenarios of bacterial keratitis, namely, a mild case and severe case, to 2936 ophthalmologists from 144 countries around the world. The survey consisted of 29 questions. We performed descriptive statistics and a comparative analysis of the answers according to the participants' continent of practice, practice setting, seniority, and subspecialty.

RESULTS

We received 237 surveys from 54 countries (8% response rate). The proportion of respondents performing microbiological investigations was higher in North America, Asia, Europe, and Oceania than Africa and South America (p < 0.05). This ratio was also higher among ocular surface specialists than for other ophthalmologists (p < 0.001). For mild cases, fluoroquinolone monotherapy and a combination of two or more antibiotics were prescribed by 46% and 41% respondents, respectively. For severe cases, fluoroquinolone monotherapy and a combination of antibiotics were prescribed by 20% and 78% respondents, respectively. Fluoroquinolone monotherapy was the most commonly prescribed treatment in South America, Africa, and Oceania. A combination of two antibiotics was preferentially prescribed in the rest of the world. Topical steroids were prescribed in both circumstances, respectively, in 72% and 75% of cases.

CONCLUSION

Our results highlight essential geographical disparities in the current management of bacterial keratitis over five continents.

Clinical Observation of Corneal Endothelial Plaques With Fungal and Bacterial Keratitis by Anterior Segment Optical Coherence Tomography and In Vivo Confocal Microscopy

PURPOSE

Endothelial plaque is an important sign of fungal keratitis and is related to diagnosis, surgical indications, and prognosis. However, bacterial keratitis sometimes involves fibrin formation on the back corneal surface, similar to endothelial plaques. Because corneal infiltration interferes with precise observation of the posterior corneal plaque, distinguishing pathogens with a slitlamp is difficult. We hope to assist clinicians in early diagnosis and timely treatment by observing the connection state of endothelial plaques and the corneal endothelium through anterior segment optical coherence tomography (AS-OCT) and the different forms of endothelial plaques in infectious keratopathy through in vivo confocal microscopy (IVCM).

METHODS

We analyzed 52 patients in the Eye Hospital of the First Affiliated Hospital of Harbin Medical University who were clearly diagnosed with fungal or bacterial keratitis with endothelial plaques. All patients underwent AS-OCT and IVCM on admission.

RESULTS

According to the smear, IVCM, or fungal and bacterial culture results, the patients were diagnosed with fungal (28 patients) or bacterial keratitis (24 patients). AS-OCT in 25 patients diagnosed with fungal keratitis revealed that the corneal endothelium-endothelial plaque boundary was unclear and wavy, and 24 patients had unclear cell boundaries and a large number of compactly distributed inflammatory cells in the endothelial layer according to IVCM. AS-OCT in 23 patients diagnosed with bacterial keratitis revealed clear corneal endothelium-endothelial plaque boundaries, and insufficient endothelial cell boundaries with a large number of visible and scattered inflammatory cell structures were observed through IVCM in 22 patients.

CONCLUSIONS

Corneal endothelial plaque detection by AS-OCT and IVCM can be used for early diagnosis of infectious keratitis.

Predisposing factors, microbiological features and outcomes of patients with clinical presumed concomitant microbial and herpes simplex keratitis

BACKGROUND/OBJECTIVES

To describe the predisposing factors, pathogens and outcomes in patients with clinical presumed concomitant microbial and herpes simplex keratitis (HSK) at Sydney Eye Hospital, Australia over a 5-year period.

SUBJECTS/METHODS

A retrospective case review was conducted. Patients with clinical presumed concomitant microbial and HSK from 2012 to 2016 were identified from pathology and hospital coding databases. Data were extracted from the medical records. VA was converted to the logarithm of the minimum angle of resolution (logMAR). 'Poor' outcome was defined as final VA worse than 6/60, or decrease in VA during treatment, or presence of complication, or needed surgical intervention.

RESULTS

126 episodes in 121 patients were included; median age 70 years (range 18-96); 56% male. Predisposing factors included blepharitis 20/126 (16%) cases, and corneal transplantation 19 (15%). Forty-six (37%) cases had prior HSK. Coagulase-negative staphylococci 51/116 (44%), Staphylococcus aureus 11 (9%), and Pseudomonas aeruginosa 11 (9%) were the most common isolates. The median VA at initial visit was 1.7 logMAR (range 0.04-2.7) and at final visit, 0.98 logMAR (range 0-2.7) (P < 0.05). Complications occurred in 70 episodes: persistent epithelial defect in 38 (30%); intraocular pressure elevation in 15 (12%), and corneal perforation in 12 (10%). 'Poor' outcome was recorded in 46/75 (61%) episodes.

CONCLUSIONS

Patients with clinical presumed concomitant microbial and HSK face significant ocular morbidity and poor visual outcome. In our setting, previous HSK, corneal and ocular surface disease, were common predisposing factors and Gram-positive bacteria were the most commonly associated organisms.

Epidemiology and analysis of potential risk factors of high-risk human papillomavirus (HPV) in Shanghai China: A cross-sectional one-year study in non-vaccinated women

Data regarding human papillomavirus (HPV) prevalence, its associated risk factors, and women's knowledge about this disease before the HPV vaccine was approved are limited in Shanghai, China. Therefore, we investigated these questions among females in Shanghai and aimed to provide comprehensive data to guide HPV vaccination and present the biopsychosocial risk factors that impact high-risk HPV infection, and evaluate the level of knowledge and awareness of this disease among women aged 21-65 years old. A total of 6619 (aged from 21 to 65) women from different communities volunteered to participate in the HPV screening and complete questionnaires from December 2016 to December 2017 in the Department of Obstetrics and Gynecology of nine hospitals in Shanghai. Data were analyzed using sample logistic regression to assess biopsychosocial risk factors that impact high-risk HPV infection and knowledge of HPV infection. A total of 632 (9.5%) cases were positive for high-risk HPV test, 22.6% of them were HPV 16/18 infection, 77.4% of them were non HPV 16/18 infection. 40 potential risk factors may be related to high-risk HPV infection, and there were 19 factors' p value < 0.1 from single factor logistic analysis. Finally, multivariable regression revealed education level, type of vaginitis, history of hyperlipidemias, family history of cancer, number of pregnancies, number of sex partners were independent risk factors for high-risk HPV infection (p < 0.05). When stratified by education level, women who finished graduate school had significantly greater knowledge of cervical cancer, cervical screening, and the relationship between HPV and cervical cancer than other groups (p < 0.05). The prevalence rate of high-risk HPV was a little lower than other regions in China and other countries, which may be related to regions, races, living habits, and economy. A less reported finding is that the history of vaginitis and the history of hyperlipidemias in our study were related to HPV infection. The majority of the participants had poor knowledge regarding cervical cancer, cervical screening, and the relationship between HPV and cervical cancer. Hence, these results should be served as a wake-up call for the government to increase knowledge and awareness via the media and doctors.

Topical Steroids as Adjunctive Therapy for Bacterial Keratitis: Evidence From a Retrospective Case Series of 313 Cases

PURPOSE

The aim of this study was to report topical steroid usage in bacterial keratitis and analyze the effects of steroids on patients' outcomes to the main causative organisms.

DESIGN

A retrospective case-series.

METHODS

This study included all patients with corneal scrape positive bacterial keratitis from January 2012 to December 2016 at the Sydney Eye Hospital, Sydney, Australia. Cases were identified from pathology results and hospital coding, and data collected from medical records.

RESULTS

A total of 313 eyes from 308 patients with a mean age of 51 years [interquartile range (IQR) 36-72] were included. Of these patients, 192 (61%) were treated with topical steroids. High-dose steroids were prescribed in 22 (11%) cases, regular-dose in 88 (46%), and low-dose in 82 (43%). The median time until the implementation of steroid use was 4 days (IQR 3-7). Patients prescribed with topical steroids had significantly longer healing times than the "no steroid" group (11 vs 6.5, P < 0.001). Patients with Pseudomonas aeruginosa keratitis and topical steroid use had worse clinical outcomes, with a higher proportion having longer healing times (P = 0.04) and corneal scarring (P = 0.02).

CONCLUSIONS

Adjuvant topical steroid therapy did not affect visual acuity, patient outcomes or the rate of adverse effects but may delay epithelial healing in bacterial keratitis in these patients. Topical steroids may have a differential effect depending on the specific causative organisms; however, a clinical trial is needed to assess this.

Atypical Keratitis Caused by Rothia Dentocariosa

Purpose: To report a case of atypical keratitis caused by Rothia dentocariosa.Methods: Retrospective case review.Results: A 49 year-old woman of South Asian descent presented with a non-discrete corneal ulcer with a small overlying epithelial defect in the right eye. Cultures were obtained, a topical fluoroquinolone was continued, and a topical steroid was added. The following day, the infiltrate was noted to have worsened and developed a branching appearance. Antifungals were initiated. The culture grew Rothia dentocariosa. A series of intrastromal cefuroxime injections, followed by topical penicillin G drops, led to complete resolution within 8 weeks. A review of the literature revealed only one previously reported case of Rothia dentocariosa keratitis.Conclusions: Rothia dentocariosa may cause an atypical keratitis requiring a prolonged treatment course for resolution. In our case, a combination of cefuroxime and penicillin was effective.