The role of Serratia marcescens in soft contact lens associated ocular infections. A review

Microbial Adherence to Contact Lenses and Pseudomonas aeruginosa as a Model Organism for Microbial Keratitis

Microbial keratitis (MK), the infection of the cornea, is a devastating disease and the fifth leading cause of blindness and visual impairment around the world. The overwhelming majority of MK cases are linked to contact lens wear combined with factors which promote infection such as corneal abrasion, an immunocompromised state, improper contact lens use, or failing to routinely disinfect lenses after wear. Contact lens-related MK involves the adherence of microorganisms to the contact lens. Therefore, this review discusses the information currently available regarding the disease pathophysiology, the common types of microorganisms causing MK, physical and organic mechanisms of adhesion, material properties which are involved in adhesion, and current antimicrobial strategies. This review also concludes that Pseudomonas aeruginosa is a model organism for the investigation of contact lens microbial adherence due to its prevalence in MK cases, its extremely robust adhesion, antimicrobial-resistant properties, and the severity of the disease it causes.

Effect of polymicrobial interactions on antimicrobial resistance: an in vitro analysis in human ocular infections

Purpose: Investigate the effect of polymicrobial interactions on antimicrobial resistance (AMR) of ocular pathogens in polymicrobial settings, compared with monomicrobial infections. Methods: Polymicrobial interactions were labeled as antagonistic, synergistic or indifferent based on a reduction, an increase or no change, respectively, in antibiotics' MIC by the Vitek 2 compact system, compared with monomicrobial pathogens. Results: Staphylococcus epidermidis showed antagonistic polymicrobial interactions (22.6%); Pseudomonas aeruginosa showed synergistic interactions (62.5%); multidrug-resistant Acinetobacter baumannii showed increased susceptibility to select antibiotics; Serratia ficaria (inherently colistin resistant) became colistin-susceptible in polymicrobial combinations. Conclusion: Both antagonistic and synergistic interactions exist among human pathogens in polymicrobial settings. Gram-positive pathogens had significantly higher antagonistic polymicrobial interactions (increased MICs: 20.4%) compared with Gram-negative ones (synergistic: 59.4%).

Clinico-microbiological Features and Treatment Outcomes of Serratia Keratitis and Comparison with Pseudomonas aeruginosa Keratitis

PURPOSE

To describe clinico-microbiological features and outcomes of Serratia keratitis and to compare them with Pseudomonas aeruginosa keratitis.

METHODS

Cases of microbiologically proven Serratia keratitis and P. aeruginosa keratitis were reviewed. Data regarding demographic and clinical characteristics, and outcomes were recorded.

RESULTS

39 patients with pure Serratia keratitis were included. Median presenting vision was 1.8 logMAR (IQR, 0.8-2.4) and median infiltrate size was 5 mm (IQR 3-7.8 mm). An ocular risk factor was present in 35 (89.7%) cases. S. marcescens was the most common species (31/39, 79.5%). Medical resolution was observed in 36/39 (92.3%) cases, while three (7.7%) eyes needed penetrating keratoplasty. On comparing with P. aeruginosa keratitis (58 eyes), no difference in outcomes (p = .14) was noted.

CONCLUSION

Serratia keratitis usually occurs in eyes with a compromised surface and has good resolution with medical therapy. Both Serratia and P. aeruginosa keratitis have similar outcomes.

Microbial Contamination of Rigid Gas Permeable (RGP) Trial Lenses and Lens Cases in China

Purpose: This study aimed to evaluate the microbial contamination level and its influencing factors of rigid gas permeable (RGP) trial lenses and lens cases in China.Materials and Methods: A total of 107 RGP trial lenses and lens cases were collected from 7 main hospitals or optometric centers in China. Three sites including the lenses, case interiors and case screw tops were sampled for bacterial and fungal culture and identification. The contamination rates of these three sites and their relationship with lens care regimes were further analyzed.Results: The overall contamination rate was 73.8% for either lenses or cases, and 43.0% of lenses, 57.0% of case interiors and 65.4% of case screw tops respectively. The most frequently isolated microorganisms were Serratia spp., Burkholderia spp., Pandoraea spp., and Achromobacter spp. from all three sites. The contamination rate was positively related to the lens use frequency. Compared with dry-stored lenses, the contamination rate was significantly higher in wet-stored group (P < .001*). Inadequate disinfection and improper lens and case care regimes were also associated with higher contamination rates.Conclusions: Our study reported that the RGP trial lenses and cases used for fittings had a considerably high contamination rate. The safe use of RGP trial lenses and education of optometrists on the regular maintenance of trial lenses should be emphasized.

Identification and Visualization of a Distinct Microbiome in Ocular Surface Conjunctival Tissue

Purpose

Knowledge of whether microorganisms reside in protected niches of the conjunctiva is potentially significant in terms of minimizing risks of contact lens inflammation/infection and endophthalmitis. We define if and how microbial communities from limbal and forniceal conjunctival tissue differ from those on the conjunctival surface.

Methods

Human limbal and forniceal conjunctival tissue was obtained from 23 patients undergoing pterygium surgery and analyzed with data from a recent study of conjunctival surface swabs (n = 45). Microbial communities were analyzed by extracting total DNA from tissue samples and surface swabs and sequencing the 16S rRNA gene using the Illumina MiSeq platform. Sequences were quality filtered, clustered into operational taxonomic units (OTUs) at 97% similarity. OTUs associated with blank extraction and sampling negative controls were removed before analysis. Fluorescent in situ hybridization (FISH) was performed on cyrosections of limbal and forniceal conjunctival tissue.

Results

There was a significant difference in bacterial community structure between the conjunctival surface and fornix (P = 0.001) and limbus (P = 0.001) tissue. No difference was found in bacterial communities between the limbus and fornix (P = 0.764). Fornix and limbal samples were dominated by OTUs classified to the genus Pseudomonas (relative abundance 79.9%), which were found only in low relative abundances on conjunctival surfaces (6.3%). Application of FISH showed the presence of Pseudomonas in the forniceal tissue sample.

Conclusions

There is a discrete tissue-associated microbiome in freshly-collected human limbal and fornix tissue, which is different from the microbial community structure and composition of the ocular surface microbiome.

Corneal Ring Infiltrates Caused by Serratia marcescens in a Patient with Human Immunodeficiency Virus

PURPOSE

To describe corneal ring infiltrates caused by Serratia marcescens in a patient with human immunodeficiency virus (HIV-1) who wore contact lenses.

METHODS

A case study of a patient with keratitis due to an infection caused by S. marcescens and exhibiting corneal ring infiltrates was reviewed for history, clinical manifestation, microscopic study, and management.

RESULTS

A 29-year-old man who had a history of contact lens wear and HIV-1 infection was admitted to hospital because of blurred vision, redness, and corneal infiltrates in the shape of a ring in the left eye. The visual acuity (VA) in both eyes was hand movement (uncorrected). Corneal scrapings were performed. The culture results of the corneal specimens revealed S. marcescens. The culture results of the contact lens disclosed the same organism. The corneal ulcer responded well to treatment with topical gentamycin sulfate 14 mg/ml. The final VA remained hand movement.

CONCLUSIONS

S. marcescens can cause ring infiltrates in a HIV-1 patient who wears contact lenses. The treatment result for S. marcescens keratitis in a HIV-1 patient who wore contact lenses was favorable after intensive use of fortified topical antibiotics.

Proteomics in the Study of Bacterial Keratitis

Bacterial keratitis is a serious ocular infection that can cause severe visual loss if treatment is not initiated at an early stage. It is most commonly caused by Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, or Serratia species. Depending on the invading organism, bacterial keratitis can progress rapidly, leading to corneal destruction and potential blindness. Common risk factors for bacterial keratitis include contact lens wear, ocular trauma, ocular surface disease, ocular surgery, lid deformity, chronic use of topical steroids, contaminated ocular medications or solutions, and systemic immunosuppression. The pathogenesis of bacterial keratitis, which depends on the bacterium-host interaction and the virulence of the invading bacterium, is complicated and not completely understood. This review highlights some of the proteomic technologies that have been used to identify virulence factors and the host response to infections of bacterial keratitis in order to understand the disease process and develop improved methods of diagnosis and treatment. Although work in this field is not abundant, proteomic technologies have provided valuable information toward our current knowledge of bacterial keratitis. More studies using global proteomic approaches are warranted because it is an important tool to identify novel targets for intervention and prevention of corneal damage caused by these virulent microorganisms.

Carbon-Starvation Induces Cross-Resistance to Thermal, Acid, and Oxidative Stress in Serratia marcescens

The broad host-range pathogen Serratia marcescens survives in diverse host and non-host environments, often enduring conditions in which the concentration of essential nutrients is growth-limiting. In such environments, carbon and energy source starvation (carbon-starvation) is one of the most common forms of stress encountered by S. marcescens. Related members of the family Enterobacteriaceae are known to undergo substantial changes in gene expression and physiology in response to the specific stress of carbon-starvation, enabling non-spore-forming cells to survive periods of prolonged starvation and exposure to other forms of stress (i.e., starvation-induced cross-resistance). To determine if carbon-starvation also results in elevated levels of cross-resistance in S. marcescens, both log-phase and carbon-starved cultures, depleted of glucose before the onset of high cell-density stationary-phase, were grown in minimal media at either 30 °C or 37 °C and were then challenged for resistance to high temperature (50 °C), low pH (pH 2.8), and oxidative stress (15 mM H₂O₂). In general, carbon-starved cells exhibited a higher level of resistance to thermal stress, acid stress, and oxidative stress compared to log-phase cells. The extent of carbon-starvation-induced cross-resistance was dependent on incubation temperature and on the particular strain of S. marcescens. In addition, strain- and temperature-dependent variations in long-term starvation survival were also observed. The enhanced stress-resistance of starved S. marcescens cells could be an important factor in their survival and persistence in many non-host environments and within certain host microenvironments where the availability of carbon sources is suboptimal for growth.

The corneal ulcer one-touch study: a simplified microbiological specimen collection method

PURPOSE

To determine if a new, single-sample device (ESwab; Copan Diagnostics, Inc) can simplify the traditional multi-sample approach to specimen collection in infectious keratitis.

DESIGN

Prospective, diagnostic test evaluation.

METHODS

In this institutional study, patients with suspected infectious keratitis meeting traditional criteria for diagnostic corneal specimen collection and culture were randomized to the order of first specimen collection method: ESwab or a sample directly plated for growth on chocolate agar. This was followed by standard samples for blood agar, Gram stain, Sabouraud agar, thioglycolate broth, and brain heart infusion broth in all cases. The specimens collected using the 2 approaches were analyzed separately by the laboratory in a masked fashion. The main outcome measure was positive growth on cultured media.

RESULTS

Eighty-one eyes from 80 consecutive patients were sampled. Culture positivity rate for the multi-sample method and ESwab was 70% and 69%, respectively, with a 75% agreement rate. ESwab sensitivity was 84% (95% confidence interval [CI]: 72%-93%), with a specificity of 67% (95% CI: 45%-84%). Positive and negative predictive values of the ESwab were 86% (95% CI: 74%-94%) and 64% (95% CI: 43%-82%), respectively. There was no difference in positive culture reports with respect to the order of specimen collection technique used.

CONCLUSIONS

The single-sample ESwab method is a more accessible and less cumbersome approach to corneal culturing for ophthalmologists, particularly those in the community setting who do not have access to the full set of traditional culture materials. Culture results using this single-sample approach were comparable to the multi-sample method.

Detection of virulence factors in Serratia strains isolated from contact lens-associated corneal ulcers

PURPOSE

This paper reports on the microbiological findings pertaining to three Serratia isolates from soft contact lens-related corneal ulcers, which represent a complication of contact lens wear reported with increasing frequency.

METHODS

Bacterial identification and antibiotic susceptibility testing were performed using the Vitek system. Serratia's ability to form biofilm, produce gelatinase, elastase and alkaline protease, and invade human corneal epithelial (HCE) cells was investigated. The isolates' susceptibility to the following disinfectants was tested: (a) ReNu MultiPlus(®) , containing polyaminopropyl biguanide 0.0001%; (b) Opti-Free Express(®) , containing polyquaternium-1 0.001% and myristamidopropyldimethylamine 0.0005%; (c) Opti-Free Replenish(®) , containing polyquaternium-1 0.001% and myristamidopropyldimethylamine 0.0005%, and (d) Oxysept Comfort(®) , a one-step 3% hydrogen peroxide-catalase system.

RESULTS

Two Serratia marcescens and one Serratia liquefaciens were identified. All the strains were susceptible to aminoglycosides and fluoroquinolones. No isolate formed biofilm or significantly invaded HCE cells; all produced alkaline protease and gelatinase, but not elastase. Opti-Free Express(®) and Opti-Free Replenish(®) were active against S. liquefaciens, but failed to kill the S. marcescens isolates within the minimum recommended time (6 hours). ReNu MultiPlus(®) needed 6 hours to kill one strain of S. marcescens, which is 2 hours more than recommended. Conversely, Oxysept Comfort(®) was always effective within the minimum recommended time (6 hours).

CONCLUSIONS

The ability to produce alkaline protease and gelatinase may play a major role in the pathogenesis of contact lens-related Serratia keratitis. Several types of contact lens solutions may be ineffective in eradicating Serratia from contaminated contact lens cases within the minimum recommended time. Only exposure to Oxysept Comfort(®) was always effective against Serratia in this study.

Serratia infections in a general hospital: characteristics and outcomes

We aimed to present our experience regarding infections caused by Serratia spp. in a region with relatively high antimicrobial resistance rates. We retrospectively reviewed the databases of the microbiological laboratory of the University Hospital of Heraklion, Crete (2/2004-12/2009). A total of 77 patients [67.5% men, mean age ± standard deviation (SD) = 56.9 ± 24.5 years) were identified; 37.7% were outpatients. Sixty-five (84.4%) of the 77 included patients had a Serratia marcescens isolate; the remaining 12 patients had a non-marcescens Serratia spp. The most frequently observed infections were respiratory tract infection (32.5%) and keratitis/endophthalmitis (20.8%). Seventy-three (94.9%) patients were cured. Four deaths were observed; three of them were considered as attributed to the Serratia infection. No difference was found regarding the characteristics and outcomes between patients with Serratia marcescens and non-marcescens infections. In addition, antipseudomonal penicillins and their combinations with beta-lactamase inhibitors, as well as carbapenemes, and fluoroquinolones exhibited high antimicrobial activity against both the tested Serratia marcescens and non-marcescens isolates. Our study adds useful information regarding the characteristics and outcomes of patients with Serratia infection, as well as the susceptibilities of the respective Serratia marcescens and non-marcescens isolates, in a region with relatively high levels of antimicrobial resistance.

A management dilemma: infectious keratitis associated with soft contact lens use and dubious treatment compliance

Purpose. To present a case of infectious keratitis caused by the microorganism Serratia marcescens in a contact lens user and further to confer on the most advantageous management of comparable situations. Case. After altering the routine that she used for contact lens disinfection, a 24-year-old patient presented with pain and conjunctival redness in both eyes. Slit-lamp examination revealed two infiltrates in the inferior part of the cornea in the right eye and five smaller infiltrates in the superior half of the left cornea. Appropriate treatment, after hospitalization, improved the symptoms while culture of the contact lens material revealed Serratia marcescens as the responsible infectious factor. Conclusion. Enhancing the availability of information with respect to contact lens users and customized analysis regarding treatment for a particular complication could be beneficial in order to reduce the frequency of admission to the eye clinic due to infectious keratitis. In addition, rapid laboratory testing of the infected materials should be a priority for selection of the optimal treatment regimen.

The RssB/RssA two-component system regulates biosynthesis of the tripyrrole antibiotic, prodigiosin, in Serratia marcescens

Serratia marcescens CH-1 produces a red, cell-associated pigment, prodigiosin, synthesized by enzymes encoded in the pig operon. The underlying regulatory mechanism, especially its relationship with the RssAB two-component system signaling, remained uncharacterized. Here, we show that phosphorylated RssB (RssB-P) directly binds to the promoter region of the pig operon (pigA promoter), as observed using an electrophoretic mobility shift assay. Furthermore, we identify the RssB-P binding site located downstream of the -10 and -35 regions in pigA using a DNase I footprinting assay. A compilation of the RssB-P binding sites in flhDC, rssB and pigA promoter regions reveals the presence of a conserved core sequence, GAGATTTTAGCTAAATTAATBTTT (B=C, G, or T), which we believe is the RssB binding sequence. Site-specific mutation of conserved nucleotides within the conserved RssB binding sequence in the pigA promoter region leads to absence of retardation in the presence of RssB-P in vitro and elevated transcription of pigA in vivo. These data suggest that RssAB signaling negatively regulates prodigiosin production, and such inhibition is mediated through direct and specific repression of transcriptional activity of the pig operon.

Quantitative comparison of fluoroquinolone therapies of experimental Gram-negative bacterial keratitis

PURPOSE

To determine the effectiveness of topically applied fluoroquinolones for experimental Pseudomonas or Serratia keratitis.

METHODS

Bacteria were injected intrastromally (10(3) colony forming units [CFU]). From 16 to 22 hours post-infection (PI), a single topical drop of moxifloxacin (Vigamox, 0.545%), levofloxacin (Quixin, 0.5%), ofloxacin (Ocuflox, 0.3%) or ciprofloxacin (Ciloxan, 0.3%) was applied every 30 minutes. At 23 hours PI, corneas were cultured quantitatively.

RESULTS

For Pseudomonas keratitis, untreated eyes contained 7 log CFU/cornea and antibiotic-treated eyes demonstrated a > or = 5-log reduction in CFU/cornea (p < or = 0.0001). Moxifloxacin, levofloxacin, or ciprofloxacin therapies were not significantly different from each other (p > or = 0.67). For Serratia keratitis, untreated eyes contained 7 logCFU/cornea whereas treated eyes had a > or = 2-log reduction (p < or = 0.0001). Moxifloxacin therapy proved most effective (p < or = 0.001).

CONCLUSIONS

Overall, moxifloxacin was the most effective of the four fluoroquinolones in reducing CFU/cornea in the rabbit model of gram-negative keratitis.

Kinetic analysis of growth rate, ATP, and pigmentation suggests an energy-spilling function for the pigment prodigiosin of Serratia marcescens

Serratia marcescens is a gram-negative environmental bacterium and opportunistic pathogen. S. marcescens expresses prodigiosin, a bright red and cell-associated pigment which has no known biological function for producing cells. We present here a kinetic model relating cell, ATP, and prodigiosin concentration changes for S. marcescens during cultivation in batch culture. Cells were grown in a variety of complex broth media at temperatures which either promoted or essentially prevented pigmentation. High growth rates were accompanied by large decreases in cellular prodigiosin concentration; low growth rates were associated with rapid pigmentation. Prodigiosin was induced most strongly during limited growth as the population transitioned to stationary phase, suggesting a negative effect of this pigment on biomass production. Mathematically, the combined rate of formation of biomass and bioenergy (as ATP) was shown to be equivalent to the rate of prodigiosin production. Studies with cyanide inhibition of both oxidative phosphorylation and pigment production indicated that rates of biomass and net ATP synthesis were actually higher in the presence of cyanide, further suggesting a negative regulatory role for prodigiosin in cell and energy production under aerobic growth conditions. Considered in the context of the literature, these results suggest that prodigiosin reduces ATP production by a process termed energy spilling. This process may protect the cell by limiting production of reactive oxygen compounds. Other possible functions for prodigiosin as a mediator of cell death at population stationary phase are discussed.

Relationship between climate, disease severity, and causative organism for contact lens-associated microbial keratitis in Australia

PURPOSE

To evaluate associations between disease severity, causative organism, and climatic variation in contact lens-related microbial keratitis in Australia.

DESIGN

Prospective, observational case series.

METHODS

Contact lens wearing patients (n = 236) with presumed microbial keratitis presenting to private and hospital ophthalmologists in Australia between October 1, 2003 and September 30, 2004 were identified prospectively. Clinical details, management information, and microbiology data were collected and cases were graded for severity based on lesion size and location criteria. Causative organisms were assigned to "environmental" or "endogenous" groups. Climate zone and daytime temperature and humidity were determined for the geographic location of each event. The main outcome measures were disease severity, causative organism, and climate zone.

RESULTS

Severe contact lens-related microbial keratitis was more likely to occur in warmer, humid regions of the country (P < .001), compared with smaller, increasingly peripheral corneal lesions that were more common in cooler conditions (P < .001). Culture-proven keratitis was predominantly caused by environmental organisms with Pseudomonas aeruginosa being recovered most frequently. Environmental organisms were isolated more commonly from tropical regions of the country and also accounted for nearly all cases of vision loss that occurred during the study period. Humidity did not have a significant effect on causative organism.

CONCLUSIONS

Climatic conditions play a role in disease severity and causative organism in contact lens-related microbial keratitis and therefore have implications for practitioners involved in contact lens care and contact lens wearers who live in or travel to the tropics.

Role of bacterial proteases in pseudomonal and serratial keratitis

Pseudomonas aeruginosa and Serratia marcescens can cause refractory keratitis resulting in corneal perforation and blindness. These bacteria produce various kinds of proteases. In addition to pseudomonal elastase (LasB) and alkaline protease, LasA protease and protease IV have recently been found to be more important virulence factors of P. aeruginosa . S. marcescens produces a cysteine protease in addition to metalloproteases. These bacterial proteases have a number of biological activities, such as degradation of tissue constituents and host defense-oriented proteins, as well as activation of zymogens (Hageman factor, prekallikrein and pro-matrix metalloproteinases) through limited proteolysis. In this article, the properties of these bacterial proteases are reviewed and the pathogenic roles of these proteases in pseudomonal keratitis are discussed.

Endogenous Serratia marcescens endophthalmitis with dark hypopyon: case report and review

A case of endogenous Serratia marcescens endophthalmitis in a patient with diabetes, end-stage renal disease, and an indwelling venous catheter is reported. The patient presented with a tan hypopyon and elevated intraocular pressure. Diagnosis was established by positive blood, vitreous, conjunctival, and catheter tip cultures. After a deteriorating course the eye was enucleated. Gross and histopathologic examination revealed the presence of a dark hypopyon with iris necrosis and pigment dispersion and possible spontaneous globe perforation. This is the eleventh reported case of endogenous Serratia endophthalmitis. Previous association of a pink hypopyon and of pigmented vitreous fluid and Serratia endophthalmitis has been reported. This is the first case of dark hypopyon in endogenous Serratia marcescens endophthalmitis reported in the medical literature. Previous entities associated with dark hypopyon have been limited to intraocular melanoma and Listeria monocytogenes endophthalmitis. Dark hypopyon in the appropriate clinical setting may be useful in aiding diagnostic and therapeutic decisions.

Serratia Marcescens corneal ulcer as a complication of orthokeratology

PURPOSE

To report a case of Serratia Marcescens corneal ulcer as a complication of orthokeratology treatment.

METHODS

Case report.

RESULTS

A 9-year-old male who underwent orthokeratology treatment for 6 months suffered from a corneal ulcer. The refractive state of lesion eye was -5.5D/-1.25D x 180 degrees, and visual acuity was hand motion at 30 cm. He wore a retainer lens, rigid gas permeable lens, overnight for 2 months before the corneal ulcer occurred. Ulcer became worse after tobramycin and gentamycin treatment for 2 days. After ciprofloxacin treatment, the ulcer healed and visual acuity recovered to 20/20 with spectacle correction. Cultures of the cornea tissue and contact lens storage solution both grew Serratia Marcescens, which was sensitive to ciprofloxacin.

CONCLUSION

Overnight wearing of a rigid contact lens is a risk factor for a corneal ulcer.

Antibacterial and antifungal effects of soft contact lens disinfection solutions

AIMS

To study the antibacterial and antifungal effects of soft contact lens disinfection solutions.

METHODS

Eight contact lens disinfection solutions containing hydrogen peroxide or biguanides or polyquad compounds were evaluated with respect to their ability to disinfect a saline solution experimentally contaminated with different bacteria and with a fungus. We used cultures in blood Agar, MuellerHinton agar and Saboureaud's agar to identify the bacterial and fungal growth following 14 h of exposure to the disinfection solutions.

RESULTS

Hydrogen peroxide, DYMED and polyhexamide solutions prevented the growth of the four bacteria studied. The solution containing biguanide prevented the growth of Escherichia coli and Staphylococcus epidermidis. The solution with polyquad solution only prevented the growth of Staphylococcus epidermidis and none of the disinfection solutions prevented the growth of Candida albicans. The control solution, which was saline, did not prevent the growth of either bacteria or fungi.

CONCLUSIONS

Disinfection solutions containing hydrogen peroxide, or DYMED or polyhexamide can disinfect these four bacteria but none of them prevented the growth of Candida albicans.