Intraocular penetration of rifampin in humans

Postoperative Endophthalmitis Caused by Cutibacterium (Formerly Propionibacterium) Acnes: Case Series and Review

We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by Cutibacterium acnes (C. acnes), formerly known as Propionibacterium acnes (P. acnes). This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven C. acnesfrom December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5–17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3–15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone (n = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics (n = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics (n = 1). Follow-up treatments included IOL removal (n = 2), intravitreal antibiotics (n = 1), and topical antibiotics (n = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by C. acnes(n = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by C. acnesis characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.

Revisiting systemic treatment of bacterial endophthalmitis: a review of intravitreal penetration of systemic antibiotics

BACKGROUND

Adjunctive systemic antibiotic therapy for treatment of bacterial endophthalmitis is controversial but common practice due to the severity of the disease. In the absence of guidance documents, several antibiotic regimens are being used without applying evidence-based prescribing, leading to inappropriate treatment of this serious eye condition.

OBJECTIVES

To summarize available data on intravitreal penetration of systemically administered antibiotics and to discuss their usefulness from a microbiological and pharmacological point of view.

SOURCES

We performed a systematic PubMed search of studies investigating antibiotic concentrations in the vitreous after systemic administration in humans, and selected animal models.

CONTENT

The best-documented agents achieving therapeutic levels in the vitreous are meropenem, linezolid and moxifloxacin. Vancomycin, cefazoline, ceftriaxone, ceftazidime, imipenem and trimethoprim-sulfamethoxazole reach levels justifying their use in specific situations. Available data do not support the use of ciprofloxacin, levofloxacin, aminoglycosides, aminopenicillins, piperacillin, cefepime and clarithromycin. With very limited but available promising data, the use of daptomycin and rifampicin deserves further investigation.

IMPLICATIONS

The choice of the adjunctive systemic antibiotic agent-in situations where it is considered relevant for treatment-must to date be made on an individual basis, considering microbiological aspects as well as operative status and inflammation of the eye. This review gives a systematic overview of antibiotic options and provides guidance to the clinician striving for optimal systemic antibiotic treatment of bacterial endophthalmitis.

ENDOPHTHALMITIS IN A PATIENT TREATED WITH BACILLUS CALMETTE-GUÉRIN IMMUNOTHERAPY

BACKGROUND

Intravesical Bacillus Calmette-Guérin (BCG) instillation has become one of the mainstays of adjunctive therapy in the treatment of superficial bladder cancer. Ophthalmologic complications are rare, but few cases are reported in the literature.

METHODS

Retrospective observational case report.

RESULTS

The authors report a case of unilateral Mycobacterium bovis BCG endophthalmitis after intravesical BCG instillations. Despite appropriate systemic antituberculous and corticosteroid therapy, the patient almost completely lost sight in the affected eye. This is the fourth case in the literature of proven M. bovis endophthalmitis suggesting a direct choroidal mycobacterial infection and not only a hypersensitivity immunologic reaction as previously suggested.

CONCLUSION

This case highlights the direct choroidal mycobacterial infection of the disease after BCG instillations for bladder cancer and failure of treatment despite culture-proven drug sensitivity, thus suggesting the need to revaluate adequate treatment to avoid loss of vision.

Ocular Tuberculosis

Ocular tuberculosis is an extrapulmonary mycobacterial infection with variable manifestations. The reported incidence of ocular involvement varies considerably, depending on the criteria used for diagnosis and the population sampled. However, tuberculosis is thought to affect the lungs in 80% of patients, with the remaining 20% being affected in other organs, such as the eye. It is imperative for physicians to consider this diagnosis in their differential, as ocular tuberculosis can present in a fashion similar to that of more common conditions causing ocular inflammation. In addition, prompt recognition of the clinical signs and symptoms leads to quicker initiation of antituberculosis therapy.

[Rational approach for the treatment of postoperative endophthalmitis in impoverished populations]

Due to the need for treatment guidelines for endophthalmitis in impoverished areas, we have formulated an approach which takes into account pharmacokinetic data, keeping in mind that, whether oral or intramuscular, antibiotics must achieve therapeutic intraocular levels, antibiotic susceptibility of the most common pathogens in endophthalmitis, and routine availability of bioequivalent generics in the areas in question. In this work, we present the basic guidelines for the management of postoperative endophthalmitis by ophthalmology services in impoverished areas.

Mycobacterial Infections of the Head and Neck

Mycobacteria are important causes of head and neck infections. Mycobacterial lymphadenitis may be caused by both Mycobacterium tuberculosis and a variety of nontuberculous myocbacteria. Changes in the epidemiology of tuberculosis have caused a shift of the peak age range of tuberculous lymphadenitis from childhood to ages 20 to 40 years. Short-course chemotherapy is highly effective. Mycobacterium avium has become the most common cause of nontuberculous lymphadenitis, but new mycobacterial species are increasingly recognized. Treatment consists primarily of complete surgical excision, although roles for antimycobacterial chemotherapy are being identified. Transient flares of mycobacterial lymphadenitis, which occur during initiation of antituberculous therapy and in HIV-infected patients after initiation of antiretroviral therapy, may respond to short courses of corticosteroids. Tuberculous otitis media has become uncommon. Otitis media due to nontuberculous mycobacterial infection is increasingly seen in patients with pre-existing ear disease and after surgical and otic interventions. Tuberculosis of the eye has also become uncommon but may occur via hematogenous dissemination or direct innoculation. Nontuberculous mycobacteria, most commonly Mycobacterium chelonae and Mycobacterium fortuitum, may cause keratitis, usually after some form of corneal trauma.

Oxacillin-resistant Staphylococcus aureus endophthalmitis after ganciclovir intraocular implant

PURPOSE

To describe a patient who developed oxacillin-resistant Staphylococcus aureus endophthalmitis after insertion of a ganciclovir intraocular implant.

METHOD

Case report.

RESULTS

A 42-year-old man with acquired immunodeficiency syndrome (AIDS) and a history of cytomegalovirus retinitis was admitted with right-sided eye pain and decreased visual acuity 10 days after receiving a second ganciclovir intraocular implant in the right eye. A therapeutic vitrectomy, right eye, was performed on the day of admission. A vitreal tap produced frank pus and white, fluffy debris. Cultures of the vitreal fluid grew oxacillin-resistant S aureus, sensitive only to vancomycin, rifampin, and trimethoprim/sulfamethoxazole. The patient was successfully treated with removal of both ganciclovir implants in the right eye and a 4-week course of vancomycin and rifampin. However, the infection left the patient blind in the infected eye.

CONCLUSION

Bacterial endophthalmitis is an infrequent but serious complication of the ganciclovir intraocular implant.