Endogenous Endophthalmitis Caused by Klebsiella pneumoniae: A Ten-Year Retrospective Study in Western China

Endogenous Endophthalmitis - A Major Review

Endogenous endophthalmitis (EE) is an uncommon but potentially devastating ocular infection involving the inner layers of the eye. The global incidence of EE is on the rise. Common ocular signs and symptoms associated with EE include conjunctival injection, ocular pain, and reduced visual acuity. On clinical examination, a history of prior or coexisting systemic infections, symptoms (e.g., fever, malaise), and localizing features may be noted. Clinical diagnosis is often challenging, resulting in critical delays that contribute to a poor prognosis. Blood cultures and ocular fluid samples can aid in conforming causative pathogen(s), after which empirical antibiotic therapy, both systemic and intravitreal, should be instated. The use of steroids to suppress inflammation remains controversial. Surgical options include pars plana vitrectomy. Overall prognosis varies depending on host and pathogen factors, and early diagnosis and initiation of appropriate treatment are crucial.

Gram-Negative Endogenous Endophthalmitis: A Systematic Review

Background: Gram-negative bacteria are causative agents of endogenous endophthalmitis (EBE). We aim to systematically review the current literature to assess the aetiologies, risk factors, and early ocular lesions in cases of Gram-negative EBE. Methods: All peer-reviewed articles between January 2002 and August 2022 regarding Gram-negative EBE were included. We conducted a literature search on PubMed and Cochrane Controlled Trials. Results: A total of 115 studies and 591 patients were included, prevalently Asian (98; 81.7%) and male (302; 62.9%). The most common comorbidity was diabetes (231; 55%). The main aetiologies were Klebsiella pneumoniae (510; 66.1%), Pseudomonas aeruginosa (111; 14.4%), and Escherichia coli (60; 7.8%). Liver abscesses (266; 54.5%) were the predominant source of infection. The most frequent ocular lesions were vitreal opacity (134; 49.6%) and hypopyon (95; 35.2%). Ceftriaxone (76; 30.9%), fluoroquinolones (14; 14.4%), and ceftazidime (213; 78.0%) were the most widely used as systemic, topical, and intravitreal anti-Gram-negative agents, respectively. The most reported surgical approaches were vitrectomy (130; 24.1%) and evisceration/exenteration (60; 11.1%). Frequently, visual acuity at discharge was no light perception (301; 55.2%). Conclusions: Gram-negative EBEs are associated with poor outcomes. Our systematic review is mainly based on case reports and case series with significant heterogeneity. The main strength is the large sample spanning over 20 years. Our findings underscore the importance of considering ocular involvement in Gram-negative infections.

CONCOMITANT PYOGENIC LIVER AND INTRAOCULAR ABSCESSES IN KLEBSIELLA ENDOGENOUS ENDOPHTHALMITIS: CASE REPORT AND REVIEW OF LITERATURE

PURPOSE

To describe a rare presentation of Klebsiella pneumoniae endogenous endophthalmitis with concurrent intraocular and liver abscesses.

METHODS

Case Report.

RESULTS

A middle-aged man presented with a red and painful eye with a preceding febrile gastrointestinal illness. Examination and work-up revealed concomitant intraocular and liver abscesses that were treated by pars plana vitrectomy, drainage of subretinal abscess, inpatient admission, and systemic antibiotics. The patient ultimately underwent enucleation of the eye because of persistent pain and poor visual prognosis.

CONCLUSION

Klebsiella pneumoniae endogenous endophthalmitis is a rare and potentially devastating disease that requires high clinical suspicion and early diagnosis. Practitioners should consider systemic etiologies and communicate guarded prognoses in this serious systemic disease.

METAGENOMIC NEXT-GENERATION SEQUENCING DETECTS PATHOGENS IN ENDOPHTHALMITIS PATIENTS

PURPOSE

To investigate the utility of metagenomic next-generation sequencing (mNGS) in identifying the pathogens in endophthalmitis.

METHODS

In this prospective study, 36 cases of endophthalmitis were recruited. All patients received surgical treatment and intraocular drug lavage. The samples of vitreous or aqueous humor were extracted for mNGS and microbiological culture. The diagnostic performance of pathogens was compared between mNGS and culture.

RESULTS

The positive rates of mNGS and culture were 88.89% (32/36) and 27.78% (10/36), respectively. There was a statistically significant difference between mNGS and culture (Chi-square = 27.657; P < 0.01). Staphylococcus epidermidis, Streptococcus pneumoniae, and Klebsiella pneumoniae were the most pathogenic bacteria in traumatic, postoperative, and endogenous endophthalmitis, respectively. The concordance of pathogen identified by mNGS and culture was 70% for culture-positive cases. Antibiotic resistance genes were identified in 9 cases. There was a marginal correlation between the final visual acuity and the microbial sequence read (Spearman correlation coefficient = 0.498; P = 0.05).

CONCLUSION

Metagenomic next-generation sequencing has a higher positive rate of identifying pathogens in endophthalmitis than in culture. It can also provide information on antibiotic resistance and visual prognosis. However, caution must be taken when interpreting the results of mNGS because they may not be concordant with culture.

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.

Visual outcome of endogenous endophthalmitis in Thailand

To evaluate a 10-year visual outcome of endogenous endophthalmitis (EE) patients. A 10-year retrospective chart review of EE patients. Thirty-eight patients (40 eyes) were diagnosed with EE at the mean age of 42. Among the identifiable pathogens (71.1% culture positive), the causative agents were predominantly gram-negative bacteria (48.1%). The most common specie was Klebsiella pneumoniae (25.9%). About a quarter of the patients required surgical eye removal, and the remaining 45.7% had visual acuity (VA) worse than hand motion at one month after the infectious episode. The most common complication was ocular hypertension (52.5%). Poor initial VA was significantly associated with a worse visual outcome in the early post-treatment period (p 0.12, adjusted OR 10.20, 95% CI 1.65–62.96). Five patients continued to visit the clinic for at least ten years. One patient had gained his vision from hand motion to 6/7.5. Two patients had visual deterioration, one from corneal decompensation, and the other from chronic retinal re-detachment. Two patients developed phthisis bulbi, with either some VA perception of light or no light perception. Poor initial VA is the only prognostic factor of a poor early post-treatment visual outcome of EE.

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.