Fungal Endophthalmitis Outbreak after Cataract Surgery, South Korea, 2020

The Effectiveness and Safety of Intravitreal Injections of Voriconazole in the Treatment of Fungal Endophthalmitis: A Systematic Review

Background: Fungus endophthalmitis is a rare and serious infection that is treated with systemic and topical antifungal drugs. There is no clear consensus on the treatment of fungal endophthalmitis with intravitreal injections (IVIs) of voriconazole. This systematic review aims to summarize the literature on IVIs of voriconazole for fungal endophthalmitis. Methods: We conducted a systematic review of the literature to determine the effectiveness and safety of IVIs of voriconazole in the treatment of fungal endophthalmitis. We searched databases such as PubMed and Embase using the following search terms "Endophthalmitis" AND "Intravitreal Injections" AND "Voriconazole" with date limits of January 1, 1900, to December 31, 2022. We included all reports on humans, which described clinical outcomes of IVIs of voriconazole in the treatment of fungal endophthalmitis, including randomized controlled trials (RCTs) and case series. A descriptive synthesis of the data was conducted with a pooling of data for interventions. Results: One RCT and 21 retrospective studies were analyzed in this review. In these reports, a wide range of heterogeneous treatment regimens was used, including IVI in combination with other drugs, systemic therapy in combination with other agents, and surgery. Combined with other treatments, intravitreal voriconazole results in a favorable anatomical and clinical cure that was well tolerated. Conclusions: Reports on IVIs of voriconazole for fungal endophthalmitis demonstrate a heterogeneous approach to treatment. Of these, IVIs of voriconazole in anatomical and clinical outcomes appeared to be highly effective, although more data on its safety are needed.

Clinical Factors, Treatment Selection, and Outcomes in Postcataract Fungal Endophthalmitis from Contaminated Viscoelastics

PURPOSE

To investigate the factors associated with treatment outcomes of postcataract surgery fungal endophthalmitis outbreaks related to contaminated viscoelastics.

DESIGN

Retrospective analysis of clinical data from multiple institutions.

SUBJECTS

This study included 228 eyes of 210 patients who were diagnosed with postcataract surgery fungal endophthalmitis related to the use of viscoelastic material (Unial, Unimed Pharmaceutical Inc); they were followed up for 6 months after the diagnosis.

METHODS

Clinical features and causative species were identified and treatment outcomes were analyzed in patients who underwent 6 months of follow-up. Propensity score matching was conducted to elucidate the impact of vitrectomy timing and intraocular lens (IOL) removal on treatment outcomes.

MAIN OUTCOME MEASURES

Clinical factors and selection of treatment modalities associated with treatment outcomes at 6 months.

RESULTS

Baseline visual acuity (P < 0.01), age (P = 0.05), and the presence of corneal edema (P < 0.01) were closely associated with poor best-corrected visual acuity (BCVA) at 6 months. Patients who underwent immediate vitrectomy after diagnosis showed significantly better BCVA at 6 months (mean logarithm of minimum angle of resolution 0.26 ± 0.43 vs. 0.52 ± 0.52, P = 0.03) and greater degree of visual improvement (mean -0.17 ± 0.37 improvement vs. 0.10 ± 0.57 deterioration, P = 0.03) than those who underwent deferred vitrectomy. Patients who underwent IOL removal during vitrectomy required a lower number of intravitreal antifungal agent injections (mean 8.9 ± 9.1 vs. 16.7 ± 12.2, P < 0.01) and showed a lower incidence of repeated vitrectomy (20% vs. 82%, P < 0.01) than in those without IOL removal.

CONCLUSIONS

In postcataract fungal endophthalmitis, prompt vitrectomy at the time of diagnosis resulted in better treatment outcomes, and IOL removal reduced the treatment burden. Prompt and aggressive surgical intervention should be considered for postcataract fungal endophthalmitis.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Construction of a postoperative infection outbreak investigation form: A tool for early detection and control measures

BACKGROUND

To develop an investigation form for postoperative infection outbreak (PIO), and to identify sources of the outbreak in the early stage.

METHODS

After an exhaustive literature review, we used the Delphi method to determine the indicators and relative risk scores of the assessment tools through 2 rounds of specialist consultation and overall consideration of the opinions and suggestions of 20 specialists.

RESULTS

A total of 203 studies of PIO were eligible for inclusion. The mean authority coefficient (Cr) was 0.87. Kendall's W coefficient of the specialist consultation was 0.704 after 2 rounds of consultation (P < .005), suggesting that the specialists had similar opinions. Based on 4 primary items and 19 secondary items of the source of PIO, and tripartite distribution characteristics of infected patients, we constructed the PIO investigation form.

CONCLUSIONS

The PIO investigation form can be used in the investigation of the early-stage cluster of cases, it's a prerequisite for taking effective control measures, avoiding PIO occurrence. However, the effect of the investigation form needs to be further evaluated.

Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management

Nosocomial clusters of fungal infections, whilst uncommon, cannot be predicted and are associated with significant morbidity and mortality. Here, we review reports of nosocomial outbreaks of invasive fungal disease to glean insight into their epidemiology, risks for infection, methods employed in outbreak detection including genomic testing to confirm the outbreak, and approaches to clinical and infection control management. Both yeasts and filamentous fungi cause outbreaks, with each having general and specific risks. The early detection and confirmation of the outbreak are essential for diagnosis, treatment of affected patients, and termination of the outbreak. Environmental sampling, including the air in mould outbreaks, for the pathogen may be indicated. The genetic analysis of epidemiologically linked isolates is strongly recommended through a sufficiently discriminatory approach such as whole genome sequencing or a method that is acceptably discriminatory for that pathogen. An analysis of both linked isolates and epidemiologically unrelated strains is required to enable genetic similarity comparisons. The management of the outbreak encompasses input from a multi-disciplinary team with epidemiological investigation and infection control measures, including screening for additional cases, patient cohorting, and strict hygiene and cleaning procedures. Automated methods for fungal infection surveillance would greatly aid earlier outbreak detection and should be a focus of research.