Bilateral endogenous endophthalmitis caused by vancomycin-resistant Staphylococcus epidermidis in a neonate
© Relhan et al.; licensee Springer. 2015
Received: 2 October 2014
Accepted: 26 February 2015
Published: 10 April 2015
Neonatal bilateral endogenous endophthalmitis is rare and often results in devastating visual outcome.
An 18-day-old neonate presented with whitening of the cornea in the left eye. The child was examined under anesthesia, and a diagnosis of bilateral endogenous endophthalmitis was made. Vitreous biopsy from the left eye showed no growth. Blood samples showed growth of Staphylococcus epidermidis which was multidrug resistant (including vancomycin) but sensitive to piperacillin-tazobactam. The patient was managed with bilateral intravitreal injections of piperacillin-tazobactam and systemic cefpodoxime. Systemic and topical antibiotics were given for 3 and 8 weeks, respectively, and infection was controlled. At 2-year follow-up, the right eye is fixing and following to light with clear view of the fundus and the left eye has a clear cornea with red glow of the fundus.
Vancomycin-resistant S. epidermidis may be a cause of endogenous endophthalmitis. Intravitreal piperacillin-tazobactam and systemic cefpodoxime were used to eliminate the infection in this neonate.
KeywordsEndogenous endophthalmitis Neonatal endophthalmitis Vancomycin resistance
Endogenous endophthalmitis in the pediatric population is rare and is usually associated with poor visual outcomes. Endogenous endophthalmitis in neonates constitutes 0.1% to 4% of all endogenous endophthalmitis cases [1-3], with the highest incidence of cases reported in India and the lowest in the United States. Gram-positive organisms are causative in 30% to 35% of endogenous endophthalmitis [4,5]. Potential risk factors [6,7] for neonatal endogenous endophthalmitis are immune-compromised status, low birth weight (<1,500 g), bacteremia, prematurity, blood transfusion, respiratory infection, perinatal infection, hospital admission, intravenous catheters, and retinopathy of prematurity. Vancomycin resistance among enterococci, coagulase-negative Staphylococci, and Bacillus is being increasingly reported  in ocular infections. Herein, we report bilateral endogenous endophthalmitis due to multidrug-resistant gram-positive cocci in a neonate of age 18 days.
Treatment details of the patient
Day of presentation (age in days)
1 (18th day of life)
Left eye - anterior chamber wash + vitreous biopsy
Both eyes - IOAB (V + C + D)a
Topical treatment in both eyes - ciprofloxacin 0.3% four times a day, prednisolone acetate 1% every 3 h, and atropine 1% eye ointment at nighttimeb
Systemic treatment - intravenous cefpodoxime by a pediatricianc
3 (21st day of life)
Both eyes - IOAB (V + C + D)a
8 (26th day of life)
Both eyes - IOAB (P/T + D)d
13 (31st day of life)
Left eye - IOAB (P/T + D)d
Vitreous biopsy was negative for any growth while the blood culture showed gram-positive organisms (Staphylococcus epidermidis) which were resistant to vancomycin, amoxicillin, kanamycin, cephalothin, and erythromycin by the Kirby-Bauer disk diffusion method. Urine cultures of the neonate and the mother and culture of a vaginal swab of the mother showed no growth. The isolates were sensitive to piperacillin-tazobactam (112.5 μg/0.05 ml) which was administered intravitreally as mentioned in Table 1. In the subsequent week, the child’s right pupil was mid-dilated with a good view of the disk and macula while the left cornea continued to be opaque with decreased signs of ocular inflammation.
Vancomycin resistance among gram-positive bacterial endophthalmitis has become a major global health issue . Vancomycin - a glycopeptide - is the drug of choice for methicillin-resistant coagulase-negative Staphylococcus and methicillin-resistant Staphylococcus aureus (MRSA) infections [10,11]. Biofilm formation  and alteration of binding sites of drug  are the mechanisms of acquiring resistance to vancomycin. These resistant traits are then selected for in the presence of vancomycin. The Endophthalmitis Vitrectomy Study in 1996 reported the vancomycin sensitivity of gram-positive organisms to be 100%. A few reports of vancomycin resistance among Bacillus, Enterococcus, and Staphylococcus species causing endophthalmitis have been published recently [11,13,14]. In this patient, the organism was sensitive to piperacillin-tazobactam, cefotaxime, doxycycline, clarithromycin, cefixime, and gentamycin. Piperacillin-tazobactam is a combination of beta-lactam antibiotic with beta-lactamase inhibitor in a ratio of 8:1 (piperacillin/tazobactam) and has broad antibacterial activity against gram-positive and gram-negative pathogens [9,15]. Endogenous endophthalmitis is associated with poor anatomical and visual outcomes. In a study of 26 neonates  with endogenous endophthalmitis, 22 out of 26 cases (84.61%) became phthisical. Khera et al.  reported a single case of endogenous endophthalmitis, caused by vancomycin-resistant gram-positive cocci, in an adolescent resulting in enucleation. In our case, the child had a better outcome with complete resolution of endophthalmitis in both eyes and achieved fixing and following in the right eye. Maternal infections, sepsis during childbirth, low birth weight, etc. are the reported predisposing factors for neonatal endogenous endophthalmitis. In the present case, detailed history (both mother and child) did not reveal the predisposing factor. The fact that the child was born by a vaginal delivery in the rural India may raise the possibility of infection in perinatal or postnatal period.
In this case, no immunological workup to rule out impaired immunity was done. However, the child responded to the antibiotics well without any further recurrence or disease. Another limitation was that antibiotic resistance was assayed by disk diffusion only and not by minimum inhibitory concentration (MIC) because this assay was not available. Additionally, cultures were positive only from blood and not intraocular fluid; however, the subsequent response to treatment supports our clinical impression that the child’s bacteremia was the cause of endophthalmitis, implicating multidrug-resistant S. epidermidis as the target pathogen. To the best of our knowledge, this is the first reported case of vancomycin-resistant bilateral endogenous endophthalmitis in a neonate with good outcomes. This report emphasizes the need of early management including intravitreal antibiotics guided by culture sensitivities which can result in a favorable outcome.
In conclusion, early recognition of antibiotic resistance and treatment with appropriate antibiotics (as in our case with piperacillin-tazobactam) were associated with resolution of infection. Ocular and extraocular culture and sensitivities should be obtained as early as possible to isolate the causative organism and best chose an appropriate therapy. Appropriate early intervention can result in favorable outcome.
The written informed consent from the parents of child was taken before initiating the treatment. IRB of our institute does not require approval to write case report up to 3 cases.
- IOAB (V + C + D):
Intravitreal antibiotics (vancomycin + ceftazidime + dexamethasone)
- IOAB (P/T + D):
Intravitreal antibiotics (piperacillin-tazobactam + dexamethasone)
We gratefully acknowledge Rajawardhan Mallipudi for collection of data and photographic support. He is working as an optometrist at L V Prasad Eye Institute, Vijayawada. We are thankful to the Uveitis Society of India (USI) and the International Ocular Inflammation Society (IOIS) for funding the publication of this manuscript.
Dr Albini receives consulting honoraria from Bausch & Lomb, Allergan, ThromboGenics and Eleven Biotherapeutics. Dr Flynn receives research support from Saten Pharmaceutical Co. and Vindico Medical Education.
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