Open Access

Post-traumatic vancomycin-resistant enterococcal endophthalmitis

  • Roxane J Hillier1Email author,
  • Parnian Arjmand2,
  • Gabriel Rebick3,
  • Mario Ostrowski3 and
  • Rajeev H Muni1
Journal of Ophthalmic Inflammation and Infection20133:42

https://doi.org/10.1186/1869-5760-3-42

Received: 3 September 2012

Accepted: 17 January 2013

Published: 18 March 2013

Abstract

The emergence of antibiotic-resistant organisms among severe ocular infections is of grave concern. We describe the first reported case of vancomycin-resistant enterococcal endophthalmitis following ocular trauma, uniquely caused by Enterococcus gallinarum. The organism demonstrated intrinsic resistance to ceftazidime and vancomycin but responded favorably to a combination of intravitreal and intravenous ampicillin, plus intravitreal amikacin. When faced with a multidrug-resistant organism, the ophthalmologist must consider alternative antibiotic strategies.

Keywords

Endophthalmitis Enterococcus Vancomycin resistance Ocular trauma

Dear Editor

The emergence of vancomycin-resistant enterococcal (VRE) endophthalmitis is of grave concern. To date, five cases of VRE endophthalmitis have been reported in the literature, associated with previous ocular surgery or immunosuppression [15]. In these cases, the causative organisms were Enterococcus faecium and Enterococcus faecalis. We describe the first reported case of VRE endophthalmitis following ocular trauma, uniquely caused by Enterococcus gallinarum.

Case description

A 38-year-old male sustained trauma to the left eye while hammering farm machinery without protective eyewear. At presentation, 15 h later, the visual acuity (VA) was hand movements. Anterior segment examination confirmed a 3-mm linear corneal laceration with iris tissue and lens capsule to the wound. A fibrinous reaction and 0.5-mm hypopyon were evident. Fundoscopy revealed a healthy posterior pole, with no vitritis. A CT scan of the orbit identified the presence of a metallic intraocular foreign body (IOFB). The patient proceeded to primary repair, pars plana lensectomy, vitrectomy, removal of IOFB, and partial air-fluid exchange. The patient was left aphakic. Intraoperatively, dense vitritis and florid vasculitis, obscuring the optic disc and vessels, were noted to have developed in the short interval between presentation and surgery. A vitreous specimen was sent for microbiologic evaluation, and intravitreal vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, dexamethasone 0.4 mg/0.1 ml, and intravenous moxifloxacin 400 mg were administered. On post-operative day 1, VA dropped to light perception, with a 2-mm hypopyon and absent red reflex. Initial gram stain of the vitreous specimen identified gram-positive cocci in pairs. A second intravitreal injection of vancomycin 1 mg/0.1 ml was administered empirically. Oral moxifloxacin 400 mg once daily and topical fortified vancomycin, fortified ceftazidime, and prednisolone 1% were commenced. On post-operative day 2, there was no clinical improvement. The primary organism was identified as vancomycin-resistant E. gallinarum, sensitive to ampicillin and gentamicin. Light growth of a gram-negative bacillus was also seen. Intravitreal ampicillin 5 mg/0.1 ml and amikacin 0.4 mg/0.1 ml were administered. A 2-week course of intravenous ampicillin 2 g every 4 h was commenced, plus intravenous clindamycin 600 mg every 8 h and oral moxifloxacin 400 mg once daily to cover the gram-negative organism (subsequently identified as an Acinetobacter species). Topical therapy was switched to fortified gentamicin and prednisolone 1%. The infection responded quickly to this regime, and topical therapy was tapered over subsequent weeks. Recovery was complicated by subsequent inferior retinal detachment, which underwent successful surgical management. At 7 months post-injury, the VA improves to 20/80 (aphakic correction).

Comment

Current consensus regarding initial empirical treatment of post-traumatic endophthalmitis is the administration of intravitreal vancomycin and ceftazidime, with adjunctive intravenous vancomycin and ceftazidime, or oral moxifloxacin while awaiting culture results [6]. However, when faced with multidrug resistance or polymicrobial infection, the ophthalmologist must consider alternative antibiotic strategies. Enterococci are gram-positive organisms with intrinsic resistance to many antibiotics including cephalosporins. While frequently sensitive to vancomycin, the clinician must consider VRE particularly in previously hospitalized patients and in areas of high VRE prevalence [3]. Furthermore, certain species including E. gallinarum demonstrate intrinsic vancomycin resistance. Intravitreal ampicillin [2, 3] and amikacin [2] have been used to successfully treat VRE endophthalmitis, as in this case. The aggressive nature of enterococcal endophthalmitis and the potential for synergism with combination therapy may supersede concerns about the potential for aminoglycoside-related retinal toxicity. We selected intravitreal amikacin as it has a somewhat better toxicity profile than intravitreal gentamicin [7]. Regarding systemic therapy, ocular VRE infection has been successfully managed with agents such as intravenous linezolid [2, 5] and penicillin G [3]. The single report of quinupristin/dalfopristine use in an immunocompromised patient with VRE endophthalmitis resulted in panuveitis and enucleation [1]. Intravenous daptomycin may be another potentially useful agent, with known efficacy against VRE and good intravitreal penetration. In this case, prompt treatment in accordance with organism culture and sensitivities afforded a favorable outcome for this patient.

Consent

Written informed consent was obtained from the patient for publication of this report.

Abbreviations

IOFB: 

intraocular foreign body

VRE: 

vancomycin-resistant enterococcus

Declarations

Authors’ Affiliations

(1)
Ophthalmology Department, St Michael’s Hospital
(2)
McMaster University
(3)
Infectious Disease Service, St. Michael’s Hospital

References

  1. Esmaeli B, Holz ER, Ahmadi MA, Krathen RA, Raad II: Endogenous endophthalmitis secondary to vancomycin-resistant enterococci infection. Retina 2003,23(1):118–119. 10.1097/00006982-200302000-00024PubMedView ArticleGoogle Scholar
  2. Bains HS, Weinberg DV, Feder RS, Noskin GA: Postoperative vancomycin-resistant Enterococcus faecium endophthalmitis. Arch Ophthalmol 2007,125(9):1292–1293. 10.1001/archopht.125.9.1292PubMedView ArticleGoogle Scholar
  3. Tang C-W, Cheng C-K, Lee T-S: Community-acquired bleb-related endophthalmitis caused by vancomycin-resistant enterococci. Can J Ophthalmol 2007,42(3):477–478. 10.3129/i07-057PubMedView ArticleGoogle Scholar
  4. Rishi E, Rishi P, Nandi K, Shroff D, Therese KL: Endophthalmitis caused by Enterococcus faecalis : a case series. Retina 2009,29(2):214–217. 10.1097/IAE.0b013e31818eccc7PubMedView ArticleGoogle Scholar
  5. Sharma S, Desai RU, Pass AB, Saffra NA: Vancomycin-resistant enterococcal endophthalmitis. Arch Ophthalmol 2010,128(6):794–795. 10.1001/archophthalmol.2010.77PubMedView ArticleGoogle Scholar
  6. Bhagat N, Nagori S, Zarbin M: Post-traumatic infectious endophthalmitis. Surv Ophthalmol 2011,56(3):214–251. 10.1016/j.survophthal.2010.09.002PubMedView ArticleGoogle Scholar
  7. D'Amico DJ, Caspers-Velu L, Libert J, Shanks E, Schrooyen M, Hanninen LA, Kenyon KR: Comparative toxicity of intravitreal aminoglycoside antibiotics. Am J Ophthalmol 1985,100(2):264–275.PubMedView ArticleGoogle Scholar

Copyright

© Hillier et al.; licensee Springer. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.