Open Access

Endophthalmitis after open globe injuries: changes in microbiological spectrum and isolate susceptibility patterns over 14 years

  • Animesh Jindal1,
  • Avinash Pathengay1Email author,
  • Kopal Mithal1,
  • Subhadra Jalali2,
  • Annie Mathai2,
  • Rajeev Reddy Pappuru2,
  • Raja Narayanan2,
  • Jay Chhablani2,
  • Swapna R Motukupally4,
  • Savitri Sharma4,
  • Taraprasad Das2, 3 and
  • Harry W FlynnJr5
Journal of Ophthalmic Inflammation and Infection20144:5

https://doi.org/10.1186/1869-5760-4-5

Received: 29 December 2013

Accepted: 10 February 2014

Published: 18 February 2014

Abstract

Background

The objective of this study was to evaluate the microbiologic spectrum and antimicrobial susceptibility of isolates in post-traumatic endophthalmitis and compare with our earlier published report. A retrospective review was conducted on 581 consecutive patients with culture-proven post-traumatic endophthalmitis at L. V. Prasad Eye Institute, India, from January 2006 to March 2013.

Findings

A total of 620 isolates from 581 patients were identified (565 bacteria and 55 fungi). The most common isolate was Bacillus spp. (106/620, 17.1%) closely followed by Streptococcus pneumoniae (105/620, 16.9%), and coagulase-negative Staphylococci (97/620, 15.6%). In our earlier report, the commonest bacteria included Streptococcus spp. (30/139, 21.6%) and gram-positive coagulase-negative micrococci (26/139, 18.7%). Gram-positive isolates were usually susceptible to vancomycin (98.2%). Gram-negative isolates were generally susceptible to gatifloxacin (92.9%), ofloxacin (89.4%), chloramphenicol (88.6%, Pseudomonas isolates were often resistant), amikacin (83.5%), and ceftazidime (77.2%). Fourteen years ago, the most sensitive antibiotic was ciprofloxacin for both gram-positive bacteria (95.12%) and gram-negative bacteria (100%).

Conclusions

The microbiological spectrum of post-traumatic endophthalmitis has remained unchanged over the last 14 years, and Bacillus spp. continues as the most common infecting organism. Vancomycin is the drug of choice for empiric coverage of gram-positive bacteria. Susceptibility of gram-negative bacteria to commonly used antimicrobials (amikacin and ciprofloxacin) has decreased by 10% - 15% and to ceftazidime has increased by 10.5%.

Keywords

Open globe injuryEndophthalmitisMicrobiology

Findings

Background

Open globe injuries (OGI) are a common cause of infectious endophthalmitis. The incidence of endophthalmitis in this setting varies from 3% to 48% in various studies, depending on a variety of factors which include setting of trauma, delay of repair, retained intraocular foreign body, and involvement of the crystalline lens [1]. Post-traumatic endophthalmitis is either a community-acquired infection from the unsterile material causing trauma or caused by the inoculation of the normal ocular flora at the time of injury. The purpose of the study is to describe the microbial spectrum and antimicrobial susceptibility in cases of endophthalmitis after OGI and to compare the results with the earlier published data from the same center [2].

Methods

This was a retrospective, non-comparative, consecutive case series. Microbiology records were reviewed of all the culture-proven endophthalmitis cases after OGI treated at L. V. Prasad Eye Institute, Hyderabad, India, between January 2006 and March 2013. Bacterial isolates were identified using Analytical Profile Index (API, Bio Meriux, France). The isolate susceptibility to various antimicrobials was determined by the Kirby-Bauer disk diffusion method. Susceptibilities for fungal isolates were not performed. The study was approved by the Institutional Review Board of L. V. Prasad Eye Institute and adhered to the guidelines of the Declaration of Helsinki.

Results

A total of 620 isolates from 581 samples were identified. A total of 38 samples (6.5%) had polymicrobial infection; 37 samples grew two isolates, and one sample grew three organisms. The isolates included gram-positive cocci (296, 47.7%), gram-positive bacilli (117, 18.8%), gram-negative bacteria (142, 22.9%), fungi (55, 8.87%), and Corynebacterium (10, 1.61%) (Table 1).
Table 1

Microbiological spectrum and antimicrobial susceptibilities in patients with endophthalmitis following open globe injuries

Organism

Total/percentage(previous study)2

Total/percentage (current study)

Amikacin

Cefazolin

Ceftazidime

Chloramphenicol

Gentamicin

Gatifloxacin

Ciprofloxacin

Moxifloxacin

Vancomycin

Ofloxacin

   

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

n

S

%

Gram-positive cocci

63/45.3

296/47.7

274

155

56.5

294

266

90.4

137

79

57.6

295

284

96.2

295

217

73.5

292

263

90.1

296

219

73.9

239

206

86.2

289

284

98.2

295

240

81.4

 Coagulase-negative Staphylococcus

25/18

97/15.6

86

81

94.2

96

90

93.7

41

18

43.9

96

93

96.9

97

89

91.7

97

96

98.9

97

75

77.3

75

69

92

95

93

97.9

97

76

78.4

Staphylococcus aureus

5/3.6

11/1.8

11

11

100

11

11

100

5

3

60

11

11

100

11

10

90.9

11

10

90.9

11

5

45.4

10

8

80

11

11

100

11

6

54.5

Streptococcus sp.

30/21.6

172/27.7

163

52

31.9

172

154

89.5

81

54

66.6

172

166

96.5

172

108

62.7

169

143

84.6

172

127

73.8

143

119

83.2

168

165

98.2

171

143

83.6

 Other gram-positive cocci

3/2.2

16/2.6

14

11

78.6

15

11

73.3

10

4

40.0

16

14

87.5

15

10

66.7

15

14

93.3

16

12

75.0

11

10

90.9

15

15

100

16

15

93.7

Gram-positive bacilli

24/17.3

117/18.8

114

109

95.6

115

63

54.7

75

12

16

117

109

93.1

117

112

95.7

117

116

99.1

116

108

93.1

101

99

98.0

114

109

95.6

117

116

99.1

Bacillus sp.

20/14.4

106/17.1

103

101

98.1

104

54

51.9

67

8

11.9

106

98

92.4

106

105

99.1

106

105

99.0

106

101

95.2

94

92

97.9

103

98

95.1

106

106

100

 Other GPB

4/2.9

11/1.8

11

8

72.7

11

9

81.8

8

4

50

11

11

100

11

7

63.6

11

11

100

10

7

70

7

7

100

11

11

100

11

10

90.9

Gram negative organism

25/18

142/25

140

117

83.5

16

7

43.7

136

105

77.2

141

125

88.6

142

125

88.0

141

131

92.9

142

123

86.6

116

96

82.7

16

4

25

142

127

89.4

Pseudomonas sp.

10/7.2

16/2.6

16

12

75

1

0

0

16

11

68.7

16

5

31.2

16

12

75

16

12

75.0

16

11

68.7

13

8

61.5

1

0

0

16

11

68.7

Enterobacter sp.

2/1.4

25/4.0

25

22

88

5

2

40

23

21

91.3

25

24

96

24

23

95.8

25

24

96

25

24

96

19

19

100

5

2

40

25

24

96

E. coli

4/2.9

14/2.3

14

12

85.7

-

-

-

14

12

85.7

14

13

92.8

14

13

92.8

14

11

78.6

14

11

78.6

12

7

58.3

-

-

-

14

10

71.4

Haemophilus sp.

-

14/2.3

14

7

50

-

-

-

13

5

38.5

14

14

100

14

11

78.6

14

14

100

14

12

85.7

13

11

84.6

-

-

-

14

14

100

 Other gram-negative organisms

9/6.5

73/11.8

71

64

90.1

10

5

50

70

56

80

72

69

95.8

74

66

89.2

72

70

97.2

73

65

89

59

51

86.4

10

2

20

73

68

93.2

Corynebacterium

5/3.6

10/1.6

5

4

80

10

9

90

3

0

0

10

9

90

10

9

90

10

9

90.0

10

7

70

8

6

75.0

10

10

100

10

9

90

 Total bacteria

119/85.6

565/91.1

533

385

72.2

435

345

79.3

351

196

55.8

563

527

93.6

564

463

82.0

560

519

92.7

564

457

81.1

464

407

87.7

429

407

94.8

564

492

87.2

 Total fungi

20/14.4

55/8.9

Not done

  Aspergillus

9/6.5

20/3.2

  Acremonium

1/0.7

1/0.32

  Bipolaris

1/0.7

2/0.32

  Cladosporium

1/0.7

2/0.32

  Candida

-

3/0.48

  Fusarium

2/1.4

1/0.16

All isolates were not tested for susceptibility to all antibiotics leading to ‘n’ being less than the total isolates. GPB, gram-positive bacilli; n, number of isolates tested for antibiotic susceptibility; S, number of isolates sensitive to the antibiotic.

The most common organism isolated was Bacillus spp. (106/620, 17.1%) followed by Streptococcus pneumoniae (105/620, 16.9%) and coagulase-negative Staphylococci (97/620, 15.6%). Enterobacter was the most common gram-negative isolate (25 of 142 gram-negative isolates). Aspergillus spp. was the most common fungus (20 of 55 fungal isolates) (Table 1).

The spectrum of the isolates identified in this series was similar to that reported in 1999 from the same center [2], with coagulase-negative Staphylococci (CoNS), Streptococcus, and Bacilllus sp. being the three most common organisms (Table 1). The only differences in the spectrum of organisms were the relatively lower incidence of fungal endophthalmitis in the current study (current 8.9% vs earlier 14.4%) and higher incidence of gram-negative isolates (current 25% vs earlier 18%). But, both of these were not statistically significant (p = 0.257 and 0.058, respectively).

Both gram-positive cocci and gram-positive bacilli were generally susceptible to vancomycin (98.2% and 95.6%, respectively). Bacillus sp. was also susceptible to vancomycin (95.1%) as well as to gentamicin (99.1%), amikacin (98.1%), chloramphenicol (92.4%), ciprofloxacin (95.2%), ofloxacin (100%), gatifloxacin (99.1%), and moxifloxacin (97.9%) but its susceptibility to ceftazidime was very poor (11.9%). Gram-negative bacteria were generally susceptible to gatifloxacin (92.9%) followed by ofloxacin (89.4%), chloramphenicol (88.6%), ciprofloxacin (86.6%), amikacin (83.5%), and ceftazidime (77.2%). Among the fluoroquinolones, both gram-positive and gram-negative organisms were most susceptible to gatifloxacin (92.7% and 92.9%, respectively). The antimicrobial susceptibilities of the various isolates are detailed in the Table 1.

Discussion

The susceptibility of gram-positive organisms continues to be highest to vancomycin. Susceptibility of CoNS to ciprofloxacin had reduced from 100% in 1999 report [2] to 77.3% in the current report (p = 0.007). Similar fluoroquinolone susceptibility trend towards CoNS was noted in the report by Schimel et al. [3]. Susceptibility of gram-negative organisms has slightly decreased over the last two decades. In the 1999 report, gram-negative organisms were 100% susceptible to ciprofloxacin and 95% to amikacin [2]. This has now reduced to 86.6% and 83.5%, respectively, but this change was statistically not significant (p = 0.078 and p = 0.206, respectively). The susceptibility of gram-negative isolates to ceftazidime has increased from 66.7% in 1999 [2] to 77.2% in the current study, and this difference is also not significant (p > 0.05).

The current study indicates that the microbiological spectrum in post-traumatic endophthalmitis has remained the same over the last two decades. Intravitreal vancomycin remains the drug of choice for empiric coverage of gram-positive bacteria. Susceptibility of gram-negative bacteria to commonly used antimicrobials including amikacin and ciprofloxacin has decreased by 10% to 15% and to ceftazidime has increased by 10.5% as compared to the past two decades though statistically not significant. Thus, intravitreal amikacin can be used for empiric coverage of gram-negative bacteria. Ofloxacin is a good option as a systemic antibiotic for broad-spectrum empiric coverage. Also, we report a high prevalence of Bacillus endophthalmitis in open globe injuries that are known to be highly virulent with rapid progression to panophthalmitis [4]. Similar high prevalence of Bacillus endophthalmitis following open globe injuries has been reported in the literature [5, 6].

Conclusions

The microbiological spectrum remains similar over the past 14 years. The susceptibility of gram-negative organisms to commonly used antibiotics has decreased over the time period. Empiric treatment of post-traumatic endophthalmitis with broad-spectrum, combination antibiotics based on the susceptibility pattern in that region is very important for successful anatomical and visual outcomes.

Declarations

Authors’ Affiliations

(1)
L V Prasad Eye Institute
(2)
Srimati Kannuri Santhamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute
(3)
L V Prasad Eye Institute, Bhubaneswar Eye Institute
(4)
Jhaveri Microbiology Centre, L V Prasad Eye Institute
(5)
Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami

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Copyright

© Jindal et al.; licensee Springer. 2014

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 credited.