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Year : 2020  |  Volume : 68  |  Issue : 7  |  Page : 1249-1251

Management of cluster endophthalmitis does not stop at clinical care

Srimati Kanuri Santamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India

Date of Web Publication25-Jun-2020

Correspondence Address:
Dr. Taraprasad Das
Srimati Kanuri Santamma Centre for Vitreoretinal Diseases, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_502_20

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How to cite this article:
Das T. Management of cluster endophthalmitis does not stop at clinical care. Indian J Ophthalmol 2020;68:1249-51

How to cite this URL:
Das T. Management of cluster endophthalmitis does not stop at clinical care. Indian J Ophthalmol [serial online] 2020 [cited 2023 Apr 1];68:1249-51. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2020/68/7/1249/287564

Cluster endophthalmitis is the occurrence of endophthalmitis much higher than the local incidence pattern or occurrence of two or more cases of infection at a time, or the occurrence of repeated postoperativee infection under similar circumstances— with the same surgeon, same staff, or in the same operating room. This calls for many interlinked actions and responsibilities on the service provider. These essentially include (1) to treat the patients most appropriately to salvage the best possible vision, (2) identify the source of infection to prevent another outbreak, and (3) build the psychosocial confidence in both the caregivers and the care seekers.

Treatment of the infected eyes is on the similar lines of the endophthalmitis vitrectomy study (EVS) recommended standard of care,[1] but more often vitrectomy than vitreous tap is required, and culture-susceptibility specific (as opposed to empiric) intraocular antibiotics benefit the patients. The outcome depends on the speed of instituting treatment, the possibilities of doing a good vitrectomy, and the susceptibility of the infecting microorganism. A good vitrectomy is possible when the cornea is not grossly affected and the causative organisms are not multidrug resistant (MDR).

There are three sources of infection after an intraocular surgery— the patient, the health personnel, and the surgical supply. Potential sources of these outbreaks usually include bacterial contamination from the surgical instruments, irrigating fluids, intraocular lens, or the surgical environment. Isolated cases of acute postoperative endophthalmitis usually arise from the patient's own commensal bacteria and these are mainly gram-positivee cocci. In contrast, gram-negative organisms are commonly associated with epidemics of cluster endophthalmitis outbreaks after cataract surgery. Pseudomonas aeruginosa is more often reported gram-negative microorganisms in cluster endophthalmitis from India.[2],[3],[4] Molecular microbiological methods are essential to prove an unquestionable association of the microorganism isolated from the vitreous of the infected eye and other suspected sources of infection, be it the surgical supply or the healthcare personnel.[5],[6] The functional success (defined as best-corrected final visual acuity ≥ 20/200) in 101 cases of reported cluster Pseudomonas aeruginosa endophthalmitis in India in the recent past including the one reported in this issue of the journal is under 25% [Table 1].[2],[3],[4],[7] Worse is the outcome when the cornea is involved (does not allow good vitrectomy) and the infecting organism is MDR. Between the two, MDR is the greater evil.
Table 1: Cluster endophthalmitis caused by Pseudomonas aeruginosa in India[2],[3],[4],[7]

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MDR is insensitivity or resistance of a microorganism to the administered antimicrobials despite earlier sensitivity to it. MDR could be primary (the microorganism has never encountered the drug of interest), secondary (acquired resistance that arises after exposure to the drug), or clinical (the drug concentration is insufficient to impact the microorganism).[8] A large study spanning 25 years and an analysis of over 3300 culture-positive cases of infective endophthalmitis in India have reported an increase in the resistance of gram-negative organism to ceftazidime from 31% in 2005 to 62% in 2015.[9] Another study from the same center in India has shown that all 56 MDR gram-negative organism (59% of them were Pseudomonas aeruginosa) were 100% susceptible to imipenem and only partially susceptible to amikacin, ciprofloxacin, and gentamicin (43%, 41%, and 30%, respectively)[10] Resistance to ceftazidime has been recorded by the EVS group in the USA (11%),[1] and this has been confirmed in reports from India (up to 40%).[11],[12],[13] In addition to imipenem, colistin and piperacillin are considered good alternatives to treat MDR Pseudomonas spp. In the current report from Central India, susceptibility of Pseudomonas aeruginosa to colistin, piperacillin, and imipenem was 82%, 68%, and 64%, respectively by disc diffusion method.[6] [The Clinical and Laboratory Standrad Institute, CLSI, guidelines do not recommend testing of colistin and imipenem by disk diffusion method].

Colistin is a multicomponent polypeptide antibiotic that is mainly composed of colistin A and colistin B. It is available as colistin sulfate (tablets or syrup for oral use and powder for topical use), and colistin methanesulfonate (colistimethate sodium [CMS]). Colistin binds to the lipopolysaccharides and phospholipids in the outer cell membrane of gram-negative bacteria and disrupts the outer cell membrane.[14]

Imipenem is a β-lactam antibiotic highly resistant to the β-lactamase enzymes produced by many MDR gram-negative bacteria, particularly Pseudomonas aeruginosa and Enterococcus species. Imipenem inhibits cell wall synthesis by binding to penicillin-binding proteins.[15] Piperacillin/tazobactam is a combination medicine containing antibiotics, piperacillin and β-lactamase inhibitor, tazobactam. The combination has activity against many gram-positive and gram-negative bacteria including Pseudomonas aeruginosa. Tazobactam inhibits β-lactamase and prevents the destruction of piperacillin. Piperacillin kills bacteria by inhibiting the synthesis of bacterial cell walls. It binds to specific penicillin-binding proteins (PBPs) located inside bacterial cell walls.[16] [Table 2] lists the dosage for ophthalmic and systemic therapy of these drugs.
Table 2: Antibiotics for multidrug-resistant gram-negative bacterial endophthalmitis

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Culture of the ocular fluid (vitreous or aqueous) and the intraocular lens, if extracted, and antibiotic susceptibility testing of the culture isolates is essential to effectively treat cluster endophthalmitis. This is traditionally performed by inoculating the material in a number of culture media and grow them both aerobically and anaerobically. The species identification is done by the traditional biochemical tests or automated Vitek 2 system. But the responsibility of the care provider does not stop with this. Every effort must be made to identify the source of cluster infection by subjecting to similar microbiological tests of materials collected from all possible sources, such as the surgical instrument and supply, and the environment including the air conditioning ducts. However, these methods do not establish a cause-effect relationship with certainty unless the offending organism from the patient and suspected source are proven to be identical by molecular method. The methods used in many centers investigating cluster endophthalmitis include polymerase chain reaction with enterobacterial repetitive intergenic consensus (ERIC- PCR),[2],[3] high sequence genotyping,[5] random amplification of polymorphic DNA (RAPD) assay,[6] and pulsed-field gel electrophoreses of the organism (Pseudomonas aeruginosa).[17] These molecular tests unequivocally establish the source of infection so that one could institute appropriate measures to prevent a recurrence. This is the most crucial inquiry in every outbreak of cluster endophthalmitis.

The Royal College of Ophthalmology, UK provides a very comprehensive guideline for managing the outbreak of postoperative endophthalmitis.[18] It recommends constituting a team that includes physicians, microbiologists, and operating room nurses. The team collects a comprehensive list of notes from the medical records and investigates the operating room, pre- and postoperative areas, central stores, and sterilization areas. Depending on the number of cases, a color-coded alert is made as follows [18]:

Green- 1 case of endophthalmitis; 1 in ≥100 cases, or 2 in ≥600 cases;

Amber- 1 case in 75 cases, 2 cases in 300-500 cases, 3 cases in 700-800 cases;

Red- 2 cases in ≤200 cases, 3 cases in ≤600 cases, 4 cases in ≤ 800 cases.

A 'green alert' calls for heightened vigilance, but an 'amber' or 'red alert' may necessitate the closure of operating rooms to investigate for the cause of the outbreak.

Finally, the psychosocial aspect of care cannot be ignored. In an environment of mental and physical trauma to the patient and family, to the operating physician and the eye care facility, one is required to maintain a dignified calm, and use an alert and logical mind to tide over the crisis of restoring confidence to everyone involved with the incident. The report in this issue dealing with six clusters of Pseudomonas endophthalmitis is from the same region that had encountered similar incidents a few years ago.[19] On both occasions, appropriate care had been provided though vision in many eyes could not be saved due to late presentation, advanced disease status, and virulent organisms. But a proper investigation was not done to identify the cause. A national policy should be made where reporting such outbreaks and a thorough inquiry are made mandatory.

  References Top

Endophthalmitis Vitrectomy Study Group. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 1995;113:1479-96.  Back to cited text no. 1
Pinna A, Usai D, Sechi LA, Zanetti S, Jesudasan NC, Thomas PA, et al. An outbreak of post-cataract surgery endophthalmitis caused by Pseudomonas aeruginosa. Ophthalmology 2009;116:2321-6.  Back to cited text no. 2
Ramappa M, Majji AB, Murthy SI, Balne PK, Nalamada S, Garudadri C, et al. An outbreak of acute post-cataractsurgery pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution. Ophthalmology 2012;119:564-70.  Back to cited text no. 3
Samant P, Ramugade S. Successful use of intravitreal and systemic colistin in treating multidrug resistant Pseudomonas aeruginosa post-operative endophthalmitis. Indian J Ophthalmol 2014;62:1167-70.  Back to cited text no. 4
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Kenchappa P, Sangwan VS, Ahmed N, Rao KR, Pathengay A, Mathai A, et al. High-resolution genotyping of Pseudomonas aeruginosa strains linked to acute post cataract surgery endophthalmitis outbreaks in India. Ann Clin Microbiol Antimicrob 2005;4:19.  Back to cited text no. 5
Satpathy G, Patnayak D, Titiyal JS, Nayak N, Tandon R, Sharma N, et al. Post-operative endophthalmitis: Antibiogram and genetic relatedness between Pseudomonas aeruginosa isolates from patients and phacoemulsifiers. Indian J Med Res 2010;131:571-7.  Back to cited text no. 6
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Parchand SM, Agrawal D, Chatterjee S, Gangwe A, Mishra M, Agrawal D. Post-cataract surgery cluster endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa: A retrospective cohort study of six clusters. Indian J Ophthalmol 2020;68:1424-31.  Back to cited text no. 7
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Tanwar J, Das S, Fatima Z, Hameed S. Multidrug resistance: An emerging crisis. Int Pres Infect Dis 2014. doi: 10.1155/2014.541340.  Back to cited text no. 8
Joseph J, Sontam B, Guda AJM, Gandhi J, Sharma S, Tyagi M, et al. Trends in microbiological spectrum of endophthalmitis at a single tertiary care ophthalmic hospital in India: A review of 25 years. Eye 33:1990-5.  Back to cited text no. 9
Dave VP, Pathengay A, Nishant K, Pappuru RR, Sharma S, Narayanan R, et al. Clinical presentations, risk factors, and outcome of ceftazidime- resistant gram-negative endophthalmitis. Clin Exp Ophthalmol 2017;45:254-60.  Back to cited text no. 10
Kunimoto DY, Das T, Sharma S, et al. Microbiologic spectrum and susceptibility of isolates: Part I. Postoperative endophthalmitis. Endophthalmitis Research Group. Am J Ophthalmol 1999;128:240-2.  Back to cited text no. 11
Kunimoto DY, Das T, Sharma S, Jalai S, Majji AB, Gopinathan U, et al. Microbial spectrum and susceptibility of isolates. Part II. Post-traumatic endophthalmitis. Am J Ophthalmol 1999;128:242-4.  Back to cited text no. 12
Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000;48:123-8.  Back to cited text no. 13
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Natioan RL, Li J. Colistin in the 21st century. Curr Opin Infect Dis 2009;22:535-43.  Back to cited text no. 14
Rodloff AC, Goldstein EJC, Torres A. Two decades of imipenem therapy. J Antimicrob Chemother 2006;58:916-29.  Back to cited text no. 15
Perry CM, Markham A. Piperacillin/tazobactum: An updated review of its use in the treatment of bacteril infections. Drugs 1999;57:805-43.  Back to cited text no. 16
Hoffmann KK, Weber DJ, Gergen MF, Rutala WA, Tate G. Pseudomonas aeruginosa related postoperative endophthalmitis linked to contaminated phacoemulsifier. Arch Ophthalmol 2002;120:90-3.  Back to cited text no. 17
Ophthalmic service guidance, Royal College of Ophthalmology: Managing an outbreak of postoperative endophthalmitis 2016. Available from: www.rcophth.ac.uk [Last accessed on 2020 Mar 05].  Back to cited text no. 18
Malhotra S, Mandal P, Patanker G, Agrawal D. Clinical profile and visual outcome in cluster endophthalmitis following cataract surgery in Central India. Indian J Ophthalmol 2008;56:157-8.  Back to cited text no. 19
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  Authors Top

Dr. Taraprasad Das
Dr Das is currently the Vice Chairman of the L V Prasad Eye Institute, Hyderabad and faculty at the Srimati Kanuri Shantamma Centre for Vitreo-retinal diseases, LVPEI, Hyderabad, India. He is the fellow of National Academy of Medical Sciences, India; Regional Chair, International Agency for Prevention of Blindness; and Vice President, Asia Pacific Academy of Ophthalmology. His reserch includes both clinical (diabetic retinopathy, infectious endophthalmitis) and public health ophthalmology. He has received 18 research grants, published 269 research papers, written 52 book chapters and has authored / edited 10 books. His recognitions include American Academy of Ophthalmology Senior Achievement award, Ravenshaw university Honaris Causa and Government of India civil honor, Padmasri.


  [Table 1], [Table 2]

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