Analysis of Inpatients with Contact Lens Related Bacterial Keratitis: Causative Microorganisms, Clinical Aspects, and Prognostic Factors

Chan Ho Cho; Sang-Bumm Lee

doi:10.3341/jkos.2013.54.9.1327

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Cho and Lee: Analysis of Inpatients with Contact Lens Related Bacterial Keratitis: Causative Microorganisms, Clinical Aspects, and Prognostic Factors

Original Article

J Korean Ophthalmol Soc 2013;54(9):1327-1338.

Published online: 7 September 2013

DOI: https://doi.org/10.3341/jkos.2013.54.9.1327

Analysis of Inpatients with Contact Lens Related Bacterial Keratitis: Causative Microorganisms, Clinical Aspects, and Prognostic Factors

Chan Ho Cho, MD, Sang-Bumm Lee, MD, PhD

Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea

Address reprint requests to Sang-Bumm Lee, MD, PhD Department of Ophthalmology, Yeungnam University Medical Center, #170 Hyeonchung-ro, Nam-gu, Daegu 705-717, Korea Tel: 82-53-620-3445, Fax: 82-53-626-5936 E-mail: sbummlee@ynu.ac.kr

∗ This study was presented as a poster at the 106th Annual Meeting of the Korean Ophthalmological Society 2011.

Received 29 December 20129 May 2013 Accepted 26 July 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate causative microorganisms, clinical characteristics, and prognostic factors for inpatients with contact lens related bacterial keratitis.

Methods

Seventy-three eyes of inpatients with contact lens related bacterial keratitis and hospitalized at Yeungnam University Hospital between January 1998 and December 2011 were reviewed retrospectively. Their bacteriological profiles and clinical characteristics were evaluated.

Results

Females in their 20s (35/73 eyes, 47.9%) were the most common gender and age group. Thirty eyes (30/45 eyes, 66.7%) used daily-wear soft contact lenses. The most common predisposing factor was sleeping while wearing contact lenses (30 eyes, 41.1%). Positive culture rate was 53.4%. The ratio of gram-positive and -negative bacteria was 8.3%: 91.6%. The most commonly-isolated microorganisms were Pseudomonas spp. (39.6%), followed by Serratia spp. (29.2%). The characteristics of the corneal lesions were: a central lesion in 49 eyes (67.1%), a lesion less than 5 mm² in size in 54 eyes (74.0%), and hypopyon in 8 eyes (11.0%). The mean log MAR BCVA improved from 0.93 ± 0.88 on the initial visit to 0.25 ± 0.48 on the final visit. Twelve eyes (16.4%) had a BCVA of 0.3 or less after remission medical treatment. A BCVA less than 0.1 on the initial visit was a significant risk factor for poor visual outcome (p = 0.005) after remission medical treatment.

Conclusions

BCVA less than 0.1 on the initial visit, epithelial defect sized over 5 mm², epithelial healing time over 10 days, and central corneal lesion were associated with poor visual outcome after remission medical treatment in contact lens related bacterial keratitis.

Keywords: Bacterial isolates, Bacterial keratitis, Contact lens, Prognostic factor, Visual outcome

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Table 1.

Demographics and clinical course of patients

Characteristic	No. of cases (%)	Mean ± SD	Range
Total patients	73 (100.0)
Age (year)		24.5 ± 7.3	14-43
Gender Male	15 (20.5)
Female	58 (79.5)
No. of culture positive / No. of culture test	39 / 73 (53.4)
Symptom to treatment interval (day)		4.4 ± 4.8	1-25
Duration of contact lens usage (year, n = 44*)		5.2 ± 5.5	0.1-20
Follow up period (month)		3.2 ± 6.2	1.5-35
Duration of hospitalization (day)		7.7 ± 2.8	2-19

^* Consists of identified data only.

Table 2.

Microbiological profiles of the cultures from the cornea in contact lens related bacterial keratitis patients

Bacteria	Species	No. of isolates (%)		Total
Bacteria	Species	1998-2004	2005-2011	Total
Gram (+) (n = 4, 8.3%)
	Staphylococcus species
	S. epidermidis	1	1	2 (4.2)
	S. aureus	0	1	1 (2.1)
	Streptococcus species
	S. mitis	0	1	1 (2.1)
Gram (-) (n = 44, 91.7%)
	Pseudomonas species
	P. aeruginosa	9	5	14 (29.1)
	P. putida	0	1	1 (2.1)
	P. pickettii	1	0	1 (2.1)
	Other Pseudomonas spp.	1	2	3 (6.3)
	Enterobacteriaceae
	Serratia species
	S. marcescens	7	6	13 (27.1)
	S. liquefaciens	0	1	1 (2.1)
	Enterobacter species
	E. cloacae	0	2	2 (4.2)
	E. aerogenes	1	1	2 (4.2)
	E. agglomerans	1	0	1 (2.1)
	Klebsiella species
	K. pneumoniae	2	0	2 (4.2)
	K. oxytoca	1	0	1 (2.1)
	Escherichia species
	E. coli	1	0	1 (2.1)
	Achromobacter species
	A. xylosoxidans	1	0	1 (2.1)
	Chryseobacterium species
	C. indologenes	0	1	1 (2.1)

Total		26	22	48* (100.0)

^* Eight eyes had mixed bacterial infection in total 39 eyes, Mixed infection of two bacterial species (7 eyes : P. aeruginosa & K. pneumoniae, P. aeruginosa & C. indologenes, P. aeruginosa & S. liquefaciens, P. aeruginosa & K. oxytoca, Other Pseudomonas spp. & S. marcescens, S. marcescens & K. pneumoniae, S. marcescens & A. xylosoxidan s), Mixed infection of three bacterial species (1 eye : P. aeruginosa, E. coli & E. aerogenes).

Table 3.

Predisposing factors, symptom durations, and topical medications prior to patient presentation to our clinic (N=73)

Characteristic	No. of cases (%)
Predisposing factor
Sleeping with wearing contact lens	30 (41.1)
Mechanical trauma	2 (2.7)
Water contaminant	2 (2.7)
Unidentified	39 (53.4)
Contact lens wearing pattern
Daily contact lens wear ≥12 hours	35 (47.9)
Daily contact lens wear <12 hours	38 (52.1)
Contact lens type (N=45*)
Daily wear soft	30 (66.7%)
Extended wear soft	8 (17.8%)
Rigid gas permeable	2 (4.4%)
Therapeutic bandage	5 (11.1%)
Symptom to treatment interval^†
＞5 days	51 (69.9)
≥ 5 days	22 (30.1)
Previous use of topical antibiotics (N=65^‡)
Yes	45^§(69.2)
Fluoroquinolone	39 (86.7)
Ofloxacin	4 (10.3)
Levofloxacin	25 (64.1)
Gatifloxacin or Moxifloxacin	10 (25.6)
Aminoglycoside	13 (28.9)
Tobramycin	13 (28.9)
Other antibiotics	4 (8.9)
No	20 (30.8)

^* Consists of identified data only;

^† Days between symptom onset and patient presentation at our clinic;

^‡ Topical antibiotics identified prior to clinical presentation at our clinic;

^§ Number of eyes which has been identified for the use of topical antibiotics by patients at the time of presentation. (Sum of the number of eyes with each subgroup does not add up 100% because of overlap of subgroups).

Table 4.

Clinical characteristics at initial presentation, epithelial healing time, and visual outcome of contact lens related bacterial keratitis according to the isolated microorganisms

Characteristic		No. of cases (%)						p-value^‡
Characteristic		All cases (n = 73)		Pseudomonas spp. (n = 19)		Serratia spp. (n = 14)		p-value^‡
Corneal lesion	Location
	Central*	49 (67.1)		14 (73.7)		8 (57.1)
	Marginal^†	24 (32.9)		5 (26.3)		6 (42.9)		0.266
	Size
	<5 mm²	54 (74.0)		12 (63.2)		11 (78.6)
	≥5 mm²	19 (26.0)		7 (36.8)		3 (21.4)		0.455
	Hypopyon
	Yes	8 (11.0)		3 (15.8)		2 (14.3)
	No	65 (89.0)		16 (84.2)		12 (85.7)		1.000

Epithelial	1-5	22 (30.1)		3 (15.8)		5 (35.7)
healing time (day)	6-1011-15	39 (53.4) 9 (12.3)		9 (47.4) 5 (26.3)		7 (50.0) 1 (7.1)
	16-21	3 (4.1)		2 (10.5)		1 (7.1)


	Mean ± SD	7.7 ± 3.9		10.1 ± 5.0		7.4 ± 4.4		0.046^§
BCVA	Snellen acuity	Initial	Final	Initial	Final	Initial	Final

	HM	2 (2.7)	0 (0.0)	2 (10.5)	0 (0.0)	0 (0.0)	0 (0.0)
	<0.1	22 (30.1)	4 (5.5)	9 (47.4)	1 (5.3)	5 (35.7)	1 (7.1)
	0.1-0.2	11 (15.1)	5 (6.8)	2 (10.5)	3 (15.8)	2 (14.3)	0 (0.0)
	0.3-0.5	19 (26.0)	14 (19.2)	3 (15.8)	5 (26.3)	3 (21.4)	5 (35.7)
	0.6-1.0	19 (26.0)	50 (68.5)	3 (15.8)	10 (52.6)	4 (28.6)	8 (57.1)


	Mean ± SD	0.93 ± 0.88	0.25 ± 0.48	1.44 ± 1.03	0.39 ± 0.63	0.85 ± 0.79	0.26 ± 0.45	0.071^∏
	(log MAR)	p < 0.001		p < 0.001		p = 0.013		0.487^#

BCVA = best corrected visual acuity.

^* Corneal lesion is located within 1/2 radius from the center of the cornea;

^† Corneal lesion is located within 1/2 radius from the limbus;

^‡ Calculated the p-value between Pseudomonas spp. and Serratia spp. by Fisher's exact test;

^§ The p-value was calculated using Mann-Whitney U test to compare the means of two groups between Pseudomonas spp. and Serratia spp.;

^∏ The p-value of initial BCVA between Pseudomonas spp. and Serratia spp.

^# The p-value of final BCVA between Pseudomonas spp. and Serratia spp.

Table 5.

Clinical characteristics according to the previous use of topical antibiotics and culture positivity in contact lens related bac-terial keratitis

Characteristic	Previous use of topical antibiotics			Outcome of culture
Characteristic	Yes (n = 45)	No (n = 20)	p-value*	Culture positive (n = 39)	Culture negative (n = 34)	p-value*
No. of culture positive	23 (51.1%)	10 (50.0%)	0.934^†	-	-	-
Topical antibiotics previously used	-	-	-	23 (59.0%)	22 (64.7%)	0.615^†
Symptom to treatment interval (day)	5.4 ± 5.5	2.5 ± 3.3	0.012	4.1 ± 4.1	4.7 ± 5.7	0.594
Daily wear CL: extended wear CL	30:12	16:2	0.192^‡	13:5	17:3	0.438^‡
Corneal lesion within central 3 mm	32 (71.1%)	10 (50.0%)	0.100^†	24 (61.5%)	25 (73.5%)	0.277^†
Epithelial defect size (mm²)	5.3 ± 9.3	2.7 ± 2.8	0.094	5.5 ± 11.6	4.9 ± 7.3	0.777
Hypopyon	3 (6.7%)	2 (10.0%)	0.639^‡	5 (12.8%)	3 (8.8%)	0.716^‡
Epithelial healing time (day)	6.9 ± 3.8	8.4 ± 3.4	0.141	8.7 ± 4.2	6.5 ± 3.3	0.016
Duration of hospitalization (day)	6.2 ± 2.3	6.6 ± 2.3	0.573	8.3 ± 3.1	7.0 ± 2.1	0.038
Initial BCVA (log MAR)	0.79 ± 0.74	0.70 ± 0.85	0.667	1.03 ± 0.95	0.82 ± 0.80	0.299
Final BCVA (log MAR)	0.20 ± 0.33	0.12 ± 0.21	0.271	0.30 ± 0.52	0.19 ± 0.43	0.316

Values are presented as mean ± SD or n (%).

^* p-value was calculated using independent t-test;

^† p-value was calculated using chi-square test;

^‡ p-value was calculated using Fisher’s exact test.

Table 6.

Prognostic factors for poor visual outcome in contact lens related bacterial keratitis (univariate logistic regression analysis)

Factor		Incidence		Odds ratio	95% CI^†	p-value
Factor		No. of eyes	%*	Odds ratio	95% CI^†	p-value
Gender
	Female	58	15.5	1.00
	Male	15	20.0	1.36	0.32-5.81	0.677
Culture
	Negative	34	14.7	1.00
	Positive	39	17.9	1.94	0.53-7.11	0.320
Cultured organisms
	Serratia spp.	14	28.6	1.00
	Pseudomonas spp.	19	31.6	2.77	1.47-16.46	0.263
Sleeping with wearing contact lens
	No	43	14.0	1.00
	Yes	30	20.0	1.54	0.45-5.34	0.495
Daily contact lens wearing time
	<12 hours	38	13.2	1.00
	≥12 hours	35	20.0	1.66	0.47-5.78	0.434
Contact lens type
	Daily wear	30	6.7	1.00
	Extended wear	8	12.5	2.00	0.15-25.34	0.593
Previous use of topical antibiotics
	Yes	45	15.6	1.00
	No	20	5.0	0.29	0.03-2.49	0.257
Symptom to treatment interval
	<5 days	51	19.6	1.00
	≥5 days	22	9.1	0.41	0.08-2.05	0.278
Location of corneal lesion
	Marginal	24	4.2	1.00
	Central	49	22.4	6.66	0.81-55.00	0.078
Size of epithelial defect
	<5 mm²	54	11.1	1.00
	≥5 mm²	19	31.6	3.69	1.02-13.37	0.047
Hypopyon
	No	65	13.8	1.00
	Yes	8	37.5	3.73	0.76-18.40	0.106
Epithelial healing time
	<10 days	54	11.1	1.00
	≥10 days	19	31.6	3.69	1.02-13.37	0.047
Initial best corrected visual acuity
	≥0.1	49	2.0	1.00
	<0.1	24	45.8	40.62	4.78-344.13	0.001
Duration of contact lens usage
	<3 year	44	18.2	1.00
	≥3 year	29	13.8	0.72	0.20-2.65	0.622

^* Percentage of eyes which had poor visual outcome of final BCVA of 0.3 or less;

^† Confidence interval.

Table 7.

Prognostic factors for poor visual outcome in contact lens related bacterial keratitis (multivariate logistic regression analysis*)

Factor	Odds ratio	95% CI^†	p-value
Central corneal lesion	0.54	0.03-10.01	0.678
Size of epithelial defect ≥5 mm²	2.08	0.42-10.24	0.370
Epithelial healing time ≥10 days	2.08	0.42-10.24	0.370
Initial best corrected visual acuity less than 0.1	41.65	3.17-550.47	0.005

^* Multivariate logistic regression analysis was performed for the factors which had p-value less than 0.1 in univariate logistic regression analysis; † Confidence interval.

Table 8.

Comparison of microbial isolates of contact lens related bacterial keratitis with the results of other studies

	Green³	Preechawat¹⁴	Sharma¹²	Tchah⁷	This study
Study period	1999-2004	1998-2002	1991-2000	1995-1997	1998-2011
Nation	Austrailia	Thailand	South india	Korea	Korea
No. of bacterial isolates	37	59	25	218	48
Positive culture rate (%)	77.4	72.4	89.2	54.0	53.4
Ratio (%) of G(+) : G(-)^*	16:84	7:93	44:56	9:91	8:92
The most common isolates (%)	PAE (78.3)	PAE (62.7)	PAE (44.0)	PAE (60.1)	PAE (29.1)
The 2nd common isolates (%)	SPN (2.7)	KPN (11.9)	SEPI (16.0)	SMA (9.0)	SMA (27.1)
^* The ratio (%) of gram positive and gram negative bacteria in positive culture.

PAE = P. aeruginosa; SPN = S. pneumoniae; SEPI = S. epidermidis; KPN = K. pneumoniae; SMA = S. marcescens.

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