PDF
ePub
Citation
Print
Abstract
Purpose
The purpose of this study was to evaluate the clinical aspects of inpatients with bacterial keratitis according to culture positivity.
Methods
This was a retrospective review of 98 cases of inpatients with bacterial keratitis who were treated between January 2011 and December 2016 in Yeungnam University Hospital. Epidemiology, predisposing factors, clinical characteristics, and treatment outcomes were compared between culture positive (CP, 39 eyes) and culture negative (CN, 59 eyes) groups. Risk factors for poor clinical outcome were evaluated in the total cohort and analyzed using multivariate logistic regression.
Results
Pseudomonas spp. (31%) and Staphylococcus spp. (24%) were common in the CP group. There were no significant differences in previous ocular surface disease, contact lens wear, or hypopyon between the two groups. Epithelial defect size ≥5 mm2 (51%:31%, p = 0.04) and initial visual acuity <0.1 (Snellen) (51%:31%, p = 0.04) were significantly higher in the CP group than in the CN group. Epithelial healing time ≥14 days (18%:5%, p = 0.08) and poor clinical outcome (28%:20%, p = 0.37) were more common in the CP group than in the CN group. Risk factors for poor clinical outcome were previous ocular surface disease (odds ratio [OR] = 11.29, 95% confidence interval [CI] = 2.01–63.41, p = 0.006) and previous ocular surgery (OR = 6.98, 95% CI = 1.51–32.20, p = 0.01).
Conclusions
The CP group showed relatively worse initial clinical characteristics than the CN group. Treatment outcomes were slightly worse in the CP group than in the CN group; however, this difference was not statistically significant. Previous ocular surface disease and previous ocular surgery were associated with poor clinical outcome.
Figures and Tables
Figure 1
Visual acuity comparison of culture positive (CP) and culture negative (CN) group at enrollment and final visit. On the box-whisker plots, the boxes include 50% of the measured values (between the 25th and 75th percentiles) and the median (horizontal line). The error bars indicate 1.5 times the interquartile distance from the upper and lower box edges. The outliers (values more than 1.5 interquartile ranges from the box) are shown as circles and the extreme values (values more than 3.0 interquartile ranges from the box) are shown as triangles. p-values were obtained by paired t-test (between enrollment and final visit) and independent t-test (between CP and CN). Hand motions, light perception (LP), and no LP were assigned values of 2.3, 2.6, and 2.9, respectively.
Table 1
Isolated microbiological profile (49 bacterial isolates) of culture positive 39 eyes
10 eyes were mixed infection: P. aeruginosa, S. epidermidis (1 case); P. putida, S. aureus (1 case); P. putida, E. faecium (1 case); S. aureus, E. faecalis (1 case); S. marcescens, A. xylosoxidans (1 case); S. maltophilia, E. cloacae (1 case); A. baumannii, E. cloacae (1 case); Moraxella group, P. stutzeri (1 case); A. xylosoxidans, P. putida (1 case); S. marcescens, E. faecium (1 case).
Table 3
Predisposing factors of bacterial keratitis according to culture positivity
Values are presented as number (%).
CP = culture positive; CN = culture negative; DM = diabetes mellitus.
*Total numbers can be greater than 100% because of some patients with multiple predisposing factors; †the p-value was calculated using chi-square test; ‡Bullous keratopathy (CP 1 case and CN 2 cases), band keratopathy (CP 1 case), phlyctenular keratoconjunctivitis (CN 1 case), recurrent corneal erosion (CP 1 case), and peripheral ulcerative keratitis (CP 1 case); §including cataract surgery (CP 3 cases and CN 1 case), pars plana vitrectomy (CP 1 case and CN 2 cases), laser epithelial keratomileusis (CP 1 case and CN 1 case), Ahmed valve implantation (CP 1 case), trabeculectomy (CP 1 case), and excision of pterygium (CP 1 case).
Table 4
Clinical characteristics and treatment outcomes of bacterial keratitis according to culture positivity
Values are presented as mean ± standard deviation or number (%).
CP = culture positive; CN = culture negative; PED = persistent epithelial defect; BCVA = best corrected visual acuity; logMAR = logarithm of the minimal angle resolution.
*The p-value was calculated using chi-square test; †central lesion is located within 1/2 radius from the center of the cornea; ‡independent t-test; §hand motions, light perception (LP), and no LP were assigned values of 2.3, 2.6, and 2.9, respectively; ∥all patients underwent amniotic membrane transplantation; #clinical outcomes were assessed at final visit or at the completion of treatment and classified by modifying the criteria defined by Green et al.18
Table 5
Risk factors for poor clinical outcome* in the total cohort of patients with bacterial keratitis (univariate and multivariate logistic regression analysis†)
OR = odds ratio; CI = confidence interval; DM = diabetes mellitus; OSD = ocular surface disease; BCVA = best corrected visual acuity.
*Clinical outcomes were assessed at final visit or at the completion of treatment and classified by modifying the criteria defined by Green et al18; †multivariate logistic regression analysis was performed using the enter method for the factors with the p-value < 0.1 in univariate logistic regression analysis.
References
1. Erie JC, Nevitt MP, Hodge DO, Ballard DJ. Incidence of ulcerative keratitis in a defined population from 1950 through 1988. Arch Ophthalmol. 1993; 111:1665–1671.
2. Liu HY, Chu HS, Wang IJ, et al. Microbial keratitis in Taiwan: a 20-year update. Am J Ophthalmol. 2019; 205:74–81.
3. Bograd A, Seiler T, Droz S, et al. Bacterial and fungal keratitis: a retrospective analysis at a university hospital in Switzerland. Klin Monbl Augenheilkd. 2019; 236:358–365.
4. Asbell P, Stenson S. Ulcerative keratitis. Survey of 30 years' laboratory experience. Arch Ophthalmol. 1982; 100:77–80.
5. Lichtinger A, Yeung SN, Kim P, et al. Shifting trends in bacterial keratitis in Toronto: an 11-year review. Ophthalmology. 2012; 119:1785–1790.
6. Orlans HO, Hornby SJ, Bowler IC. In vitro antibiotic susceptibility patterns of bacterial keratitis isolates in Oxford, UK: a 10-year review. Eye (Lond). 2011; 25:489–493.
7. Wilhelmus KR. Review of clinical experience with microbial keratitis associated with contact lenses. CLAO J. 1987; 13:211–214.
8. Blanton CL, Rapuano CJ, Cohen EJ, Laibson PR. Initial treatment of microbial keratitis. CLAO J. 1996; 22:136–140.
9. Jones DB. Decision-making in the management of microbial keratitis. Ophthalmology. 1981; 88:814–820.
10. Morlet N, Minassian D, Butcher J. Risk factors for treatment outcome of suspected microbial keratitis. Ofloxacin study group. Br J Ophthalmol. 1999; 83:1027–1031.
11. Park JH, Lee SB. Analysis on inpatients with infectious keratitis: causative organisms, clinical aspects and risk factors. J Korean Ophthalmol Soc. 2009; 50:1152–1166.
12. Sun HJ, Lee JY, Kim SY, Jung MS. Clinical features of infectious keratitis in west coast area of Chungcheongnam-do, Korea. J Korean Ophthalmol Soc. 2010; 51:658–663.
13. Levey SB, Katz HR, Abrams DA, et al. The role of cultures in the management of ulcerative keratitis. Cornea. 1997; 16:383–386.
14. Schaefer F, Bruttin O, Zografos L, Guex-Crosier Y. Bacterial keratitis: a prospective clinical and microbiological study. Br J Ophthalmol. 2001; 85:842–847.
15. Yoon JH, Jung JW, Moon HS, et al. Antibiotics susceptibility in bacterial keratitis and proper initial treatment. J Korean Ophthalmol Soc. 2013; 54:38–45.
16. Kosrirukvongs P, Buranapongs W. Topical ciprofloxacin for bacterial corneal ulcer. J Med Assoc Thai. 2000; 83:776–782.
17. Basak SK, Basak S, Mohanta A, Bhowmick A. Epidemiological and microbiological diagnosis of suppurative keratitis in Gangetic West Bengal, eastern India. Indian J Ophthalmol. 2005; 53:17–22.
18. Green MD, Apel AJ, Naduvilath T, Stapleton FJ. Clinical outcomes of keratitis. Clin Exp Ophthalmol. 2007; 35:421–426.
19. Bhadange Y, Das S, Kasav MK, et al. Comparison of culture-negative and culture-positive microbial keratitis: cause of culture negativity, clinical features and final outcome. Br J Ophthalmol. 2015; 99:1498–1502.
20. Mukerji N, Vajpayee RB, Sharma N. Technique of area measurement of epithelial defects. Cornea. 2003; 22:549–551.
21. Botelho PJ, Johnson LN, Arnold AC. The effect of aspirin on the visual outcome of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol. 1996; 121:450–451.
22. Wilhelmus KR, Schlech BA. Clinical and epidemiological advantages of culturing bacterial keratitis. Cornea. 2004; 23:38–42.
23. Bourcier T, Thomas F, Borderie V, et al. Bacterial keratitis: predisposing factors, clinical and microbiological review of 300 cases. Br J Ophthalmol. 2003; 87:834–838.
24. Hsiao CH, Sun CC, Yeh LK, et al. Shifting trends in bacterial keratitis in Taiwan: a 10-year review in a tertiary-care hospital. Cornea. 2016; 35:313–317.
25. Mark JM, Edward JH. Cornea, fundamentals, diagnosis and management. 4th ed. vol. 1. Amsterdam: Elsevier;2017. chap. 10.
26. Panhalkar S, Thomas A, Alexander TA, Koshi G. Bacterial and mycotic agents of corneal ulcers in Vellore. Indian J Ophthalmol. 1985; 33:289–293.
27. Rahimi F, Hashemian MN, Khosravi A, et al. Bacterial keratitis in a tertiary eye centre in Iran: a retrospective study. Middle East Afr J Ophthalmol. 2015; 22:238–244.
28. van der Meulen IJ, van Rooij J, Nieuwendaal CP, et al. Age-related risk factors, culture outcomes, and prognosis in patients admitted with infectious keratitis to two Dutch tertiary referral centers. Cornea. 2008; 27:539–544.
29. Groden LR, Rodnite J, Brinser JH, Genvert GI. Acridine orange and Gram stains in infectious keratitis. Cornea. 1990; 9:122–124.
30. Samuel LP, Balada-Llasat JM, Harrington A, Cavagnolo R. Multicenter assessment of Gram stain error rates. J Clin Microbiol. 2016; 54:1442–1447.
31. Sharma S, Taneja M, Gupta R, et al. Comparison of clinical and microbiological profiles in smear-positive and smear-negative cases of suspected microbial keratitis. Indian J Ophthalmol. 2007; 55:21–25.
32. McDonald TO, Borgmann AR, Roberts MD, Fox LG. Corneal wound healing. I. Inhibition of stromal healing by three dexamethasone derivatives. Invest Ophthalmol. 1970; 9:703–709.
33. Katz NN, Wadud SA, Ayazuddin M. Corneal ulcer disease in Bangladesh. Ann Ophthalmol. 1983; 15:834–836.
34. Hahn YH, Hahn TW, Choi SH, et al. Epidemiology of infectious keratitis(I) : a multi-center study. J Korean Ophthalmol Soc. 1998; 39:1633–1651.
35. Mun Y, Kim MK, Oh JY. Ten-year analysis of microbiological profile and antibiotic sensitivity for bacterial keratitis in Korea. PLoS One. 2019; 14:e0213103.
36. Kim MR, Lee SB. Clinical and microbiological analysis of Gram-positive bacterial keratitis, a 15-year review. J Korean Ophthalmol Soc. 2014; 55:1432–1444.
37. Cho EY, Lee SB. Gram-negative bacterial keratitis: a 15-year review of clinical aspects. J Korean Ophthalmol Soc. 2015; 56:1479–1488.
38. Shalchi Z, Gurbaxani A, Baker M, Nash J. Antibiotic resistance in microbial keratitis: ten-year experience of corneal scrapes in the United Kingdom. Ophthalmology. 2011; 118:2161–2165.
39. Green M, Carnt N, Apel A, Stapleton F. Queensland microbial keratitis database: 2005-2015. Br J Ophthalmol. 2019; 103:1481–1486.
40. Kim WJ, Kweon EY, Lee DW, et al. Prognostic factor and antibiotic susceptibility in bacterial keratitis: results of an eight-year period. J Korean Ophthalmol Soc. 2009; 50:1495–1504.
41. Cho CH, Lee SB. Analysis of inpatients with contact lens related bacterial keratitis: causative microorganisms, clinical aspects, and prognostic factors. J Korean Ophthalmol Soc. 2013; 54:1327–1338.
42. Kim SJ, Lee SB. Analysis on elderly inpatients with infectious keratitis: causative organisms, clinical aspects, and risk factors. J Korean Ophthalmol Soc. 2010; 51:1554–1567.
43. Green M, Apel A, Stapleton F. Risk factors and causative organisms in microbial keratitis. Cornea. 2008; 27:22–27.
44. Miedziak AI, Miller MR, Rapuano CJ, et al. Risk factors in microbial keratitis leading to penetrating keratoplasty. Ophthalmology. 1999; 106:1166–1170.
45. Musch DC, Sugar A, Meyer RF. Demographic and predisposing factors in corneal ulceration. Arch Ophthalmol. 1983; 101:1545–1548.
46. Forster RK. Conrad Berens Lecture. The management of infectious keratitis as we approach the 21st century. CLAO J. 1998; 24:175–180.
47. Phua J, Ngerng W, See K, et al. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Crit Care. 2013; 17:R202.
XML Download