The clinical differentiation of bacterial and fungal keratitis: a photographic survey

Abstract

Purpose: The purpose of this study was to determine whether clinical signs of infectious keratitis can be used to identify the causative organism.

Methods: Eighty photographs of eyes with culture-proven bacterial keratitis or smear-proven fungal keratitis were randomly selected from 2 clinical trials. Fifteen cornea specialists from the F. I. Proctor Foundation and the Aravind Eye Care System assessed the photographs for prespecified clinical signs of keratitis, and they identified the most likely causative organism.

Results: Clinicians were able to correctly distinguish bacterial from fungal etiology 66% of the time (P < 0.001). The Gram stain, genus, and species were accurately predicted 46%, 25%, and 10% of the time, respectively. The presence of an irregular/feathery border was associated with fungal keratitis, whereas a wreath infiltrate or an epithelial plaque was associated with bacterial keratitis.

Conclusions: Cornea specialists correctly differentiated bacterial from fungal keratitis more often than chance, but in fewer than 70% of cases. More specific categorization led to less successful clinical distinction. Although certain clinical signs of infectious keratitis may be associated with a bacterial or fungal etiology, this study highlights the importance of obtaining appropriate microbiological testing during the initial clinical encounter.

Trial registration: ClinicalTrials.gov NCT00324168.

Figure 1.

These photographs are representative of the survey given to clinicians as they were asked to differentiate fungal versus bacterial etiologies. The causative organism and the proportion of clinicians who correctly identified the organism as fungal versus bacterial was (A) Streptococcus pneumoniae, 60% correctly identified as bacterial; (B) Pseudomonas aeruginosa, 93% correctly identified as bacterial; (C) Aspergillus flavus, 93% correctly identified as fungal; and (D) Fusarium spp, 67% correctly identified as fungal.

Figure 2.

The aggregate results when looking at all clinicians and applicable photographs. * Based on all photographs, n = 79 photos. † Gram stain was examined for bacterial ulcers only, n = 40 photos. ‡ Based on photographs of both fungal and bacterial ulcers with available microbiologic data. For genus, n = 70 photos. For species, n = 44 photos.