Post-cataract endophthalmitis caused by multidrug-resistant Stenotrophomonas maltophilia: clinical features and risk factors

Abstract

Background: To report clinical features and risk factors of post-cataract surgery endophthalmitis (PE) due to Stenotrophomonas maltophilia.

Methods: A retrospective case review from December 10, 2010 to April 7, 2011 was performed at the Eye & ENT Hospital, Fudan University. Data were collected for surgical details, disease characteristics, antibiotic sensitivity of the pathogen, and treatment response. Visual outcomes were examined with a minimum follow-up of 12 months.

Results: Fourteen cases of S. maltophilia endophthalmitis were identified. The onset of infection occurred from 1-56 days postoperatively (median, 13.5 days). Obvious cellular reactions were found in all patients in the anterior chamber, along with the absence of pupil synechia. Retinal periphlebitis was an early sign of PE. S. maltophilia was positive in eight patients (57.1%). The fluids from aspiration tubes revealed the same bacteria, which were resistant to multiple drugs (e.g., amino glycosides, most of the β-lactams, aztreonam, imipenem, and ciprofloxacin), except levofloxacin. Compared with the culture-negative group, the infection was more rapid, more severe, and more difficult to control in the culture-positive group. Among 14 patients, 11 patients (78.6%) underwent pars plana vitrectomy (PPV) with intravitreal injection. Three patients had PPV twice, and three patients had intraocular lens and capsular bag removal. A final visual acuity of ≥20/100 was achieved by 13/14 patients (92.9%). Complications included retinal detachment in three cases (21.4%) and recurrence of infection in two cases (14.8%). Statistical analysis showed that age over 90 years and posterior capsule rupture were risk factors of infection (P=0.034 and P=0.034, respectively). The phacoemulsifier allowed potential contamination between the aspiration and irrigation tubes.

Conclusions: S. maltophilia should be considered a pathogenic organism of PE. The infection often occurs in older patients with posterior capsule rupture. Intravitreal or systemic administration of effective antibiotics and earlier initial PPV may contribute to better clinical outcomes. Tubes with connections between aspiration and irrigation should be avoided during surgery.

Figure 1

Slit lamp photograph of patient 1. Cells were found in the anterior chamber.

Figure 2

A thin fibrin membrane was deposited on the surface of the intraocular lens.

Figure 3

Retinal periphlebitis was observed during vitrectomy surgery.

Figure 4

The connection between the Aspiration tube and Irrigation tube. (a) Fluid containing dye was injected into the aspiration tube with a syringe. (b) The fluid containing dye can be seen traveling from the aspiration tube to the irrigation tube of the drainage cassette assembly, with an I/A set (BL5113) from a Stellaris 1.8-mm Stablechamber phaco pack with a MICS needle. The arrow shows the direction of the fluids.