Post-cataract surgery cluster endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa: A retrospective cohort study of six clusters

Abstract

Purpose: To analyze clinical presentations, antibiotic susceptibility, and visual outcomes in six clusters of post cataract surgery endophthalmitis caused due to multidrug-resistant Pseudomonas aeruginosa (MDR-PA). This was a hospital-based retrospective cohort study.

Methods: Our study comprised sixty-two patients from six nonconsecutive clusters of post cataract surgery endophthalmitis caused by MDR-PA referred to our tertiary eye care institute. Demographic details, best-corrected visual acuity (BCVA), clinical features, microbiological findings, and patient management were reviewed.

Results: The interval between onset of symptoms and presentation ranged from 1 to 7 (mean: 4.61 and median: 5) days. The presenting BCVA was no light perception in 17 (27.4%) eyes, light perception in 35 (56.4%) eyes, and hand movement or better in 10 (16.1%) eyes. All patients had hypopyon and vitreous exudates. Corneal infiltrates were noted in 40 (64.5%) eyes. Panophthalmitis was diagnosed in 20 (32.2%) eyes. The surgical intervention included intraocular antibiotics (IOAB) in 8 (12.9%) eyes, pars plana vitrectomy with IOAB in 26 (41.9%) eyes, and evisceration in 23 (37.09%) eyes. At 6 weeks, BCVA of 20/200 or better was achieved in 9 (14.5%) eyes. Pseudomonas aeruginosa was least resistant to colistin (8.3%), piperacillin (31.8%), and imipenem (36.1%). Ceftriaxone and ceftazidime resistance was seen in 80.5% and 70% isolates, respectively.

Conclusion: Cluster endophthalmitis due to MDR-PA has poor visual outcomes with high rates of evisceration. In the setting of cluster endophthalmitis where MDR-PA is the most common etiology, piperacillin or imipenem can be the first drug of choice for empirical intravitreal injection for gram-negative coverage while awaiting the drug susceptibility report.

Keywords: Antibiotics resistance; cataract surgery; cluster endophthalmitis; endophthalmitis; multidrug-resistant pseudomonas aeruginosa; pseudomonas aeruginosa.

Figure 1

(a-d) Slit-lamp images of various patients from cluster 6 at presentation showing (a) total corneal infiltrates; (b) wound gaping, wound infiltrates, and uveal tissue prolapse with corneal infiltrates; (c) partially extruded optic and haptic of posterior chamber intraocular lens with total corneal melt and uveal tissue prolapse; (d) superior corneal infiltrates and half chamber hypopyon

Figure 2

(a and b) Anterior segment image of a patient of cluster 6 (a) at presentation showing corneal edema, Descemet's membrane folds, fibrinous reaction, and hypopyon in anterior chamber (b) at 3 months following pars plana vitrectomy and intraocular antibiotics showing clear cornea, quiet anterior chamber, and PCIOL in place

Figure 3

(a and b) (a) Blood agar plate showing confluent, moist, greyish colonies of Pseudomonas aeruginosa. (b) Nonnutrient agar plate with various antibiotic discs (Kirby-Bauer disk diffusion method) demonstrating antibiotic susceptibility of piperacillin (red arrow), ceftriaxone (blue arrow), and ceftazidime (green arrow)