Microbial keratitis in Sao Paulo, Brazil: a 10-year review of laboratory results, epidemiological features, and risk factors / Ceratite microbiana em São Paulo, Brasil: uma revisão de 10 anos dos resultados de laboratório, características epidemiológicas e fatores de risco

ABSTRACT Purpose: To study epidemiological data, laboratory results, and risk factors associated with microbial keratitis. Methods: We conducted a retrospective study of corneal sample cultures from patients with microbial keratitis from January 2010 to December 2019. Results were analyzed according to the etiological diagnosis of bacterial, mycotic, or parasitic infection and were associated with related risk factors. Results: We analyzed 4810 corneal samples from 4047 patients (mean age 47.79 ± 20.68 years; male 53.27%). The prevalence of bacterial, fungal, and Acanthamoeba infections were 69.80%, 7.31%, and 3.51%, respectively. The most frequently isolated bacteria were coagulase-negative Staphylococcus (CoNS) (45.14%), S. aureus (10.02%), Pseudomonas spp. (8.80%), and Corynebacterium spp. (6.21%). Among CoNS, the main agent was S. epidermidis (n=665). For mycotic keratitis, Fusarium spp. (35.42%) and Candida parapsilosis (16.07%) were the most common agents among filamentous and yeasts isolates, respectively. Contact lens use was associated with a positive culture for Acanthamoeba spp. (OR = 19.04; p < 0.001) and Pseudomonas spp. (OR = 3.20; p < 0.001). Previous ocular trauma was associated with positive fungal cultures (OR = 1.80; p = 0.007), while older age was associated with positive bacterial culture (OR = 1.76; p = 0.001). Conclusions: Our findings demonstrated a higher positivity of corneal sample cultures for bacteria. Among those, CoNS was the most frequently identified, with S. epidermidis as the main agent. In fungal keratitis, Fusarium spp. was the most commonly isolated. Contact lens wearers had higher risks of positive cultures for Acanthamoeba spp. and Pseudomonas spp. Ocular trauma increased the risk of fungal infection, while older age increased the risk of bacterial infection.

RESUMO Objetivo: Estudar os dados epidemiológicos, resultados laboratoriais e fatores de risco associados às ceratites infecciosas. Métodos: Estudo retrospectivo das amostras de cultura de córnea em pacientes com ceratites infecciosas entre Janeiro/2010 a Dezembro/2019. Os resultados foram analisados de acordo com o diagnóstico etiológico de infecção bacteriana, fúngica ou parasitária e correlacionado com os fatores de risco relacionados. Resultados: Quatro mil, oitocentas e dez amostras corneanas de 4047 pacientes (média de idade de 47,79 ± 20,68 anos; homens em sua maioria (53,7%) foram incluídas. A prevalência de infecções por bactéria, fungo e Acanthamoeba foram de 69.80%, 7,31%, and 3,51%, respectivamente. A maioria das bactérias mais frequentemente isoladas foram Staphylococcus coagulase-negativo (CoNS) (45,14%), S. aureus (10,02%), Pseudomonas spp. (8,80%), e Corynebacterium spp. (6,21%). Dentre CoNS, o principal agente foi S. epidermidis (n = 665). Nas ceratites fúngicas, Fusarium spp. (35,42%) e Candida parapsilosis (16,07%) foram os agentes mais comuns entre os filamentosos e leveduriformes, respectivamente. O uso de lentes de contato foi associado à cultura positiva para Acanthamoeba spp. (OR = 19,04; p < 0,001) e Pseudomonas spp (OR = 3,20; p < 0,001). Trauma ocular prévio foi associado a culturas positivas para fungo (OR = 1,80; p = 0,007), e idade avançada foi associada a culturas positivas para bactéria (OR = 1,76; p = 0,001). Conclusões: Nossos achados demonstraram uma maior positividade para bactérias em amostras de cultura corneana. Dentre estas, CoNS foi mais frequentemente identificado, sendo S. epidermidis o principal agente. Nas ceratites fúngicas, Fusarium spp. Foi o mais comumente isolado. O risco de positividade para Acanthamoeba spp. e Pseudomonas spp. foi maior em usuários de lentes de contato. Trauma ocular aumentou o risco de cultura positiva para fungo, ao passo que idade mais avançada aumentou o risco de infecção bacteriana.

Shewanella algae keratitis

A 75-year-old male with a right eye history of chronic dry eye syndrome, glaucoma status post tube shunt, and Fuchs dystrophy status post Descemet stripping endothelial keratoplasty followed by penetrating keratoplasty (PKP) presented with a 2.7 × 4.2 mm corneal ulcer, culture positive for Shewanella algae and Klebsiella oxytoca. A topical antibiotic regimen of gentamicin 14 mg/mL and vancomycin 50 mg/mL was administered according to culture sensitivities. There was concurrent use of loteprednol 0.5% (Lotemax Gel, Bausch and Lomb, Rochester, NY, USA) and later addition of erythromycin 0.5% ointment. The corneal ulcer improved with antibiotic therapy but was complicated by poor patient follow-up. Descemetocele formation prompted PKP in the right eye. The graft was successful and visual acuity improved from a low of light perception to maximum of 20/200 Snellen.

Non-viral microbial keratitis in adults: clinical and laboratory aspects

Abstract This study compares patients with and without non-viral microbial keratitis in relation to sociodemographic variables, clinical aspects, and involved causative agent. Clinical aspects, etiology and therapeutic procedures were assessed in patients with and without keratitis that were diagnosed in an Eye Care Center in Campo Grande, MS, Brazil. Patients were divided into two groups: (a) cases: 64 patients with non-viral microbial keratitis diagnosed at biomicroscopy; and (b) controls: 47 patients with other eye disorders that were not keratitis. Labor activity related to agriculture, cattle raising, and contact lens use were all linked to keratitis occurrence (p < 0.005). In patients with keratitis, the most common symptoms were pain and photophobia, and the most frequently used medicines were fourth-generation fluoroquinolones (34.4%), amphotericin B (31.3%), and natamycin (28.1%). Microbial keratitis evolved to corneal perforation in 15.6% of cases; transplant was indicated in 10.9% of cases. Regarding the etiology of this condition, 23 (42.2%) keratitis cases were caused by bacteria (Pseudomonas aeruginosa, 12.5%), 17 (39.1%) by fungi (Fusarium spp., 14.1% and Aspergillus spp., 4.7%), and 4 (6.3%) by Acanthamoeba. Patients with keratitis present with a poorer prognosis. Rapid identification of the etiologic agent is indispensable and depends on appropriate ophthalmological collection and microbiological techniques.

Non-viral microbial keratitis in adults: clinical and laboratory aspects

Abstract This study compares patients with and without non-viral microbial keratitis in relation to sociodemographic variables, clinical aspects, and involved causative agent. Clinical aspects, etiology and therapeutic procedures were assessed in patients with and without keratitis that were diagnosed in an Eye Care Center in Campo Grande, MS, Brazil. Patients were divided into two groups: (a) cases: 64 patients with non-viral microbial keratitis diagnosed at biomicroscopy; and (b) controls: 47 patients with other eye disorders that were not keratitis. Labor activity related to agriculture, cattle raising, and contact lens use were all linked to keratitis occurrence (p 0.005). In patients with keratitis, the most common symptoms were pain and photophobia, and the most frequently used medicines were fourth-generation fluoroquinolones (34.4%), amphotericin B (31.3%), and natamycin (28.1%). Microbial keratitis evolved to corneal perforation in 15.6% of cases; transplant was indicated in 10.9% of cases. Regarding the etiology of this condition, 23 (42.2%) keratitis cases were caused by bacteria (Pseudomonas aeruginosa, 12.5%), 17 (39.1%) by fungi (Fusarium spp., 14.1% and Aspergillus spp., 4.7%), and 4 (6.3%) by Acanthamoeba. Patients with keratitis present with a poorer prognosis. Rapid identification of the etiologic agent is indispensable and depends on appropriate ophthalmological collection and microbiological techniques.

Epidemiological profile of infectious keratitis / Perfil epidemiológico da ceratite infecciosa

Abstract Objective: To evaluate the epidemiologic aspects of cornea ulcers in a referred ophthalmology private practice center. Methods: Retrospective study over electronic files of patients treated for corneal ulcers during a period of 7 years by the same physician (RJMF) at Centro de Olhos São Francisco, between june 2007 and june 2014. These patients were evaluated for risk factors such as: trauma causes, co-morbidities and contact lenses use. They were also evaluated by the microorganism found at the smears, treatment and patient's outcome. Patients that didn't return with the smears results or that didn´t have a complete follow-up were excluded from the study. Results: A total of 242 patients were fully treated during this period. 55 patients were excluded and 187 patients were included. 28.88% (54/187) were positive for gram negative bacteria, 27.81% (52/187) for filamentous fungi, 16.04% (29/187) for gram positive bacteria and only 1.07% for acanthamoeba. Twenty-four patients had negative cultures and 21 patients had combined infections (bacteria + fungi or other combination). Corneal collagen Cross-linking was effective on melting arrest in 16 of the 16 patients that we have submitted to this procedure during 2008 and 2009. Among all the patients that had corneal infection and were previously using contact lenses, 81% were infected by pseudomonas or pseudomonas associated with other gram negative bacteria. Filamentous fungi had a strong association with physical trauma. While use of saline solution for contact lenses cleaning had a strong association with gram negative bacteria and biological trauma, a strong association with combined infection. Conclusion: Gram negative bacteria (Pseudomonas) followed by filamentous fungi (Fusarium sp) were the most frequent etiologic agent found in our study. Cross-link was effective on corneal melting arrest. Pseudomonas aeruginosa was the most frequent isolated agent on hydrophilic contact lenses wearers.

Resumo Objetivo: Avaliar os aspectos epidemiológicos de úlceras de córnea em um centro privado de referência oftalmológica. Métodos: Estudo retrospectivo a partir de arquivos eletrônicos de pacientes tratados por úlceras de córnea durante um período de 7 anos pelo mesmo médico (RJMF) no Centro de Olhos São Francisco, entre Junho de 2007 e Junho de 2014. Estes pacientes foram avaliados quanto a fatores de risco, trauma, co-morbidades, uso de lentes de contato, tipo de microrganismo encontrado, tratamento e evolução do doente. Os pacientes que não retornaram com os resultados das culturas ou que não possuíam um seguimento completo foram excluídos do estudo. Resultados: Um total de 242 pacientes foram tratados durante este período. 55 pacientes foram excluídos e 187 foram incluídos no estudo. 28,88% (54/187) foram positivos para as bactérias gram-negativas, 27,81% (52/187) para fungos filamentosos, 16,04% (29/187) para as bactérias gram-positivas e apenas 1,07% para acanthamoeba. Vinte e quatro pacientes tiveram culturas negativas e 21 pacientes tinham infecções combinadas (bactérias fungos + ou outra combinação). O Cross-link foi eficaz em interromper o melting em 16 dos 16 pacientes que se submeteram a este procedimento durante 2008 e 2009. Entre todos os pacientes que tiveram infecção de córnea e usavam previamente lentes de contato, 81% foram infectados por pseudomonas isolada ou pseudomonas associada ou não a outras bactérias gram-negativas. Os fungos filamentosos tiveram uma forte associação com trauma físico, uso de solução salina para a limpeza de lentes de contato teve uma forte associação com bactérias gram- negativas e trauma biológico, uma forte associação com a infecção combinada. Conclusão: Bactérias Gram negativas (em especial, Pseudomonas) seguido por fungos filamentosos (Fusarium sp) foram os agentes etiológicos mais freqüentemente encontrados em nosso estudo. O Cross-linking foi eficaz em interromper o melting de córnea. Pseudomonas aeruginosa foi o agente isolado mais frequente em usuários de lente de contato hidrofílica.

Cryotherapy on Refractory Fungal Corneal Ulcer: A Case Report

PURPOSE: We report a case of cryotherapy for fungal corneal ulcers that did not respond to antifungal agents. CASE SUMMARY: A 58-year-old man was transferred to our hospital with a left eye corneal ulcer due to pain and visual impairment in his left eye for two weeks, and he was suspected to have a history of fungal infection. At the time of admission, corneal opacity and progressive ulcerative lesions were observed at 5 o'clock in the left eye and visual acuity was 0.025, uncorrected. The corneal ulcer marginal resection, bacterial culture, and potassium hydroxide preparation (KOH) test were performed on lesion sites. Cultures of Candida albicans were reported to grow, topical antibiotics (Fortified tobramycin, Fortified cefazolin, moxifloxacin), and anti-fungal agents (fortified amphotericin B, 0.5%, Natamycin) were administered, but no improvement was observed for 2 weeks. On the 14th day after admission, Cryotherapy was performed. After surgery, eye drops were equally applied, and there was no other discomfort other than pain for 3 days after the operation. He discharged 10 days after surgery, the corneal lesion was healed and the visual acuity was improved to 0.32, uncorrected. CONCLUSIONS: We report a case of cryotherapy for fungal corneal ulcers that did not react with topical antifungal drugs and improved visual acuity and symptom improvement.