Curvularia infection of corneoscleral tunnel

Corneoscleral tunnel infection is a potentially sight threatening complication of cataract surgery. Microbiological investigations are mandatory and early surgical intervention helps in achieving favourable outcomes. Fungal infection of tunnel incisions can pose a diagnostic and therapeutic challenge. We report a case of post-operative tunnel infection with curvularia. Prompt surgical intervention and intensive topical therapy helped attain a good tectonic as well as visual recovery.

An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis

Atypical mycobacteria remain a rare cause of peritoneal dialysis catheter-related tunnel infection (TI) and poses serious risk because of the resistant nature to most antibiotic therapy. Non-tubercular mycobacterial infections lead to chronicity requiring peritoneal dialysis catheter removal. We report an 82-year-old male, with diabetic nephropathy who had a coinfection with Staphylococcus hominis and Mycobacterium abscessus who presented with pus discharge at exit site and TI. He was treated with relocation of the extraperitoneal part of the catheter with a new exit site without catheter removal and multidrug mycobacterial therapy.

Voriconazole-refractory fungal infection of phacoemulsification tunnel.

A 44-year-old man presented 28 days after cataract surgery (phacoemulsification) in right eye with multiple pinpoint infiltrates in posterior stroma at cataract surgery wound site. Visual acuity was 20/60. Corneal scraping from the floor of the corneal tunnel revealed fungus which was later identified to be Aspergillus flavus. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour. Two intracameral injections of voriconazole (50 micrograms/ 0.1 ml) were given 72 h apart, five days after starting initial therapy. Infiltrates increased in size and density in spite of 20 days of voriconazole therapy. Full-thickness patch graft was done to arrest progressive necrosis. Four months after surgery, patient had 20/60 best-corrected visual acuity. There was no recurrence in one-year follow-up. Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

A 15 year-review of peritoneal dialysis-related peritonitis: Microbiological trends and patterns of infection in a teaching hospital in Argentina / Peritonitis en diálisis peritoneal: características microbiológicas y patrones de infección a lo largo de 15 años en un hospital universitario en Argentina

This study reports the infectious peritonitis rates in 44 patients on peritoneal dialysis in three different systems over the last 15 years, covering clinical outcomes, exit-site infections, tunnel infections, causative microorganisms, and the history of susceptibility of organisms causing peritonitis, in order to establish our center-specific selection of empiric therapy. Two microbiological procedures were herein used: method A, where 100 ml of dialysate were centrifuged and cultured in standard media and into blood-culture bottles; and method B, where 10 ml were directly injected into blood-culture bottles. Swabs from the exit-site or tunnel were taken when purulent drainage was observed. There were 96 episodes of peritonitis during 110.43 patient-years (0.87 episodes/patient-year). Sensitivity of method A was 96.88% (93/96 episodes) versus 81.25% (78/96) of method B (p= 0.001). Gram stain sensitivity was 36.46%. The etiologic agents were 64 (56.64%) gram-positive cocci, 22 (19.47%) gram-negative fermentative rods, 20 (17.7%) gram-negative non fermentative rods, 5 (4.43%) yeasts, 1 (0.88%) micelial fungus, and 1 (0.88%) anaerobic rod. Fifty-five exit-site infections were documented (0.5 episodes/patient-year). Ceftazidime and imipenem showed excellent activity on gram-negative rods. There were 92.3% of methicillin-susceptible Staphylococcus aureus but only 33.3% of methicillin-susceptible coagulase- negative staphylococci; vancomycin was active against 100% of the gram-positive cocci. The clinical outcomes of peritonitis were 73 initial cure, 19 catheter removal and four related deaths. The empiric therapy in our center should be vancomycin plus ceftazidime or imipenem. Once the etiological agent and its susceptibility pattern are known, the deescalating therapy must be applied to avoid the emergence and spread of vancomycin-resistant microorganisms.

Se comunican las tasas de peritonitis infecciosa de 44 pacientes en tres sistemas diferentes de diálisis peritoneal durante los últimos 15 años. Se evaluaron evolución clínica, infecciones del sitio de salida y del túnel, y los microorganismos causales y su sensibilidad, a fin de seleccionar la mejor terapia empírica para nuestro centro. Se realizaron dos procedimientos microbiológicos, método A: 100 ml del dializado fueron centrifugados y cultivados por métodos convencionales y en frascos para hemocultivo; método B: 10 ml fueron directamente inoculados en frascos para hemocultivo. Los hisopados del sitio de salida y del túnel fueron realizados cuando se observó supuración. Se registraron 96 episodios de peritonitis en 110,43 paciente-años (0,87 episodios/paciente-año). La sensibilidad del método A fue 96,88% versus 81,25% del método B (p = 0,001). La sensibilidad de la coloración de Gram fue 36,46%. La distribución de los agentes etiológicos fue la siguiente: 64 (56,64%) cocos gram-positivos, 22 (19,47%) bacilos gram-negativos fermentadores, 20 (17,7%) bacilos gram-negativos no fermentadores, 5 (4,43%) levaduras, 1 (0,88%) hongo micelial, 1 (0,88%) bacilo anaerobio. Fueron documentadas 55 infecciones del sitio de salida (0,5 episodios/paciente-año). La ceftazidima y el imipenem mostraron una excelente actividad sobre los bacilos gram-negativos. La sensibilidad a meticilina fue de 92,3% para Staphylococcus aureus y 33,3% para estafilococos coagulasa negativos; la vancomicina fue activa frente al 100% de los cocos gram-positivos. La evolución clínica de las peritonitis fue: 73 curas, 19 remociones de catéter y cuatro muertes relacionadas. La terapia empírica en nuestro centro debería ser vancomicina más ceftazidima o imipenem. Una vez conocidos el agente etiológico y su sensibilidad, se debería aplicar la terapia de desescalonamiento para evitar la emergencia y diseminación de microorganismos resistentes a la vancomicina.

Catheter Ultrasonography as a Tool in the Diagnosis of Tunnel Infection in CAPD Patients / 대한신장학회잡지

In CAPD patients, exit site infection and peritonitis are occasionally not improved due to undetected tunnel infection. The diagnosis of tunnel infection is mainly based on the clinical symptoms and signs which seem insensitive for early diagnosis and timely intervention. We examined usefulness of catheter ultrasonography(USG) as a tool in the diagnosis of tunnel infection in various kinds of infectious complications in CAPD patients. Positive result was defined by the presence of hypoechoic area more than 2mm in diameter along the subcutaneous catheter tunnel. 26 USG were performed in 23 patients who represented normal in 4 cases, exit site infections in 6 cases, tunnel infections in 2 cases, peritonitis in 10 cases and 4 cases of combined infections. The mean age was 53.6 years and mean duration of CAPD and break-in period were 16.7 months and 24.7 days respectively. Positive USG findings were noted in 13 cases(50%). High rate of positive finding was observed in clinically suspected exit site infection (80.3%), tunnel infection(100%) and combined infections (75%). Positive results were most commonly observed near the external cuff area. The most common causative organism was S. aureus followed by Pseudomonas and CNS infections. S. aureus infection most likely resulted in positive sonographic findings and catheter loss despite of antibiotic treatment. We conclude that USG is a sensitive tool for the diagnosis of tunnel infections and tunnel infection caused by S. aureus is at high risk of catheter loss.

Catheter Ultrasonography as a Tool in the Diagnosis of Tunnel Infection in CAPD Patients / 대한신장학회잡지

In CAPD patients, exit site infection and peritonitis are occasionally not improved due to undetected tunnel infection. The diagnosis of tunnel infection is mainly based on the clinical symptoms and signs which seem insensitive for early diagnosis and timely intervention. We examined usefulness of catheter ultrasonography(USG) as a tool in the diagnosis of tunnel infection in various kinds of infectious complications in CAPD patients. Positive result was defined by the presence of hypoechoic area more than 2mm in diameter along the subcutaneous catheter tunnel. 26 USG were performed in 23 patients who represented normal in 4 cases, exit site infections in 6 cases, tunnel infections in 2 cases, peritonitis in 10 cases and 4 cases of combined infections. The mean age was 53.6 years and mean duration of CAPD and break-in period were 16.7 months and 24.7 days respectively. Positive USG findings were noted in 13 cases(50%). High rate of positive finding was observed in clinically suspected exit site infection (80.3%), tunnel infection(100%) and combined infections (75%). Positive results were most commonly observed near the external cuff area. The most common causative organism was S. aureus followed by Pseudomonas and CNS infections. S. aureus infection most likely resulted in positive sonographic findings and catheter loss despite of antibiotic treatment. We conclude that USG is a sensitive tool for the diagnosis of tunnel infections and tunnel infection caused by S. aureus is at high risk of catheter loss.