In a recently published study, Kaye et al. (2) compared two approaches to evaluating bacterial keratitis: the conventional method, in which samples are obtained by taking several corneal scrapes and placing them on different media and slides (direct method, as described by Kaye et al.), and a proposed method (indirect), in which only one scrape is placed into a tube containing brain heart broth for ulterior processing at the laboratory. Their experiments with in vitro suspensions of ocular pathogens and with enucleated pig eyes inoculated with the same organisms showed that both methods led to similar bacterial recoveries. However, the authors apparently underestimated the fact that, with a low inoculum, a variation in the results was found by both techniques due to sampling problems, as bacteria were recovered in some cases but not in others. Even more important are results obtained with real corneal specimens. Kaye et al. found no differences in the percentages of positive results obtained by both techniques. However, it seems that they overlooked the fact that around 20 to 25% of diagnoses would be missed if only one of the methods was used (the numbers of positive cultures were 16, 15, and 20 for the indirect method, the direct method, and both methods, respectively). Indeed, this rate of missed diagnoses can also be attributed to sampling, and it argues in favor of making several corneal scrapes, since sampling enhances microbial detection in infectious keratitis. This fact is remarkable, and it is in concordance with my experience of attending patients from all across Argentina in a private clinic of Buenos Aires (Centro Oftalmologico “Dr. Brunzini”) that specializes in ocular infection. At this center, both ophthalmologists and microbiologists work in a close fashion with suffering patients. Samples are obtained by taking multiple corneal scrapes with a Kimura spatula and are directly seeded onto several media (chocolate and blood agar, brain heart broth, Sabouraud agar, nonnutrient agar for acanthamoebas, and occasionally Lowenstein-Jensen medium). In addition, at a minimum, two to three smears are made for stains (Gram, calcofluor white, and occasionally Ziehl-Neelsen or Giemsa). An enormous variety of etiologic agents must be investigated, and neither clinical signs nor risk factors, although helpful, can replace a definitive diagnosis (1, 3). An etiologic agent was identified in 178 out of 253 patients (70.4%); 71.4% of the agents were bacterial (including mycobacterial), 17.1% were fungal, and 11.5% were Acanthamoeba spp. (F. Nicola, M. Maltagliatti, R. Brunzini, and M. Brunzini, J. Argent. Microbiol., abstr. 070, 2003). Similarly to Kaye et al. (2), Nicola et al. found that 55% of patients had received an antibiotic treatment before being evaluated in our center, and this clearly affected the recovery of an etiologic agent (45% versus 80%, with and without previous treatment, respectively [P < 0.01]). Moreover, in some cases, the pathogens were detected in only one of the inoculated media, and it was not unusual that very few colonies (fewer than five) grew on agar plates. It could be inferred then that bacterial load in naturally infected corneas is usually low, and in addition, significant variations in microorganism distribution in corneal abscesses occur. Finally, it is believed that expertise in both taking representative samples by firm corneal scraping and microbiologic processing of the samples, in a direct and rapid manner, is invaluable for a good diagnostic performance. Although this approach may be difficult to implement in all ophthalmologic settings, the recommendation is to make a special effort. If no laboratory-skilled assistant can be present at the time of sampling, basic microbiologic training should be given to the ophthalmologist, and fresh media should be provided as required. Data showing a rate of definitive diagnosis (70.4%) that is among the highest of those published (1, 2, 3) are the basis for this encouragement.
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