Intravitreal Ceftazidime Research Articles

Efficacy of Cefiderocol Against Endophthalmitis Isolates.

Background/Objectives: Endophthalmitis is an intraocular microbial infection that can lead to permanent blindness, even with prompt anti-microbial therapy. Multi-drug-resistant organisms are on the rise, potentially limiting the efficacy of current empiric antibiotic therapies of intravitreal ceftazidime and vancomycin. Cefiderocol is a recent FDA- and EMA-approved antibiotic for multi-drug-resistant Gram-negative bacteria. Methods: To better understand its potential utility in the treatment of ocular infections, the MIC of cefiderocol was compared to ceftazidime and amikacin in endophthalmitis bacterial isolates using Epsilometer testing. Because vancomycin is commonly given concomitantly as part of empiric endophthalmitis treatment, possible synergistic and antagonistic effects of concomitant vancomycin and cefiderocol were also evaluated. Results: Cefiderocol was found to have lower MIC values compared to ceftazidime for Pseudomonadales or Enterobacterales species. When comparing the MICs of cefiderocol and vancomycin, there appeared to be no antagonism between the two antibiotics. Conclusions: This is the first report exploring the use of cefiderocol in endophthalmitis strains. The results of this study show this is a promising antibiotic for multi-drug-resistant Gram-negative organisms but further research is needed to investigate its intraocular safety profile.

Severe Intraocular Inflammation Following Intravitreal Faricimab

Monitoring for and reporting potential cases of intraocular inflammation (IOI) in clinical practice despite limited occurrences in clinical trials, including experiences with relatively new intravitreal agents, such as brolucizumab, pegcetacoplan, or faricimab, helps balance potential benefits and risks of these agents. To provide descriptions of 3 initially culture-negative cases of acute, severe, posterior-segment IOI events occurring within the same month following intravitreal faricimab injections at a single institution. In this case series, 3 patients manifesting acute, severe IOI following intravitreal injection of faricimab were identified between September 20, 2023, and October 20, 2023. Faricimab, 6 mg (0.05 mL of 120 mg/mL solution), for neovascular age-related macular degeneration among patients previously treated with aflibercept; 1 patient also had prior exposure to bevacizumab. Visual acuity, vitreous taps for bacterial or fungal cultures, and retinal imaging. All 3 patients received intravitreal faricimab injections between September 20 and October 20, 2023, from 2 different lot numbers (expiration dates, July 2025) at 3 locations of 1 institution among 3 of 19 retina physicians. Visual acuities with correction were 20/63 OS for patient 1, 20/40 OD for patient 2, and 20/20 OS for patient 3 prior to injection. All 3 patients developed acute, severe inflammation involving the anterior and posterior segment within 3 to 4 days after injection, with visual acuities of hand motion OS, counting fingers OD, and hand motion OS, respectively. Two patients were continuing faricimab treatment while 1 patient was initiating faricimab treatment. All received intravitreal ceftazidime, 2.2 mg/0.1 mL, and vancomycin, 1 mg/0.1 mL, immediately following vitreous taps. All vitreous tap culture results were negative. One patient underwent vitrectomy 1 day following presentation. Intraoperative vitreous culture grew 1 colony of Staphylococcus epidermidis, judged a likely contaminant by infectious disease specialists. All symptoms resolved within 1 month; visual acuities with correction were 20/100 OS for patient 1, 20/50 OD for patient 2, and 20/30 OS for patient 3. In this case series, 3 patients with acute, severe IOI within 1 month at 3 different locations among 3 ophthalmologists of 1 institution following intravitreal faricimab could represent some unknown storage or handling problem. However, this cluster suggests such inflammatory events may be more common than anticipated from faricimab trial reports, emphasizing the continued need for vigilance to detect and report such cases following regulatory approval.

Long-term follow-up of a healthy man with endogenous Streptococcus anginosus endophthalmitis

We report the long-term follow-up of an immunocompetent patient who presented with slowly progressive endogenous endophthalmitis secondary to Streptococcus anginosus. A 46-year-old healthy man presented with a two-month history of right eye iritis. On examination, visual acuity was 20/60 with intraocular pressure of 6 mm Hg. There was a small layer of hypopyon with non-granulomatous anterior uveitis and vitritis. On funduscopy, fluffy white peripheral retinal and pre-retinal lesions were noted in superonasal periphery. The patient denied any present or past illness. Diagnostic pars plana vitrectomy was performed. Culture and polymerase chain reaction of the vitreous sample were positive for Streptococcus anginosus. Intravitreal vancomycin and ceftazidime and systemic ceftriaxone were administered. Work-up which included blood and urine cultures, chest x-ray, echocardiography and abdominal ultrasound was unyielding. Subsequently and because of persistent post-infectious inflammatory reaction, intravitreal and oral steroids were administered in addition to oral azathioprine later on. After one year of follow-up, visual acuity was 20/20 with near vision of Jaeger 3 + and no signs of active uveitis were seen. Therefore, Streptococcus anginosus should be considered in the differential diagnosis of a slowly progressive endophthalmitis also in immunocompetent individuals.

Morganella morganii and Enterococcus faecalis endophthalmitis following intravitreal injection

BackgroundEndophthalmitis following intravitreal injection is a potentially devastating complication of anti-VEGF injections. Post-injection endophthalmitis due to Enterococcus faecalis is rare, and no previous case of Morganella morganii endophthalmitis after intravitreal injection has been reported.Case presentationWe present the first reported case of Morganella morganii and Enterococcus faecalis endophthalmitis after intravitreal injection in an immunocompetent patient in the absence of recent ocular surgery. Our patient presented with hand movement visual acuity one day after anti-VEGF injection and demonstrated no clinical improvement despite repeated intravitreal ceftazidime and vancomycin injections. A decision was made to proceed with early vitrectomy given failure of intravitreal antibiotics. Visual acuity improved to 6/90 at 12 weeks after vitrectomy without any evidence of disease recurrence.ConclusionsPost-injection endophthalmitis due to concurrent Morganella morganii and Enterococcus faecalis infections can have visually devastating consequences despite repeated empirical and targeted intravitreal antibiotics. Lack of clinical improvement following intravitreal antibiotics should warrant consideration of early vitrectomy. Our experience is a pertinent reminder of the ever-growing threat of uncommon and multi-resistant bacteria that must be considered when treating infections such as post-injection endophthalmitis.

Endophthalmitis caused by Burkholderia cepacia complex (BCC): clinical characteristics, antibiotic susceptibilities, and treatment outcomes

PurposeTo report the clinical characteristics, antibiotic susceptibilities, and review the literature of Burkholderia cepacia complex (BCC) associated endophthalmitis.Study designRetrospective, observational case series.MethodsClinical and microbiology records were reviewed for patients evaluated at the Bascom Palmer Eye Institute and diagnosed wisth culture-confirmed endophthalmitis due to BCC. Antibiotic susceptibility profiles were generated using standard microbiologic protocols via an automated VITEK system.ResultsEndophthalmitis associated with BCC was diagnosed in three patients. Infection occurred in the setting of post-penetrating keratoplasty (PKP), glaucoma filtering surgery, and suspected trauma. All isolates demonstrated in vitro susceptibility to ceftazidime and meropenem. Presenting visual acuity (VA) ranged from hand motion to light perception. Initial treatment strategies included intravitreal ceftazidime (2.25 mg/0.1 mL) and vancomycin (1.0 mg/0.1 mL) injections with fortified topical antibiotics in 2 patients, and surgical debridement of a corneoscleral melt with patch graft along with both topical fortified antibiotics oral antibiotics in the third patient. In all 3 patients, there was no VA improvement at last follow-up, as 2 eyes ultimately underwent enucleation and 1 eye exhibited phthisis bulbi at last follow-up. BCC related endophthalmitis was reviewed among 13 reports. Treatment outcomes were generally poor and antibiotic resistance was common. These BCC isolates cases demonstrated broad resistance patterns, with susceptibilities to ceftazidime (58%), ciprofloxacin (53%), and gentamicin (33%).ConclusionsEndophthalmitis caused by B. cepacia is a rare clinical entity with generally poor visual outcomes despite prompt treatment with appropriate antibiotics.

Never forget ocular syphilis: A case series from a single tertiary centre.

A retrospective analysis of 10 consecutive patients who had serologically confirmed ocular syphilis between June 2020 and February 2023 was performed. All cases presented with ocular manifestations. Eight patients were diagnosed with syphilis and two patients with syphilis/human immunodeficiency virus co-infection. Type and duration of antibiotic treatments were diverse among the patients. Four patients had intramuscular benzyl-penicillin G 2.4 million units (MU) weekly for three weeks; four, intravenous ceftriaxone for 14 days; one, intravenous penicillin G 24 MU/day for 14 days; and the remaining patient, intravenous penicillin G 24 MU/day for a week and then oral doxycycline for two weeks. As adjunctive therapy to systemic antibiotics, oral corticosteroids in three patients and intravitreal ceftazidime (2.25 mg/0.1 mL) injections in one patient were administered. In conclusion, ocular syphilis is a re-emerging phenomenon; prompt diagnosis and proper antibiotic treatment can prevent serious ocular complications.

Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience.

Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis. Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated. 112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction. Intravitreal moxifloxacin (160µg/0.1mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

Postvitrectomy endophthalmitis caused by Morganella morganii: a case report and literature review

BackgroundPostvitrectomy endophthalmitis is a rare and serious complication following vitreoretinal surgeries. Morganella morganii, an emerging gram-negative, facultative anaerobic rod, is related to severe nosocomial infections in various organs and thus has gained importance in recent decades. Morganella morganii infection following intraocular surgery is rarely reported.Case presentationWe report an immunocompetent patient with Morganella morganii-related endophthalmitis after vitrectomy for retinal detachment who presented with hand motion visual acuity, hypopyon and a unique retrolental exudative membrane. Initially, the patient was unresponsive to empirical intravitreal ceftazidime and vancomycin but recovered with vision preservation (20/63) after surgical removal of the membrane and silicone oil tamponade.ConclusionsMorganella morganii intraocular infection is often devastating, likely due to its high multidrug-resistance rate via intrinsic ß-lactamase production, multiple acquired traits related to additional genetic mechanisms, and fimbrial adhesion, urease production, and type III secretion system-associated biofilm formation. The above characteristics of M. morganii may lead to an inadequate response to empirical intravitreal antibiotics, and early surgical intervention should be considered.

Endophthalmitis after corneal suture removal

Introduction: To report 2 patients with acute-onset endophthalmitis after intraocular lens exchange and delayed corneal suture removal. Patient and Clinical Findings: An 83-year-old woman and a 64-year-old man developed pain, decreased vision, corneal infiltrate, marked intraocular inflammation, and vitreous membranes after corneal suture removal. Topical povidone–iodine was not used before suture removal, and the wounds showed negative results for Seidel test at presentation. Diagnosis, Intervention, Outcomes: Both patients were diagnosed with acute-onset endophthalmitis. One received vitreous tap and injection (T&I) and the other received both T&I and pars plana vitrectomy. Intravitreal vancomycin and ceftazidime were administered in both patients. Cultures demonstrated streptococcal species. Outcomes were poor: 1 eye was enucleated and the other showed light perception. Conclusions: Endophthalmitis in the setting of corneal suture removal can be associated with severe vision loss. Topical povidone–iodine antisepsis and topical antibiotics should be considered for endophthalmitis prophylaxis in this procedure.

Global Current Practice Patterns for the Management of Exogenous Endophthalmitis: A Survey by the American Society of Ophthalmic Trauma

ABSTRACTObjectiveTo investigate the global practice patterns for the management of exogenous endophthalmitis.MethodsThis cross-sectional study was conducted to assess global practice patterns for the management of exogenous endophthalmitis. An online survey comprised of questions regarding the management of exogenous endophthalmitis was distributed to institutions who are members of International Globe and Adnexal Trauma Epidemiology Study Group (IGATES) or invited affiliates of the American Society of Ophthalmic Trauma and the Asia Pacific Ophthalmic Trauma Society. Responses were gathered from August 2020 to January 2021.ResultsOf 42 institutions, 36 responses were received (86% response rate), of which 33 (79%) were included in the analysis. Included centers were from Asia (36%), North America (36%), South America (12%), Africa (9%), Europe (3%), and Australia (3%). Oral antibiotics were administered in 19 (58%) institutions, with moxifloxacin as the preferred agent (n = 9, 27%). The preferred method for obtaining cultures was vitreous tap (n = 25, 76%). Most institutions (n = 26, 79%) routinely administered intravitreal vancomycin and ceftazidime, while intravitreal steroids were routinely administered at 11 centers (33%). Indications for performing vitrectomy included; decreased visual acuity (n = 14, 39%); all cases of exogenous endophthalmitis (n = 4, 12%); non-response to medical therapy (n = 4, 12%); or no view of the fundus (n = 4, 12%), indicating significant variation in surgical indications. More than half (n = 17, 52%) of responding institutions routinely admitted patients with exogenous endophthalmitis to the hospital. Institutions in the United States were less likely to administer oral antibiotics (27% vs. 73%, P = .024) and to admit patients (9% vs. 73%, P < .001) compared to other countries.ConclusionsThis study highlights the global variations in the management of exogenous endophthalmitis, especially as it pertains to surgical indications. Further establishment of evidence-based guidelines may be beneficial to provide more uniform guidance to optimize outcomes.

Clinical profile, visual outcome and root cause analysis of post-operative cluster endophthalmitis due to Burkholderia cepacia complex.

Purpose:To present varied clinical presentations, surveillance reports, and final visual outcomes of a rare outbreak of cluster endophthalmitis caused by gram-negative, opportunistic bacilli, Burkholderia cepacia complex (Bcc).Methods:Details of five patients who developed postoperative cluster endophthalmitis were collected. For each patient, an undiluted vitreous sample was collected during vitreous tap. Bacterial culture from the vitreous sample in each case had grown Bcc. Surveillance investigations for root cause analysis (RCA) were performed in the operating room (OR), admission, and day-care wards to localize the source.Results:Four patients had undergone phacoemulsification surgery, and one patient had undergone penetrating keratoplasty. Each patient received an initial dose of empiric intravitreal ceftazidime and vancomycin. The organism isolated in each case was sensitive to ceftazidime, cotrimoxazole, and meropenem and resistant to other antibiotics. Core vitrectomy was done after 48–60 hours in four patients along with intravitreal imipenem injection. One patient did not provide consent for core vitrectomy and subsequently developed phthisis bulbi. Three patients had subsequent recurrences. Two patients had a final BCVA of 20/60, two had BCVA better than 20/200, while one patient had no perception of light. None of the surveillance samples from the OR complex could isolate Burkholderia.Conclusion:Extensive OR surveillance should be done to identify the potential source of infection. However, the source may not be identifiable in few instances like in our case. Longer follow-up is recommended in cases of Bcc endophthalmitis due to the persistent nature of the infection.

Utility of 2-Deoxy-2-[18F]fluoro-Dglucose positron emission tomography/computed tomography scan in the systemic evaluation of patients with post-COVID-19 endogenous presumed fungal endophthalmitis.

A 48-year-old nondiabetic male presented with persistent breathlessness, cough, intermittent pyrexia, and grossly reduced vision in the right eye. Based on the available records, he had been diagnosed with COVID-19 earlier (based on a positive RT-PCR) and had received domiciliary care for an initial five days. Following clinical deterioration, he was admitted, treated with systemic steroids, antibiotics, and ventilatory support. Ten days post discharge, he developed a gross reduction in vision in the right eye (CF: 1 m). Five days later, he underwent a vitrectomy for endophthalmitis with intravitreal voriconazole (100 mcg), vancomycin (1 mg), and ceftazidime (2.25 mg) with a reported postoperative vision of 6/24 (20/80). Microbiology of the vitreous fluid for KOH, gram staining, and culture/sensitivity were reported as negative. He was readmitted in our tertiary care center on the 14th day postoperatively. On admission, he was afebrile, with tachycardia (heart rate: 91/min), dyspneic (respiratory rate: 21/minute) with inspiratory basilar crackles with decreased air entry bilaterally. His oxygen saturation was normal (99%). The visual acuity was HMCF in the right eye and 6/6 (20/20) in the left eye. Dilated fundus exam showed significant vitreous haze (3+) that obscured the fundus view [Fig. 1]. A large yellowish preretinal lesion was seen in the superonasal quadrant [Fig. 2]. The fundus of the left eye was normal.Figure 1: Fundus photo of the right eye revealing vitreous haze grade 3+Figure 2: Fundus photo revealing a yellow-white preretinal lesion in the superonasal quadrantBlood investigations included assessment of the hemoglobin (11.30 gm/dl), white cell counts (11,170/mm3), and serum creatinine (1.05 mg/dl), which were normal. Specific tests included C-reactive protein (45.56 mg/l), D-dimer (2910 ng/ml), and serum fibrinogen (590 mg/dl). Blood cultures for aerobic, anaerobic, and fungal cultures were negative. He underwent a whole-body 2-Deoxy-2-[18F]fluoro-D-glucose (FDG) Positron Emission Tomography/Computed Tomography (PET/CT) scan to detect a possible focus of infection. A high-grade uptake was seen in an area of patchy consolidation, and additional moderate grade uptake was seen in large cavitary lesions in each lung [Fig. 3]. Multiple nodular opacities through the rest of the lung fields demonstrated low-grade uptake. A CT-guided biopsy at an area of high uptake (right lung; lower lobe) was performed [Fig. 4]. Histopathological study showed extensive areas of necrosis enmeshed with broad aseptate hyphae. Scattered granulomas were also seen. The picture was consistent with invasive fungal infection. Fungal cultures of the lung biopsy revealed Rhizopus species. The isolates were analyzed by MALDI TOF MS (Matrix-assisted laser desorption ionization-time of flight-mass spectroscopy) to confirm a species identification of Rhizopus microsporus. The patient underwent two intravitreal amphotericin B injections (5 mcg, a week apart) along with an intravenous amphotericin B course (3 mg/kg/day) for six weeks, with no clinical improvement (perception of light only). Subsequent ultrasound examination revealed a large multilobular intraocular mass attached to the posterior pole with a thickened membrane in the mid-vitreous [Fig. 5]. The patient opted to be treated elsewhere and was discharged.Figure 3: (a-c) High-grade uptake (white arrowhead; SUV max 11.45) seen in patchy consolidation within the posterior aspect of the right lung lower lobe. Moderate grade uptake seen in large cavitary lesions in the right lung middle and lower lobes (red arrows; SUV max 7.8). (b-d) CT scans revealing multiple cavitary lesions of the right lung (red arrows)Figure 4: CT scan showing biopsy needle placement within the cavitary lesion (white arrowhead)Figure 5: Ultrasound image of the eye showing a large multilobular mass attached to the posterior pole and to a thickened mid-vitreal membranePost-COVID-19 endogenous endophthalmitis is increasingly being recognized, and identification of the systemic focus and its treatment is an integral part of treatment.[1] Fungal endophthalmitis due to mucor species has only rarely been reported.[2] The use of a FDG PET/CT scan allowed identification of a pulmonary focus and suggested potential sites of biopsy, thus increasing the possibility of a positive diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A case series with literature review on adjunctive usage of intravitreal ceftazidime in ocular syphilis with human immunodeficiency virus infection.

Penicillin is the conventional treatment for all stages of syphilis, including ocular and neurosyphilis, according to the recommendations by the Centre for Disease Control and Prevention Sexually Transmitted Disease. This case series highlighted three cases of ocular syphilis which showed prompt treatment response as early as 24h after the adjunctive intravitreal ceftazidime injection. Case Series. In case 1, there was significant improvement in the vision and vitritis after 24h of a single intravitreal ceftazidime injection. In case 2, the patient achieved his best vision after a total of three intravitreal injections in his left eye and one in his right eye. In case 3, there was a further resolution of perivascular sheathing and retinal haemorrhages seen 1week after a single intravitreal ceftazidime injection. The efficacy of intravitreal ceftazidime injection as a local adjunctive therapy in ocular syphilis treatment is noteworthy. It can be considered in cases which show suboptimal or slower treatment response despite early commencement of systemic penicillin to prevent devastating ocular sequelae.

Pharmacokinetics of Intravitreal Vancomycin and Ceftazidime in Silicone Oil-Filled Macaque Eyes.

PurposeThis study evaluated the pharmacokinetics of intravitreal vancomycin and ceftazidime in the aqueous humor of macaque eyes filled with silicone oil in the vitreous cavity.MethodsIntravitreal vancomycin (1 mg/0.1 mL) and ceftazidime (2 mg/0.1 mL) were injected into four normal macaque eyes, four vitrectomized aphakic macaque eyes, and four previously vitrectomized aphakic macaque eyes filled with silicone oil (silicone oil-filled eyes). Aqueous humor samples (0.1 mL) were obtained just before injection and at 2 and 5 hours and 1, 2, 3, 5, 7, and 10 days after injection. In each group, corneal endothelial cell density (ECD) measurements and electroretinogram (ERG) recordings were obtained before injection and after 1 month.ResultsThe half-lives of vancomycin in the aqueous humor of normal, vitrectomized, and silicone oil-filled eyes were 29.4, 21.1, and 6.8 hours, respectively, and those of ceftazidime were 20.4, 5.2, and 3.1 hours, respectively. The maximum vancomycin aqueous humor concentrations of normal, vitrectomized, and silicone oil-filled eyes were 151.4, 205.6, and 543.5 µg/mL, respectively, and the maximum ceftazidime aqueous humor concentrations are 64.6, 260.0, and 1176.3 µg/mL, respectively. There was no change in ECD, and ERG was not declined after intravitreal injection in all groups.ConclusionsThe half-lives of vancomycin and ceftazidime in the aqueous humor were shorter in silicone oil-filled eyes than in normal and vitrectomized eyes. High antibiotic concentrations in silicone oil-filled eyes seemed to be well tolerated.Translational RelevanceThis study aids in estimating how often an antibiotic should be intravitreally injected for endophthalmitis of silicone oil-filled eyes.

Commentary: Intravitreal moxifloxacin for acute postoperative endophthalmitis: Is it as safe and efficacious as the age-old recommended intravitreal vancomycin and ceftazidime?

Commentary: Intravitreal moxifloxacin for acute postoperative endophthalmitis: Is it as safe and efficacious as the age-old recommended intravitreal vancomycin and ceftazidime?

Post Pars Plana Vitrectomy Silicone Oil Related Endophthalmitis Caused by Citrobacter Koseri: A Case Report and Literature Review

Purpose: To present a rare case of a Citrobateri koseri endophthalmitis after pars plana vitrectomy silicone oil-filled eye. Case Report: A 64-year old male patient presented to our clinic for eye pain and decrease vision in the right eye. He had a history of diabetes mellitus, hypertension, and a cataract surgery in both eyes ten years before and surgery of retinal detachment in RE For a relapse of regmatogenous retinal detachment in RE a pars plana vitrectomy with silicone oil injection was performed. He received topical betamethasone, naphazoline and tetracycline 6 times a day. After one week the patient complained ocular pain and decreased vision. Examination revealed visual acuity deterioration, a severely injected conjunctiva. The cornea was edematous with Descemet’s membrane folds. The anterior chamber was hazy with cells and flare, and hypopyon was observed. A diagnosis of post vitrectomy endophthalmitis was made. Sampling of the aqueous fluid was obtained and he was empirically treated with intravitreal ceftazidime 2.0mg/0,1ml and sub-tenon injection of betamethasone (2mg). The microscopic examination of the aqueous fluid stained with Gram stain revealed the presence of numerous polymorphonuclear cells and of small gram-negative bacteria identified as C. koseri. The strain was susceptible to all the antibiotics tested. A high MIC value (16mg/L) was detected only for tetracycline. The therapy was changed to fortified ceftazidime 5%, fortified tobramycin 0.3%, atropine 1% and prednisone-eye drops administered every 2 hours along with systemic antibiotic (ceftriaxone 2g iv for 5days) and steroid treatment without any improvement. The patient underwent to a new pars plana vitrectomy, removal of the IOL, and silicone oil exchange. In this occasion silicon leakage from previous sclerotomy, pus filled vitreous cavity and some retinal hemorrhages were observed. Vancomycin and ceftazidime according to Endophthalmitis Vitrectomy Study protocol were injected in the vitreous cavity and previous topical and systemic therapy was continued, too. An improvement of visual acuity was obtained. Conclusion: Among cases of culture positive endophthalmitis, Citrobacter spp. is very rare, and this is the first report of a silicone oil related endophthalmitis caused by this microorganism.

Outcomes of Infectious Endophthalmitis in Patients with Systemic Antibiotic Allergies to Penicillins, Cephalosporins, or Vancomycin

The mainstay empiric treatments of bacterial endophthalmitis are intravitreal vancomycin and ceftazidime. In the United States, up to 10% of the general population has a reported penicillin (PCN) allergy. Despite low cross-reactivity between PCN and later-generation cephalosporins, some providers alter the intravitreal antibiotic choice for endophthalmitis because of concern for allergic reactions. We evaluated the management strategies of infectious endophthalmitis in the setting of self-reported systemic antibiotic allergies and the association with adverse reactions after standard intravitreal antibiotic administration. Single-center, retrospective cohort study. All patients with endophthalmitis between 2005 and 2019 and documented PCN, PCN-analog, cephalosporin, or vancomycin allergy who received intravitreal antibiotics on the basis of International Classification of Diseases 9th and 10th Revisions, and Current Procedural Terminology codes. Retrospective chart review. Any allergic reaction after intravitreal injection, additional surgical interventions required for treatment, and visual function at last recorded visit. Of the 65 patients included in this cohort, the most common causes of endophthalmitis were postcataract extraction surgery (n = 23, 35.4%) and postintravitreal injection (n = 11, 16.9%). All patients (65/65) received intravitreal vancomycin, and 81.5% (53/65) received intravitreal ceftazidime. Of the 53 patients who received intravitreal ceftazidime, 46 (86.8%) had allergies to PCNs alone, 5 (9.4%) had a cephalosporin allergy alone, and 2 (3.8%) had reported allergies to both PCN and cephalosporin antibiotics. Two patients (3.1%) with a documented vancomycin allergy received intravitreal vancomycin without complication. No patients exhibited any systemic or local allergic reactions or complications after intravitreal injection. There were no documented allergic reactions in this cohort of patients with systemic antibiotic allergies who were treated for infectious endophthalmitis. Our findings are consistent with previous reports of a low allergic cross-reactivity between PCN and later-generation cephalosporins. Ophthalmologists should use evidence-based practices and a careful informed consent process when choosing intravitreal antibiotics for patients with specific antibiotic allergies. In the routine patient with suspected bacterial endophthalmitis, PCN allergy may not be an absolute contraindication to intravitreal cephalosporin use.

Toll-like receptors in acute post-cataract surgery endophthalmitis.

To evaluate the expression of toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) on CD14 + cells in vitreous and blood of post-cataract surgery acute endophthalmitis. This prospective case-control pilot study enrolled 16 patients of post-cataract surgery endophthalmitis. All the cases were subjected to 23 G pars plana vitrectomy (PPV). Ten patients undergoing 23 G PPV for non-infectious conditions were taken as controls. 23 G PPV was performed, and three undiluted vitreous samples were collected in heparinized syringes from the cases and the controls. Simultaneous venous blood sample was taken, and flow cytometry was performed to detect the expression of TLR2 and TLR4 in vitreous and blood samples. The vitreous and blood samples were incubated with fluorescein isothicyanate (FITC) conjugated anti-TLR2 monoclonal antibody Alexafluor (AX) 647 and anti-TLR4 monoclonal antibody phycoerythrin. Data acquisition was done on a pre-calibrated flow cytometer. TLR analysis of the acquired flow cytometry data was then performed. Mean channel fluorescence intensity (MFI) derived from fluorescence histogram was used to study the level of cell surface TLR expression. MFI was calculated as a ratio and recorded as the MFI of the TLR2 or -4 antibody divided by the MFI of the isotype-matched negative control antibody. Core vitrectomy was done as per the comfort of the surgeon, and intravitreal antibiotics vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected. The cytological examination was done on vitreous and blood sample. The median TLR 2 and TLR4 values between cases and controls were compared by Mann-Whitney U test. Spearman's rank correlation test was used to assess the correlation between TLR expression and disease activity. Vitreous cytology evaluation showed the presence of neutrophils (81.25%, n = 13), monocytes (68.75%, n = 11) and lymphocytes (62.50%, n = 10). The level of expression of TLR2 in vitreous showed a statistically significant correlation with an increase in the time interval of cataract surgery and intervention for endophthalmitis (p < 0.05), but the same was not observed for TLR4. A drift toward higher level of expression of TLR2 and TLR4 in vitreous was observed in patients with poor outcome. TLR2 levels increase with the delay in presentation; thus, TLR2 ligands in vitreous could serve as a good target for the treatment of endophthalmitis.

Effect of intravitreal ceftazidime injection on endogenous klebsiella pneumoniae endophthalmitis, a single center case series.

To report long-term outcomes of intravitreal ceftazidime injection in patients with endogenous Klebsiella pneumoniae endophthalmitis (EKPE).This was a retrospective observational case study, including 7 eyes from 6 patients with EKPE. The medical records from January 2010 to December 2018 were reviewed.Diagnosis of EKPE was made based on the finding of endophthalmitis with concurrent systemic infection and positive blood culture result. All patients received tap and intravitreal ceftazidime injection base on the results of antibiotics sensitivity test. Visual acuity ranged from no light perception to 20/60 at initial visit, and the final visual acuity was 20/20. Two eyes underwent evisceration after intravitreal injection.Intravitreal ceftazidime injection showed favorable results in patients with EKPE.

A CASE REPORT OF CHRONIC ENDOPHTHALMITIS SECONDARY TO AQUAMICROBIUM terrae

Chronic postoperative endophthalmitis is a known complication of cataract surgery. Here, we report a case of chronic endophthalmitis following uncomplicated cataract surgery secondary to the atypical bacterium Aquamicrobium terrae . Retrospective case report of a single patient with endophthalmitis secondary to A. terrae. A 61-year-old healthy patient presented with recurrent iridocyclitis following uncomplicated cataract surgery. Repeated attempts to taper off topical steroid eyedrops were unsuccessful. Anterior chamber paracentesis cultures and vitrectomy cultures grew the same gram-negative bacillus, A. terrae , on six different occasions. The patient was treated initially with a series of intravitreal ceftazidime injections and adjuvant oral minocycline with recurrence of inflammation necessitating pars plana vitrectomy with intraocular lens removal and total capsulectomy. Inflammatory episodes recurred until residual capsule fragments were ablated using endoscopic vitrectomy. Since ablation over 18 months ago, no further recurrences have occurred and the patient has excellent visual outcome. A. terrae is a gram-negative bacillus recovered from polluted soil. This is the first case of postoperative endophthalmitis secondary to A. terrae and the first description of human infection caused by this newly identified microbe.