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CASE SERIES
Year : 2021  |  Volume : 48  |  Issue : 3  |  Page : 203-205

Endogenous endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa treated with colistin: A case series


1 Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, Bhubaneswar, Odisha, India
2 Department of Microbiology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, Bhubaneswar, Odisha, India

Date of Submission23-Jun-2021
Date of Acceptance28-Sep-2021
Date of Web Publication28-Dec-2021

Correspondence Address:
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.jss_84_21

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  Abstract 


Multidrug-resistant Pseudomonas aeruginosa is being increasingly recognized as a cause of endogenous endophthalmitis in critically ill patients. Three patients were included in this case series. Antibiogram profile in all three cases showed sensitivity to colistin only. All cases were treated with systemic and intravitreal colistin. Although there was clinical improvement, final visual outcome was poor in all cases. Intravitreal colistin can be tried in multidrug resistance cases. Final prognosis depends on early diagnosis and quick institution of appropriate therapy.

Keywords: Colistin, endogenous, endophthalmitis, multidrug resistant


How to cite this article:
Panigrahi PK, Das S, Sahoo D, Mishra A. Endogenous endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa treated with colistin: A case series. J Sci Soc 2021;48:203-5

How to cite this URL:
Panigrahi PK, Das S, Sahoo D, Mishra A. Endogenous endophthalmitis due to multidrug-resistant Pseudomonas aeruginosa treated with colistin: A case series. J Sci Soc [serial online] 2021 [cited 2022 Jan 18];48:203-5. Available from: https://www.jscisociety.com/text.asp?2021/48/3/203/333855




  Introduction Top


Endogenous endophthalmitis (EE) arises from bloodborne movement of infective organisms to eye from some other foci of infection in the body. Predisposing risk factors include immunosuppression, diabetes mellitus, malignancies, indwelling catheters, recent hospitalization, and intravenous drug abuse.[1] Pseudomonas aeruginosa is being increasingly recognized as an important pathogen in critically ill patients. There are sporadic reports of use of colistin in endophthalmitis.[2],[3],[4] We present a case series of three patients with EE due to multidrug resistant (MDR) P. aeruginosa treated with intravenous and intravitreal colistin.


  Case Reports Top


Case 1

A 70-year-old male presented with sudden onset, painful loss of vision in the right eye (RE) of 1-week duration. The patient had multiple systemic comorbidities. Fever and urinary tract infection preceded vision loss. Best-corrected visual acuity (BCVA) in RE was perception of light (PL) positive with accurate projection of rays (PR). Slit-lamp examination revealed ciliary congestion, corneal haze, 2 mm hypopyon, and pseudophakia. Ultrasound examination showed moderate reflective dot and membranous echoes with mound-like elevation in macular area suspicious of subretinal abscess [Figure 1]a. We diagnosed it as a case of EE in RE. Pars plana vitrectomy (PPVIT) was done and intravitreal vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected intravitreally at end of the procedure. The patient was started on topical moxifloxacin (0.5%) and prednisolone acetate (1%). Gram stain of vitreous aspirate showed Gram-negative bacilli. P. aeruginosa growth was obtained in MacConkey agar from both blood and vitreous aspirate [Figure 1]b. Antibiogram showed MDR and sensitivity to colistin only. The patient was started on intravenous colistin (1 million international units 12 hourly for 7 days) and received intravitreal colistin (0.1 mg/0.1 ml, 1000 International units/0.1 ml). Following treatment, there was a gradual decrease in anterior and posterior segment inflammation. The patient received 3 more doses of intravitreal colistin and dexamethasone (1 mg/0.1 ml) at weekly intervals. Six weeks following presentation, the patient had BCVA of 1/60 with macular scar and attached retina.
Figure 1: (a) Ultrasound of right eye of case 1 at presentation showing plenty of moderate reflective dots and few membranous echoes and a mound-like elevation in the macular area suggestive of subretinal abscess. (b) Pseudomonas aeruginosa growth in MacConkey agar in case 1 showing typical flat and small colonies with regular margins

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Case 2

A 33-year-old female with 65% burn injuries presented with sudden onset loss of vision in the left eye (LE) of 5 days duration. Bedside examination showed a vision of PL positive with defective PR in LE. There was significant conjunctival chemosis, corneal edema, exudates in anterior chamber, and no view of fundus. Blood culture and pus culture from the wounds, which had already been done, showed growth of MDR P. aeruginosa with sensitivity to colistin only. The patient was advised early PPVIT which she refused. The patient was started on intravenous colistin and received intravitreal colistin. She received 3 more doses of intravitreal colistin at weekly intervals. There was complete resolution of anterior chamber exudates 1 month following the presentation. On fundoscopy, optic disc and first-order retinal vessels could be hazily seen, and the retina appeared attached. Two months after initial presentation, the patient had no PL vision in LE, and the eye was becoming prepthisical. Ultrasound showed total retinal detachment. The patient refused any further intervention.

Case 3

A 72-year-old post-COVID female presented with pain, swelling, and loss of vision in RE of 4 days duration. The patient had uncontrolled diabetes and was admitted in medicine intensive care unit with bilateral pneumonia. Bedside examination showed a vision of PL positive in RE. There was marked conjunctival chemosis, corneal edema, and hypopyon in RE. There was no view of the fundus. The patient had already been started on intravenous colistin following blood culture report of MDR P. aeruginosa, sensitive to colistin only. Due to the very poor systemic status of the patient, a medical clearance for vitrectomy could not be obtained. She received intravitreal colistin following which there was a decrease in anterior chamber exudates. She received another dose of intravitreal colistin 1 week after the first injection. Two weeks following presentation, the patient suffered a massive cardiac arrest and was lost to follow-up. Salient demographic and clinical features are highlighted in [Table 1].
Table 1: Demographic and clinical profile of patients

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  Discussion Top


All three isolates in our case series were MDR strains with susceptibility to colistin. An intravitreal concentration of 1000 International Units in 0.1 ml was used in all our cases. A vial containing 1 million International units was reconstituted using 10 ml of sterile water. 0.1 ml of this reconstituted solution was drawn into a 1 ml tuberculin syringe to attain a final concentration of 1000 International units in 0.1 ml. Although there was clinical improvement in our cases, the final visual and anatomical outcomes were poor.

This could be due to more severe involvement at presentation and delay in seeking ocular treatment to start with. All patients in our series had severe systemic involvement with possible poor capacity of the immune system of the body to launch an adequate response against the offending organism. PPVIT could not be performed in cases 2 and 3. Early vitrectomy in such severe cases could have resulted in a slightly better prognosis. Multiple doses of intravitreal colistin were used in all our patients. Ocular toxicity arising out of multiple doses of intravitreal colistin can be another potential cause of poor outcome in our case series.


  Conclusion Top


MDR P. aeruginosa is commonly associated with EE in critically ill patients. Wherever sensitive, intravitreal colistin can be combined with systemic colistin to treat such conditions. To the best of our knowledge, this is the first case series on MDR EE treated with colistin.

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.



 
  References Top

1.
Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. Endogenous endophthalmitis: Diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect 2015;5:32.  Back to cited text no. 1
    
2.
Samant P, Ramugade S. Successful use of intravitreal and systemic colistin in treating multidrug resistant Pseudomonas aeruginosa post-operative endophthalmitis. Indian J Ophthalmol 2014;62:1167-70.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Taneja M, Senthil S, Paulose R, Joseph J, Sharma S, Dave VP. Intravitreal colistin for multidrug resistant acute endophthalmitis following descemet-stripping endothelial keratoplasty due to Klebsiella pneumoniae. JCRS Online Case Rep 2016;4:52-6.  Back to cited text no. 3
    
4.
Dogra M, Sharma M, Katoch D, Dogra M. Management of multi drug resistant endogenous Klebsiella pneumoniae endophthalmitis with intravitreal and systemic colistin. Indian J Ophthalmol 2018;66:596-7.  Back to cited text no. 4
[PUBMED]  [Full text]  


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