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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 41-44

Clinico-microbiological profile of orbital and periorbital infections


1 Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India
2 Department of Ophthalmology, Government Medical College, Manjeri, Kerala, India

Date of Submission04-Jan-2020
Date of Decision06-Jan-2020
Date of Acceptance15-Jan-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. S Bindu
3/965, Lakshmi, Kannur Road, Nadakkav, Kozhikode . 673 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_1_20

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  Abstract 

Context: Orbital and periorbital infections represent a spectrum of sepsis that carries significant morbidity and mortality. Knowledge of the trend of the type of organisms and their antibiotic susceptibility will help in the institution of appropriate therapy. Aim: The aim of the study was (1) to determine the common pathogens causing orbital and periorbital infections and their in vitro antibiotic sensitivity. (2) To find the correlation between the type of infection, organism isolated, and culture positivity. Materials and Methods: This was a descriptive cross-sectional study for a period of 1 year. Eighty-six patients who presented with orbital and periorbital infections were included in the study. Conjunctival swab or pus aspirate whenever available was taken for gram stain and culture and sensitivity. In vitro antibiotic sensitivity of the organisms isolated was determined. Statistical Analysis: The statistical analysis was done using SPSS version 18 software. Results: The most common infection was orbital cellulitis (34.9%). About 44.12% of swabs were culture positive, and the most common organisms isolated were Staphylococcus aureus and methicillin-resistant S. aureus in our study. The highest in vitro antibiotic susceptibility was to amikacin and gentamicin in this study. Conclusion: This study helped in identifying common causative organisms of orbital and periorbital infections and their antibiotic sensitivity. It indicates the need for modifying our empirical antibiotic therapy, indiscriminate use of which may lead to antibiotic resistance. Periodic surveillance of antibiotic resistance will help to implement interventions to limit the emergence and spread of antibiotic resistance in the community.

Keywords: Antibiotic sensitivity, culture, orbital, periorbital infections


How to cite this article:
Anupama K N, Bindu S, Jyothi P T. Clinico-microbiological profile of orbital and periorbital infections. Kerala J Ophthalmol 2020;32:41-4

How to cite this URL:
Anupama K N, Bindu S, Jyothi P T. Clinico-microbiological profile of orbital and periorbital infections. Kerala J Ophthalmol [serial online] 2020 [cited 2020 May 28];32:41-4. Available from: http://www.kjophthal.com/text.asp?2020/32/1/41/282645




  Introduction Top


Orbital and periorbital infections require early recognition and appropriate and aggressive treatment as they can lead to vision as well as life-threatening complications. Careful physical examination, proper selection of antibiotics, and surgical intervention are essential to avoid serious morbidity from these infections. As it is difficult to determine the pathogen responsible for infection without a culture sample, which may take a few days, treatment is usually instituted by an assumption of the most common causative organisms and commonly used antibiotic therapy. According to Goldstein et al.[1] and Kunimoto et al.,[2] the increasing use of antibiotics leads to resistant strains. Furthermore, indiscriminate and inadequate use of ophthalmic antibiotics may lead to the development of resistance as shown in studies by Dare et al.[3] and Milder et al.[4] Isolating the causative organisms and determining their antibiotic sensitivity will help in more effective management of these infections. It will also help in reducing the development of resistant strains.

Aim

  1. To determine the common pathogens causing orbital and periorbital infections and theirin vitro antibiotic sensitivity
  2. To find the correlation between the type of infection, organism isolated, and culture positivity.



  Materials and Methods Top


This was a descriptive cross-sectional study of 1 year duration, at a tertiary care center. Approval was obtained from the institutional ethical committee. Informed consent was obtained from all the participants. Eighty-six patients presenting with signs and symptoms of orbital and periorbital infection were included in the study. A thorough clinical examination aided with laboratory investigations and imaging helped in the diagnosis. Cases included referred patients who were already treated with oral antibiotics, with no relief as well as fresh cases.

Conjunctival swab from fornices and pus aspirate in available cases such as in abscess were taken under aseptic precautions and sent for gram stain and culture. Culture was done using blood agar/chocolate agar/Macconkey agar.In vitro antibiotic sensitivity of the organisms isolated was done using Muller–Hinton Agar.

The data were entered in Microsoft Excel, and statistical analysis was done using SPSS version 18 software (SPSS Inc., Chicago, IL, USA).


  Results Top


Eighty-six cases in this study included orbital cellulitis, preseptal cellulitis, acute dacryocystitis, lacrimal abscess, and lid abscess [Figure 1]. The mean age of patients was 42.44 ± 20.77 years. Most patients belonged to the age group of 40–49 years. There were 47 (54.7%) male and 39 (45.3%) female in the study group.
Figure 1: Frequency distribution of cases

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The most common infection in this study was orbital cellulitis (34.9%) and the least common was lacrimal abscess (5.8%) [Figure 1]. Thirty-eight cases (44.12%) were found to be culture positive, whereas remaining 48 (55.81%) were sterile [Table 1]. Out of culture-positive cases, 22 were (57.9%) pus aspirate and 16 (42.1%) were conjunctival swab. About 78.6% (22/28 cases) of pus aspirate gave positive results, whereas only 27.6% (16/58 cases) of conjunctival swabs showed positive culture [Table 1]. [Table 2] shows the culture positivity in each infection. Maximum yield was obtained in lacrimal abscess (100%).
Table 1: Culture results

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Table 2: Culture positivity in cases

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The predominant organism isolated was Staphylococcus aureus, followed by methicillin-resistant S. aureus (MRSA). Other organisms isolated include Acinetobacter, Pseudomonas, Klebsiella,  Escherichia More Details coli, Enterobacter, Corynebacterium, and Streptococcus [Figure 2]. [Table 3] shows the frequency distribution of S. aureus and MRSA isolates in each infection. S. aureus was the main isolate in preseptal cellulitis, whereas MRSA was the main organism in lid abscess.
Figure 2: Organisms isolated

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Table 3: Frequency distribution of isolated Staphylococcus aureus and methicillin-resistant Staphylococcus aureus

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The overall most commonin vitro antibiotic sensitivity was for amikacin and gentamicin, followed by cefazolin and cloxacillin [Figure 3]. [Figure 4] shows the sensitivity pattern of staphylococcus species, which was mainly to amikacin.
Figure 3: Antibiotic sensitivity

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Figure 4: Antibiotic sensitivity spectrum of staphylococcus including methicillin-resistant Staphylococcus aureus

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  Discussion Top


The mean age of the study group was 42.44 ± 20.77 years as seen in a study by Mshangila et al.[5] There was a male preponderance in our study. This is similar to the study conducted by Adeoti et al.[6] However, Mshangila et al.[5] found a female preponderance.

Orbital cellulitis was the most common infection in our study. However, the study done by Pandian et al.[7] showed pre septal cellulitis as the most common infection.

In our study, culture positivity was 44.12% which is comparable with the result obtained by Getahun et al.[8] in which culture positivity was 58.3%. Pus aspirate yielded more positive results than conjunctival swab. This finding was in consensus with study by Liu et al.[9] where cultures from eye swabs and local abscesses gave the highest positive yield, whereas blood cultures gave low positivity. Raja et al.[10] in their study found that conjunctival swab was useful in infections where there is no aspirate to culture. Everts et al.[11] found that conjunctival swabs had good predictive value in the management of acute conjunctivitis. In this study also about 30% of conjunctival swab cultures were positive. This indicates the need for taking eye swabs in ocular infections which may help in identifying the causative organism and institution of appropriate antibiotic therapy in these potentially serious conditions. Pus aspirate from lacrimal abscess gave positive culture result in all five cases.

Staphylococcus was the most common organism isolated in our study. This included S. aureus and MRSA [Figure 2]. Similar study by Adeoti et al.[6] also found out that the S. aureus is the most common organism in orbital and periorbtal infections. This is also comparable with the results obtained by Liu et al.,[9] Ferguson et al.,[12] and Suneetha et al.[13] Out of 27 cases of Staphylococcus isolated, there were 18 isolates (66.7%) of S. aureus and 9 isolates (33.3%) of MRSA. S. aureus was the pathogen isolated from all cases of preseptal cellulitis [Table 3]. Pandian et al.[7] found that MRSA constituted 38% of culture-positive cases in their study. This finding was comparable with our study where the MRSA constituted 33.3%. Community-acquired MRSA is often implicated in orbital cellulitis, which is associated with more ocular morbidity and prolonged hospital stay.[7] MRSA seen in our study was community acquired as none of the patients gave history of recent hospital stay. It indicates the need for modifying our empirical antimicrobial therapy, especially in orbital cellulitis. Maximum yield of MRSA in our study was seen in lid abscess as shown in [Table 3]. This finding is consistent with that obtained by Blomquist et al.,[14] who reported that most common manifestation of ophthalmic MRSA infection was preseptal and/or lid abscess. In a study in the UK in 2005 by Shanmugananthan et al.,[15] out of 548 external eye infections caused by Staphylococcus, only 17 (3%) were MRSA positive. However, studies by Blomquist et al.[14] and Zetola et al.[16] show an increasing prevalence of MRSA infection, as observed in our study. A study by Kluytmans-Vanden Bergh et al.[17] showed that MRSA infections are increasingly reported in healthy community-dwelling individuals without healthcare-associated risk factor. CA-MRSA has been isolated predominantly from skin and soft-tissue infections, such as abscesses, cellulitis, folliculitis, and impetigo.

Amikacin and gentamicin were the antibiotics sensitive to most of the organisms isolated in our study, as shown in [Figure 3]. Antibiotic sensitivity obtained for S. aureus was mainly for cloxacillin, cefazoline, amikacin, and gentamicin. All MRSA isolates were sensitive to amikacin and vancomycin [Figure 4]. This is comparable to the studies done by Shanmuganathan et al.[15] Dilnessa et al.,[18] and Obajuluwa et al.[19] in which S. aureus and MRSA were sensitive to vancomycin and gentamicin.


  Conclusion Top


Microbiological evaluation will help in identifying the common organisms causing orbital and periorbital infections, as well as their antibiotic sensitivity, which will help to minimize the complications and promote early recovery. Simple and cost-effective investigations such as eye swab culture may help in more effective treatment of these potentially serious infections, thus reducing patient's morbidity and mortality. The increasing prevalence of MRSA in ocular tissues should be kept in mind while treating these infections. Periodic susceptibility surveys should be done to know the emerging resistance pattern of these microbial agents, to avoid inappropriate antibiotic therapy as well as spread of antimicrobial resistance in the community.

Limitations

The problem of negative culture still persists, possibly due to inadequate specimen, delay in culture, or prior indiscriminate use of antibiotics by the patients.

As systemic antibiotics are the mainstay of therapy in orbital and periorbital infections, topical antibiotic use was not taken into consideration in this study.

Associated comorbid conditions were not taken into consideration in this study.

Acknowledgment

We would like to acknowledge the support of the Department of Microbiology, Government Medical College, Kozhikode.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goldstein MH, Kowalski RP, Gordon YJ. Emerging fluoroquinolone resistance in bacterial keratitis: A 5-year review. Ophthalmology 1999;106:1313-8.  Back to cited text no. 1
    
2.
Kunimoto DM, Sharma S, Garg P, Rao GN.In vitro susceptibility of bacterial keratitis pathogens to ciprofloxacin. Ophthalmology 1999;106:80-5.  Back to cited text no. 2
    
3.
Dave SB, Toma HS, Kim SJ. Ophthalmic antibiotic use and multidrug-resistant staphylococcus epidermidis: A controlled, longitudinal study. Ophthalmology 2011;118:2035-40.  Back to cited text no. 3
    
4.
Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injection. Ophthalmology 2012;119:1420-4.  Back to cited text no. 4
    
5.
Mshangila B, Paddy M, Kajumbula H, Ateenyi-Agaba C, Kahwa B, Seni J. External ocular surface bacterial isolates and their antimicrobial susceptibility patterns among pre-operative cataract patients at Mulago National Hospital in Kampala, Uganda. BMC Ophthalmol 2013;13:71.  Back to cited text no. 5
    
6.
Adeoti CO, Adejumo OO, Isawumi MA, Kolawole OO, Haastrup AA. Orbital cellulitis in a tertiary institution in Nigeria: Improving outcomes. Niger J Ophthalmol 2017;25:141-5.  Back to cited text no. 6
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7.
Pandian DG, Babu RK, Chaitra A, Anjali A, Rao VA, Srinivasan R. Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococcus aureus in a tertiary hospital in India. Indian J Ophthalmol 2011;59:431-5.  Back to cited text no. 7
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8.
Getahun E, Gelaw B, Assefa A, Assefa Y, Amsalu A. Bacterial pathogens associated with external ocular infections alongside eminent proportion of multidrug resistant isolates at the University of Gondar Hospital, northwest Ethiopia. BMC Ophthalmol 2017;17:151.  Back to cited text no. 8
    
9.
Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu WM. Preseptal and orbital cellulitis: A 10-year review of hospitalized patients. J Chin Med Assoc 2006;69:415-22.  Back to cited text no. 9
    
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Raja NS, Singh NN. Bilateral orbital cellulitis due to Neisseria gonorrhoeae and Staphylococcus aureus: A previously unreported case. J Med Microbiol 2005;54:609-11.  Back to cited text no. 10
    
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Everts RJ, Barnett T, Lahood BR. The utility of routine conjunctival swabs in management of conjunctivitis. N Z Med J 2011;124:64-71.  Back to cited text no. 11
    
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Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust N Z J Ophthalmol 1999;27:375-9.  Back to cited text no. 12
    
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Suneetha N, Teena MM, Usha V, Mary J. Microbiological profile of orbital abscess. Indian J Med Microbiol 2012;30:317-22.  Back to cited text no. 13
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14.
Blomquist PH. Methicillin-resistant Staphylococcus infection of the eye and orbit. Trans Am Ophthalmol Soc 2006;104:322-45.  Back to cited text no. 14
    
15.
Shanmuganathan VA, Armstrong M, Buller A, Tullo AB. External ocular infections due to methicillin-resistant Staphylococcus aureus (MRSA). Eye (Lond) 2005;19:284-91.  Back to cited text no. 15
    
16.
Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired meticillin-resistant Staphylococcus aureus: an emerging threat. The Lancet infectious diseases. 2005 May 1;5:275-86.  Back to cited text no. 16
    
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Kluytmans-Vandenbergh MF, Kluytmans JA. Community-acquired methicillin-resistant Staphylococcus aureus: Current perspectives. Clin Microbiol Infect 2006;12 Suppl 1:9-15.  Back to cited text no. 17
    
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Dilnessa T, Bitew A. Prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus isolated from clinical samples at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. BMC Infect Dis 2016;16:398.  Back to cited text no. 18
    
19.
Obajuluwa AF, Olayinka BO, Adeshina GO, Igwe JC, Onaolapo JA. Antimicrobial Susceptibility Pattern of Staphylococcus aureus Isolates from Orthopaedic Patients in Abuth, Zaria. J Food Ind Microbiol 2016;2:106.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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