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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 183-185

Postoperative endophthalmitis due to multidrug-resistant Klebsiella pneumoniae treated successfully with intravitreal colistin and core vitrectomy


1 Department of Ophthalmology, JIPMER, Puducherry, India
2 Department of Microbiology, JIPMER, Puducherry, India

Date of Submission24-Feb-2020
Date of Decision02-Mar-2020
Date of Acceptance03-Mar-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Ajax Jossy
Department of Ophthalmology, JIPMER, Old IPD Block, 1st Floor, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_23_20

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  Abstract 


We report a case of Klebsiella-related multidrug-resistant (MDR) postoperative endophthalmitis in a 60-year-old male treated successfully with colistin and core vitrectomy. Vision in the affected left eye (LE) at presentation was hand movements. Vitreous tap with intravitreal antibiotics (vancomycin and ceftazidime) showed no clinical improvement after 48 h. Gram stain of vitreous sample showed Gram-negative bacilli. Bacterial culture showed MDR Klebsiella pneumoniae isolates with sensitivity only to colistin. LE core vitrectomy was performed and intravitreal colistin was administered. At 1 month, vision in LE improved to 20/20 with no subsequent recurrence.

Keywords: Intravitreal colistin, Klebsiella pneumoniae, multidrug-resistant endophthalmitis


How to cite this article:
Deb AK, Sistla S, Chowdhury SS, Jossy A, Kasturi N. Postoperative endophthalmitis due to multidrug-resistant Klebsiella pneumoniae treated successfully with intravitreal colistin and core vitrectomy. Kerala J Ophthalmol 2020;32:183-5

How to cite this URL:
Deb AK, Sistla S, Chowdhury SS, Jossy A, Kasturi N. Postoperative endophthalmitis due to multidrug-resistant Klebsiella pneumoniae treated successfully with intravitreal colistin and core vitrectomy. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Oct 29];32:183-5. Available from: http://www.kjophthal.com/text.asp?2020/32/2/183/293290




  Introduction Top


Endophthalmitis is one of the most dreaded complications following any intraocular surgery. The incidence of endophthalmitis reported following cataract surgery ranges from 0.04% to 0.2%. Visual prognosis is often guarded in such cases; around 40% of cases have visual outcome of <20/200 while only around 30% cases recover visual acuity of better than 20/40.[1] Visual prognosis wanes further in the presence of multidrug-resistant (MDR) strains due to limited treatment options. Klebsiella pneumoniae-associated endophthalmitis generally has poor visual outcomes, despite treatment with appropriate antibiotics. MDR klebsiella strains, therefore, pose a greater challenge in management and often necessitate the use of uncommon antibiotics. We, hereby, report a case of MDR K. pneumoniae endophthalmitis after cataract surgery which showed resistance to all conventional and routinely tested antibiotics and was treated successfully with intravitreal colistin.[2],[3]


  Case Report Top


A 60-year-old male presented with sudden onset decreased vision, pain, and floaters in the left eye for 3 days' duration 1 month following uneventful cataract surgeries in both eyes. He was not a known case of diabetes mellitus or on any immunosuppressants. On examination, best-corrected visual acuity (BCVA) in the right eye (RE) was 20/20 and the left eye (LE) was hand movements. Anterior segment and fundus examination of RE were normal. LE examination showed corneal edema, anterior chamber (AC) 2 + cells and 1 + flare, posterior chamber intraocular lens (PCIOL) with whitish inflammatory deposits on the IOL. Fundus examination showed dense vitritis with disc and macula faintly visible. Ultrasonography (USG) B scan of LE on day 1 revealed mild-to-moderate vitreous echogenicities occupying the entire vitreous cavity suggestive of dense vitritis due to endophthalmitis [Figure 1]a. The patient was started on topical moxifloxacin 0.5% hourly, topical prednisolone acetate 1% hourly and homatropine 2% three times daily. LE vitreous tap was done along with intravitreal injections of vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml). Gram stain of vitreous tap showed Gram-negative bacilli. Bacterial culture on 5% sheep blood agar media showed gray moist colonies and on MacConkey media showed mucoid lactose fermenting colonies suggestive of K. pneumoniae. Antimicrobial susceptibility testing (AST) showed multidrug resistance [Table 1]. Isolated klebsiella species showed sensitivity only to colistin. Repeat USG B scan on day 3 confirmed increased vitritis compared to initial presentation [Figure 1]b. Subsequently, LE core vitrectomy was performed and intravitreal colistin (0.1 mg/0.1 ml) was administered. The patient was also started on intravenous colistin (150 mg twice daily × 7 days) and topical 1% colistin eyedrops hourly in addition to previous topical medications. On postoperative day 7, visual acuity in the LE improved to 20/40. Slit lamp examination showed clear cornea and PCIOL in situ, no hypopyon or inflammatory membrane in AC [Figure 2]a while fundus examination showed clear media with normal disc and macula [Figure 2]b. Topical steroids were tapered and stopped over the next 2 months while topical antibiotics were continued for 3 months. At 1 month, BCVA in LE improved to 20/20 which was maintained at 6th month of follow-up.
Figure 1: Ultrasonography B scan of the left eye on day 1 showed mild to moderate vitreous echogenicities occupying the entire vitreous cavity suggestive of dense vitritis (a) which increased on day 3 (b)

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Table 1: Antimicrobial susceptibility testing report of vitreous tap from the left eye

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Figure 2: Slit lamp examination 1 week after vitrectomy showed clear cornea with posterior chamber intraocular lens in situ(a) and fundus examination at 1 week showed clear media with normal disc and macula (b)

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  Discussion Top


K. pneumoniae endophthalmitis is mostly endogenous in etiology and rarely can be postoperative endophthalmitis as well. Any form of endophthalmitis with Klebsiella strain isolates has guarded visual prognosis due to virulent nature of the organism.[3],[4] MDR in such a situation makes the management further challenging. Multidrug resistance confers on the organisms an acquired nonsusceptibility to at least one agent across three or more categories of antimicrobials.[5] MDR Klebsiella strains exhibit resistance to multiple antibiotic classes namely cephalosporins, aminoglycosides, and tetracyclines. This necessitates treatment with unconventional antibiotics, for example, colistin, polymyxin B, and tigecycline.[4] Colistin belongs to the class of polymyxin antimicrobials. It acts on the cell membranes of bacteria and promotes extracellular leakage of cellular proteins, thereby causing cell death. Indications for use include infections by MDR strains of Pseudomonas aeruginosa, Acinetobacter baumannii, and K. pneumonia.[3],[4],[6] To the best of our knowledge, there are only three prior case series which had reported use of intravitreal colistin.

Samant and Ramugade have reported intravitreal use of colistin with considerable success in eight cases of MDR P. aeruginosa associated endophthalmitis.[7] Taneja et al. have reported a case of MDR K. pneumoniae-associated postkeratoplasty endophthalmitis which was treated successfully with intravitreal colistin along with combined multiple core vitrectomies.[3] Dogra et al. have reported a case of bilateral endogenous endophthalmitis which was treated successfully with intravenous colistin and multiple intravitreal colistin injections in the LE alone.[4] Our case also was treated successfully with core vitrectomy and a single dose of intravitreal colistin injection combined with intravenous colistin and topical colistin eyedrops. Visual acuity in the affected eye in our case had recovered to 20/20 which was maintained during the subsequent follow-up till date with no recurrence of infection. This highlights the possibility of complete visual recovery even in MDR cases if prompt and accurate microbiological diagnosis and sensitivity testing can be done followed by sensitivity guided treatment. However, retinal toxicity profile of colistin is not known. Although the cases reported so far have shown no adverse retinal functional or anatomical outcome, we should be cautious in using newer intravitreal agents.[7] Due to lack of pharmacodynamic and pharmacokinetic aspects of intravitreal doses of colistin, future animal studies are needed to derive at an appropriate nontoxic and effective intravitreal dose of colistin.[3]

In all cases of confirmed or suspected endophthalmitis, microbiological confirmation of the organism and AST should be done and further treatment should then be guided accordingly. In multidrug-resistant cases, prompt testing of the uncommon antibiotics such as imipenem and colistin followed by early vitrectomy and intravitreal injection of the sensitive antibiotic is mandatory to ensure optimal visual outcome.[2]

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.
Hashemian H, Mirshahi R, Khodaparast M, Jabbarvand M. Post-cataract surgery endophthalmitis: Brief literature review. J Curr Ophthalmol 2016;28:101-5.  Back to cited text no. 1
    
2.
Sanghi S, Pathengay A, Jindal A, Raval V, Nayak S, Sharma S, et al. Acute-onset postoperative endophthalmitis caused by multidrug-resistant Klebsiella pneumoniae. Clin Ophthalmol 2014;8:1783-5.  Back to cited text no. 2
    
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]  
5.
Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: An international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268-81.  Back to cited text no. 5
    
6.
Michalopoulos AS, Tsiodras S, Rellos K, Mentzelopoulos S, Falagas ME. Colistin treatment in patients with ICU-acquired infections caused by multiresistant gram-negative bacteria: The renaissance of an old antibiotic. Clin Microbiol Infect 2005;11:115-21.  Back to cited text no. 6
    
7.
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. 7
[PUBMED]  [Full text]  


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