Endogenous Endophthalmitis Associated With Intravenous Drug Abuse

Patel, Shriji; Rescigno, Ronald; Zarbin, Marco A.; Langer, Paul D.; Bhagat, Neelakshi

doi:10.1097/iae.0000000000000084

Cited by 33 publications

(22 citation statements)

References 16 publications

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“…First extensively studied during a European heroin outbreak in the 1980s, the association between Candida endophthalmitis and IVDA has now been confirmed in multiple series. 7,8,[18][19][20] Candida species were the only causative organisms identified in our patient population, with 3 patients having positive ocular cultures. Two patients had positive vitreous tap cultures, and 1 patient had a positive vitreous biopsy culture.…”

Section: Discussionmentioning

confidence: 99%

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

2017

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IMPORTANCE Intravenous drug abuse (IVDA) is a known risk factor for endogenous fungal endophthalmitis (EFE), a severe intraocular infection caused by hematogenous seeding of mycotic organisms to the eye. Reporting significant increases in heroin-related deaths since 2014, the New England region is in the midst of an opioid crisis that has led to a substantial increase in patients at risk for this vision-threatening disease.OBJECTIVE To present an update on characteristics, management, and visual outcomes in patients with EFE. DESIGN, SETTING, AND PARTICIPANTS Medical records review was initiated on July 1, 2016, evaluating all patients with EFE referred to New England Eye Center at Tufts Medical Center, a tertiary care ophthalmology practice distributed throughout Massachusetts, from May 1, 2014, to May 1, 2016. Patients with a history of IVDA and culture-proven or clinical evidence of fungal endophthalmitis were included. EXPOSURES Intravenous drug use. MAIN OUTCOMES AND MEASURES Patient demographics, comorbidities, presenting symptoms and vision, vitreoretinal findings, treatment regimens, culture data, and final visual acuities.RESULTS Ten patients (5 women) with IVDA-related EFE were identified between May 1, 2014, and May 1, 2016-an increase from 3 patients treated from May 2012 to April 2014. The mean (SD) patient age was 34 (11) years (range, 24-60 years). Presenting visual acuities ranged from 20/25 to hand motion. The most common presenting symptoms were floaters (n = 8), reduced vision (n = 6), and pain (n = 5). Initial treatment included systemic antifungals in all patients and intravitreal antifungals in 9 eyes. Five patients required pars plana vitrectomy for worsening vitritis. The most commonly isolated pathogen was Candida albicans in 20% of the patients. Final visual acuity ranged from 20/40 to 20/300. CONCLUSIONS AND RELEVANCEThe data provided in this report suggest that EFE represents severe end organ damage associated with IVDA and portends poor visual outcomes. Health care professionals must maintain a high suspicion for EFE, as patients are typically ambulatory on presentation without systemic signs of infection.

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Section: Discussionmentioning

confidence: 99%

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

2017

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“…Endogenous endophthalmitis is generally associated with a number of systemic diseases, including liver abscess, pneumonia, endocarditis, urinary tract infection, meninges infection, diabetes mellitus, immunosuppression and some of them had a history of recent hospitalization or recent surgery 20 21 22 23 24 25 26 . Zenith et al .…”

Section: Discussionmentioning

confidence: 99%

Risk factors for endophthalmitis requiring evisceration or enucleation

Zheng

et al. 2016

Sci Rep

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Endophthalmitis has devastating sequelae resulting in blindness and even loss of eyeball. Although the prognosis of endophthalmitis has much improved with the advances of antibiotics and vitreoretinal surgery, of the number of patients that required evisceration or enucleation is still significant. We retrospectively reviewed the charts of 210 eyes of 210 patients with endophthalmitis andcompared the group that required evisceration or enucleation with those that received salvaging therapies. Regression analysis was used to identify the risk factors for evisceration or enucleation. Thirty eyes (14.3%) underwent enucleation or evisceration. The group of eviscerated or enucleated eyes were older (58.7 vs. 42.2 years, p < 0.001), had more women (56.7% vs. 22.2%, p = 0.003), had poorer initial visual acuity (2.79 vs. 2.10 LogMAR, p < 0.001), and had longer duration before intervention (18.03 vs. 5.74 days, p = 0.031). The most common primary indications for endophthalmitis were infections from corneal ulcer (50.0% vs. 4.4%, p < 0.001) andfrom endogenous source (23.3% vs. 5.6%, p < 0.001). Less common indications were trauma (26.7% vs. 67.8%, p < 0.001) and postoperative (6.7% vs. 22.2%, p = 0.049) endophthalmitis. After adjusting for confounding factors, corneal ulcer-related endophthalmitis, endogenous endophthalmitis and initial visual acuity were the independent risk factors for evisceration or enucleation.

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“…Intraocular culture positivity is often low in endogenous endophthalmitis cases, reported at 14-43% in the literature of other centers [2,4,6,[15][16][17]. Given this low diagnostic yield, endophthalmitis must often be treated empirically, such as the initiation of antifungals based on a typical fundus appearance [15]. Primary vitrectomy or polymerase chain reaction (PCR) of the vitreous aspirate may be used to increase diagnostic yield [18].…”

Section: Diagnostic Testingmentioning

confidence: 99%

Endogenous Endophthalmitis: yield of the diagnostic evaluation

et al. 2020

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Background: Endogenous endophthalmitis is an infection of the eye secondary to sepsis, occurring in 0.04-0.5% of bacteremia or fungemia. Risk factors include intravenous drug abuse (IVDA), diabetes, indwelling catheters, and immune suppression. Many patients have known or suspected bacteremia or fungemia; however, culture yield is reported to be low (approximately 50%). The purpose of this study is to elucidate the yield of diagnostic evaluation including microbial cultures over a 6.5 year period at an academic center in the United States. Methods: Retrospective chart review of patients with endogenous endophthalmitis at the University of Florida from June 2011 to February 2018. Results: Included are 40 eyes of 35 patients. Endophthalmitis was secondary to an endogenous source in 23.5% of all endophthalmitis cases observed. Intraocular culture positivity was 28.6% overall but was 0% after initiation of systemic antibiotics. Most commonly identified organisms from the eye were coagulase-negative Staphylococcus and Candida. Blood culture positivity was 48.6%, most commonly Staphylococcus. IVDA was noted with increasing frequency as a risk factor. Diagnosis of endophthalmitis upon hospital admission was associated with a higher intraocular culture positivity (P = 0.040) and a shorter hospital stay (P = 0.035). Computed tomography (CT) and magnetic resonance imaging (MRI) were the highest yield imaging modalities; X-ray and non-ocular ultrasound were less diagnostically useful. Echocardiogram was positive by transesophageal route (TEE) in 22% and in 9% by transthoracic (TTE) testing. Following discharge from the hospital, 48.4% of patients failed to follow up with outpatient ophthalmology. Conclusions: Based on the results of this study, the interdisciplinary team should consider directed imaging, eye cultures prior to antimicrobial administration, thorough history for IVDA, and caution with premature discharge from the hospital.

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Endogenous Endophthalmitis Associated With Intravenous Drug Abuse

Abstract: We reviewed 21 eyes of 18 patients with EE and concurrent intravenous drug abuse over an 8-year period; our study shows extremely poor visual prognosis associated with EE in this setting.

Cited by 33 publications

References 16 publications

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

Risk factors for endophthalmitis requiring evisceration or enucleation

Endogenous Endophthalmitis: yield of the diagnostic evaluation

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