Clinical features and prognosis of 56 cases with streptococcal endophthalmitis_Chinese Journal of Ocular Fundus Diseases

Authors：

Zhang Xiuwen ¹ , Xiong Xiaomei ¹ , Li Xiaoxia ¹ , Shen Siqi ² ,  Huang Taomin ¹

1. Department of Pharmacy, Eye & ENT Hospital, Fudan University, Shanghai 200031, China;
2. School of Pharmacy, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China;

Corresponding author：

Huang Taomin, Email: taominhuang@126.com

Keywords：

Endophthalmitis; Streptococci; Visual outcomes; Antibiotic susceptibility

DOI：

10.3760/cma.j.cn511434-20230508-00202

Video：

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Objective To investigate the clinical settings, antibiotic susceptibilities, management and outcomes of streptococcal endophthalmitis. Methods A retrospective observational case series study. Fifty six eyes of 56 patients diagnosed with streptococcal endophthalmitis in Eye & ENT Hospital, Fudan University from 2012 to 2022 were collected. The treatment followed the general principles of relevant guidelines, including pars plana vitrectomy (PPV), vitreous injection of antibiotics (IVI), vitreous injection of glucocorticoids and systemic application of antibiotics. The follow-up time was (11.9±17.0) months. Patients' clinical characteristics, pathogenic distribution and antibiotic susceptibilities, treatment and outcomes in their medical records were retrospectively collected and analyzed. Results All 56 patients had monocular onset, including 39 (69.6%, 39/56) males and 17 (30.4%, 17/56) females, 26 (46.4%, 26/56) with left eyes involved and 30 (53.6%, 30/56) with right eyes involved. Their average age was (25.0±24.4) years. Ocular trauma was the leading cause of streptococcal endophthalmitis (73.2%, 41/56), followed by ophthalmic surgery (23.2%, 13/56) and endogenous infection (3.6%, 2/56). The streptococcal species included Streptococcus viridans (50.0%, 28/56), Streptococcus pneumoniae (18/56, 32.1%) and β-hemolytic Streptococcus (17.9%, 10/56). The susceptibility rates of Streptococcus to penicillin, cefatriaxone, vancomycin and levofloxacin were 66.0%, 57.1%, 94.1% and 92.4%, respectively. Patients received PPV+IVI and IVI as initial treatment were 49 eyes (87.5%, 49/56) and 7 eyes (12.5%, 7/56), respectively. Vitreous injection of glucocorticoids were performed in 17 eyes (30.4%, 17/56); and systemic antibiotics were applied in 52 cases (92.9%, 52/56). At the final follow-up, 47 eyes were recorded with visual acuity. Twenty (35.7%, 20/56) had best corrected visual acuity (BCVA)≥0.05 and 27 (48.2%, 27/56) had BCVA ＜0.05, of which 1 (1.8%, 1/56) had an eyeball enucleation. The etiology of endophthalmitis, streptococcal species, initial treatment with PPV, vitreous injection of glucocorticoids, and systemic antibiotics did not significantly affect patients' visual outcomes (P＞0.05). Timely visit to the hospital after the onset of symptoms (≤3 days) was significantly associated with achieving a final BCVA above 0.05 (P=0.025). Conclusions Ocular trauma was the primary cause of streptococcal endophthalmitis. Streptococcus viridans is the most common pathogenic bacterium. Streptococci had high susceptibility to vancomycin, but patients' visual outcomes were poor.

Citation： Zhang Xiuwen, Xiong Xiaomei, Li Xiaoxia, Shen Siqi, Huang Taomin. Clinical features and prognosis of 56 cases with streptococcal endophthalmitis. Chinese Journal of Ocular Fundus Diseases, 2023, 39(9): 735-740. doi: 10.3760/cma.j.cn511434-20230508-00202 Copy

1.	Jacobs DJ, Leng T, Flynn HJ, et al. Delayed-onset bleb-associated endophthalmitis: presentation and outcome by culture result[J]. Clin Ophthalmol, 2011, 5: 739-744. DOI: 10.2147/OPTH.S17975.
2.	Miller JJ, Scott IU, Flynn HJ, et al. Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment[J]. Am J Ophthalmol, 2005, 139(6): 983-987. DOI: 10.1016/j.ajo.2005.01.025.
3.	Wykoff CC, Parrott MB, Flynn HJ, et al. Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009)[J]. Am J Ophthalmol, 2010, 150(3): 392-398. DOI: 10.1016/j.ajo.2010.04.010.
4.	McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: causative organisms and possible prevention strategies[J]. Retina, 2011, 31(4): 654-661. DOI: 10.1097/IAE.0b013e31820a67e4.
5.	Abu EA, Al-Amro SA, Al-Mosallam AA, et al. Post-traumatic endophthalmitis: causative organisms and visual outcome[J]. Eur J Ophthalmol, 1999, 9(1): 21-31. DOI: 10.1177/1120672199 00900104.
6.	Kuriyan AE, Weiss KD, Flynn HJ, et al. Endophthalmitis caused by streptococcal species: clinical settings, microbiology, management, and outcomes[J]. Am J Ophthalmol, 2014, 157(4): 774-780. DOI: 10.1016/j.ajo.2013.12.026.
7.	Yospaiboon Y, Meethongkam K, Sinawat S, et al. Predictive factors in the treatment of streptococcal endophthalmitis[J]. Clin Ophthalmol, 2018, 12: 859-864. DOI: 10.2147/OPTH.S161217.
8.	Kurniawan ED, Rocke JR, Sandhu SS, et al. Predictors of visual outcome and the role of early vitrectomy in streptococcal endophthalmitis[J]. Clin Exp Ophthalmol, 2018, 46(4): 424-431. DOI: 10.1111/ceo.13077.
9.	Lemley CA, Han DP. Endophthalmitis: a review of current evaluation and management[J]. Retina, 2007, 27(6): 662-680. DOI: 10.1097/IAE.0b013e3180323f96.
10.	Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group[J]. Arch Ophthalmol, 1995, 113(12): 1479-1496. DOI: 10.1001/archopht.1995.01100 120009001.
11.	Yang Y, Sui W, Duan F, et al. Post-traumatic endophthalmitis caused by streptococcus species in preschool children: clinical features, antibiotic susceptibilities and outcomes[J]. Eye (Lond), 2022, 36(1): 95-101. DOI: 10.1038/s41433-021-01449-6.
12.	中华医学会眼科学分会眼外伤学组. 中国外伤性感染性眼内炎防治专家共识(2023年)[J]. 中华眼科杂志, 2023, 59(2): 90-95. DOI: 10.3760/cma.j.cn112142-20221018-00521.China Ocular Trauma Society. Chinese expert consensus on the prophylaxis and management of traumatic infectious endophthalmitis (2023)[J]. Chin J Ophthalmol, 2023, 59(2): 90-95. DOI: 10.3760/cma.j.cn112142-20221018-00521.
13.	中华医学会眼科学分会眼底病学组, 中华医学会眼科学分会白内障及屈光手术学组中华医学会眼科学分会眼外伤学组, 中华医学会眼科学分会青光眼学组. 中国眼科手术后感染性眼内炎诊疗专家共识(2022年)[J]. 中华眼科杂志, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.Chinese Vitreo-Retina Society of Chinese Medical Association, Chinese Cataract and Refractive Surgery Society, China Ocular Trauma Society, Glaucoma Group of Ophthalmology Branch of Chinese Medical Association. Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)[J]. Chin J Ophthalmol, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.
14.	北京医学会检验分会. 感染性眼病的病原微生物实验室诊断专家共识[J]. 中华检验医学杂志, 2022, 45(1): 14-23. DOI: 10.3760/cma.j.cn114452-20210728-00460.Laboratory Branch of Beijing Medical Association. Expert consensus on laboratory diagnosis of pathogenic microorganisms in ocular infectious diseases[J]. Chin J Lab Med, 2022, 45(1): 14-23. DOI: 10.3760/cma.j.cn114452-20210728-00460.
15.	Jiang X, Wan Y, Yuan H, et al. Incidence, prophylaxis and prognosis of acute postoperative endophthalmitis after cataract surgery: a multicenter retrospective analysis in northern China from 2013 to 2019[J]. Infect Drug Resist, 2022, 15: 4047-4058. DOI: 10.2147/IDR.S332997.
16.	Staropoli PC, Flynn HJ, Miller D, et al. Endophthalmitis caused by streptococcus: clinical outcomes and antimicrobial susceptibilities 2014-2019[J]. Ophthalmic Surg Lasers Imaging Retina, 2021, 52(4): 182-189. DOI: 10.3928/23258160-20210330-02.
17.	Yoshida M, Yokokura S, Nishida T, et al. Endogenous endophthalmitis caused by group B streptococcus; case reports and review of 35 reported cases[J]. BMC Ophthalmol, 2020, 20(1): 126. DOI: 10.1186/s12886-020-01378-0.
18.	Yang Y, Wong Y, Li Y, et al. Clinical features, antibiotic susceptibilities, and outcomes of endophthalmitis caused by streptococcal infection: children vs. adults[J]. Antibiotics (Basel), 2023, 12(6): 962. DOI: 10.3390/antibiotics12060962.
19.	Kattan HM, Flynn HJ, Pflugfelder SC, et al. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery[J]. Ophthalmology, 1991, 98(2): 227-238. DOI: 10.1016/S0161-6420(91)32312-1.
20.	Pokharel D, Doan AP, Lee AG. Group B streptococcus endogenous endophthalmitis presenting as septic arthritis and a homonymous hemianopsia due to embolic stroke[J]. Am J Ophthalmol, 2004, 138(2): 300-302. DOI: 10.1016/j.ajo.2004.02.068.
21.	Wu Z, Uzcategui N, Chung M, et al. Group B streptococcal endogenous endophthalmitis in a neonate[J]. Retina, 2006, 26(4): 472-473. DOI: 10.1097/01.iae.0000238540.13638.e3.
22.	Mao LK, Flynn HJ, Miller D, et al. Endophthalmitis caused by streptococcal species[J]. Arch Ophthalmol, 1992, 110(6): 798-801. DOI: 10.1001/archopht.1992.01080180070030.
23.	Chen KJ, Chong YJ, Sun MH, et al. Streptococcus pneumoniae endophthalmitis: clinical settings, antibiotic susceptibility, and visual outcomes[J/OL]. Sci Rep, 2021, 11(1): 6195[2021-03-18]. https://pubmed.ncbi.nlm.nih.gov/33737573/. DOI: 10.1038/s41598-021-85456-3.
24.	Ng JQ, Morlet N, Pearman JW, et al. Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)'s fifth report[J]. Ophthalmology, 2005, 112(7): 1199-1206. DOI: 10.1016/j.ophtha.2005.01.050.

1. Jacobs DJ, Leng T, Flynn HJ, et al. Delayed-onset bleb-associated endophthalmitis: presentation and outcome by culture result[J]. Clin Ophthalmol, 2011, 5: 739-744. DOI: 10.2147/OPTH.S17975.
2. Miller JJ, Scott IU, Flynn HJ, et al. Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment[J]. Am J Ophthalmol, 2005, 139(6): 983-987. DOI: 10.1016/j.ajo.2005.01.025.
3. Wykoff CC, Parrott MB, Flynn HJ, et al. Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002-2009)[J]. Am J Ophthalmol, 2010, 150(3): 392-398. DOI: 10.1016/j.ajo.2010.04.010.
4. McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: causative organisms and possible prevention strategies[J]. Retina, 2011, 31(4): 654-661. DOI: 10.1097/IAE.0b013e31820a67e4.
5. Abu EA, Al-Amro SA, Al-Mosallam AA, et al. Post-traumatic endophthalmitis: causative organisms and visual outcome[J]. Eur J Ophthalmol, 1999, 9(1): 21-31. DOI: 10.1177/1120672199 00900104.
6. Kuriyan AE, Weiss KD, Flynn HJ, et al. Endophthalmitis caused by streptococcal species: clinical settings, microbiology, management, and outcomes[J]. Am J Ophthalmol, 2014, 157(4): 774-780. DOI: 10.1016/j.ajo.2013.12.026.
7. Yospaiboon Y, Meethongkam K, Sinawat S, et al. Predictive factors in the treatment of streptococcal endophthalmitis[J]. Clin Ophthalmol, 2018, 12: 859-864. DOI: 10.2147/OPTH.S161217.
8. Kurniawan ED, Rocke JR, Sandhu SS, et al. Predictors of visual outcome and the role of early vitrectomy in streptococcal endophthalmitis[J]. Clin Exp Ophthalmol, 2018, 46(4): 424-431. DOI: 10.1111/ceo.13077.
9. Lemley CA, Han DP. Endophthalmitis: a review of current evaluation and management[J]. Retina, 2007, 27(6): 662-680. DOI: 10.1097/IAE.0b013e3180323f96.
10. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group[J]. Arch Ophthalmol, 1995, 113(12): 1479-1496. DOI: 10.1001/archopht.1995.01100 120009001.
11. Yang Y, Sui W, Duan F, et al. Post-traumatic endophthalmitis caused by streptococcus species in preschool children: clinical features, antibiotic susceptibilities and outcomes[J]. Eye (Lond), 2022, 36(1): 95-101. DOI: 10.1038/s41433-021-01449-6.
12. 中华医学会眼科学分会眼外伤学组. 中国外伤性感染性眼内炎防治专家共识(2023年)[J]. 中华眼科杂志, 2023, 59(2): 90-95. DOI: 10.3760/cma.j.cn112142-20221018-00521.China Ocular Trauma Society. Chinese expert consensus on the prophylaxis and management of traumatic infectious endophthalmitis (2023)[J]. Chin J Ophthalmol, 2023, 59(2): 90-95. DOI: 10.3760/cma.j.cn112142-20221018-00521.
13. 中华医学会眼科学分会眼底病学组, 中华医学会眼科学分会白内障及屈光手术学组中华医学会眼科学分会眼外伤学组, 中华医学会眼科学分会青光眼学组. 中国眼科手术后感染性眼内炎诊疗专家共识(2022年)[J]. 中华眼科杂志, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.Chinese Vitreo-Retina Society of Chinese Medical Association, Chinese Cataract and Refractive Surgery Society, China Ocular Trauma Society, Glaucoma Group of Ophthalmology Branch of Chinese Medical Association. Chinese expert consensus on the diagnosis and management of infectious endophthalmitis after ophthalmic surgery (2022)[J]. Chin J Ophthalmol, 2022, 58(7): 487-499. DOI: 10.3760/cma.j.cn112142-20220301-00088.
14. 北京医学会检验分会. 感染性眼病的病原微生物实验室诊断专家共识[J]. 中华检验医学杂志, 2022, 45(1): 14-23. DOI: 10.3760/cma.j.cn114452-20210728-00460.Laboratory Branch of Beijing Medical Association. Expert consensus on laboratory diagnosis of pathogenic microorganisms in ocular infectious diseases[J]. Chin J Lab Med, 2022, 45(1): 14-23. DOI: 10.3760/cma.j.cn114452-20210728-00460.
15. Jiang X, Wan Y, Yuan H, et al. Incidence, prophylaxis and prognosis of acute postoperative endophthalmitis after cataract surgery: a multicenter retrospective analysis in northern China from 2013 to 2019[J]. Infect Drug Resist, 2022, 15: 4047-4058. DOI: 10.2147/IDR.S332997.
16. Staropoli PC, Flynn HJ, Miller D, et al. Endophthalmitis caused by streptococcus: clinical outcomes and antimicrobial susceptibilities 2014-2019[J]. Ophthalmic Surg Lasers Imaging Retina, 2021, 52(4): 182-189. DOI: 10.3928/23258160-20210330-02.
17. Yoshida M, Yokokura S, Nishida T, et al. Endogenous endophthalmitis caused by group B streptococcus; case reports and review of 35 reported cases[J]. BMC Ophthalmol, 2020, 20(1): 126. DOI: 10.1186/s12886-020-01378-0.
18. Yang Y, Wong Y, Li Y, et al. Clinical features, antibiotic susceptibilities, and outcomes of endophthalmitis caused by streptococcal infection: children vs. adults[J]. Antibiotics (Basel), 2023, 12(6): 962. DOI: 10.3390/antibiotics12060962.
19. Kattan HM, Flynn HJ, Pflugfelder SC, et al. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery[J]. Ophthalmology, 1991, 98(2): 227-238. DOI: 10.1016/S0161-6420(91)32312-1.
20. Pokharel D, Doan AP, Lee AG. Group B streptococcus endogenous endophthalmitis presenting as septic arthritis and a homonymous hemianopsia due to embolic stroke[J]. Am J Ophthalmol, 2004, 138(2): 300-302. DOI: 10.1016/j.ajo.2004.02.068.
21. Wu Z, Uzcategui N, Chung M, et al. Group B streptococcal endogenous endophthalmitis in a neonate[J]. Retina, 2006, 26(4): 472-473. DOI: 10.1097/01.iae.0000238540.13638.e3.
22. Mao LK, Flynn HJ, Miller D, et al. Endophthalmitis caused by streptococcal species[J]. Arch Ophthalmol, 1992, 110(6): 798-801. DOI: 10.1001/archopht.1992.01080180070030.
23. Chen KJ, Chong YJ, Sun MH, et al. Streptococcus pneumoniae endophthalmitis: clinical settings, antibiotic susceptibility, and visual outcomes[J/OL]. Sci Rep, 2021, 11(1): 6195[2021-03-18]. https://pubmed.ncbi.nlm.nih.gov/33737573/. DOI: 10.1038/s41598-021-85456-3.
24. Ng JQ, Morlet N, Pearman JW, et al. Management and outcomes of postoperative endophthalmitis since the endophthalmitis vitrectomy study: the Endophthalmitis Population Study of Western Australia (EPSWA)'s fifth report[J]. Ophthalmology, 2005, 112(7): 1199-1206. DOI: 10.1016/j.ophtha.2005.01.050.

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