Pneumococcal Endophthalmitis after Ocular Surgery -- Alaska, California

Endophthalmitis, a catastrophic condition associated with loss of visual acuity in up to 77% of cases (1), complicates 0.1% of the more than 36,000 corneal transplant surgeries done in the United States and Canada each year (2,3). Some of these infections are caused by organisms transmitted by donor corneas (4-6). This report summarizes four cases in which such infection occurred.

Alaska. In June 1988, two patients developed endophthalmitis following corneal transplant surgery. Both transplants were performed by the same surgeon using transplant tissue harvested 5 days earlier from a 3-year-old drowning victim. One patient, a 40-year-old man, required enucleation of the affected eye; the other patient, an 11-year-old boy, had loss of vision in the affected eye after the infection resolved. Both patients had signs of infection within 48 hours after the transplant surgery. Streptococcus pneumoniae type 14 was isolated from conjunctival swabs of the affected eyes of both patients. Antimicrobial resistance patterns were identical, including intermediate resistance to gentamicin (minimum inhibitory concen trations=8 ug/mL). Donor corneoscleral tissue was not cultured. Both grafts had been stored in commercially available McCarey-Kaufman buffered medium containing gentamicin (100 ug/mL). Each patient had received a single subconjunctival injection of gentamicin after transplantation.

California. In May 1989, two patients developed endophthalmitis following corneal transplantation performed on the same day by different surgeons in different cities. Each transplant used tissue obtained from a 29-year-old motorcycle-crash victim who had been supported on a ventilator for 4 days before death. In one patient, a 76-year-old woman, gram-positive cocci were detected in exudate from a corneal ulcer, and S. pneumoniae was isolated from donor corneoscleral tissue. For the other patient, a 30-year-old man, S. pneumoniae was isolated from vitreous material; however, culture was not obtained on this corneoscleral tissue before transplantation. Serotyping and antimicrobial susceptibility testing were not performed on these isolates. Both patients had symptoms of infection within 24 hours after transplant surgery. The grafts were harvested 3 days before the transplantations and stored in McCarey-Kaufman buffered medium containing 100 ug/mL gentamicin. Each patient had received a single subconjunctival injection of gentamicin following transplantation and both required enucleation of the affected eyes.

CDC examined S. pneumoniae survival in the buffered medium (containing gentamicin) under conditions recommended for cornea storage; 6000 colony-forming units (CFU) of a S. pneumoniae strain isolated from one of the Alaska patients were inoculated into 5 mL of the same buffered cornea storage medium containing 100 ug/mL gentamicin and kept at 4 C (39.2 F). S. pneumoniae was detectable in the medium after 4 days (720 CFU) and 11 days (160 CFU), but not after 14 days. Reported by: M Jones, MD, J Middaugh, MD, State Epidemiologist, Alaska Dept of Health and Social Svcs. R Benjamin, MD, Alameda County Health Dept, Oakland; SB Werner, MD, DO Lyman, MD, State Epidemiologist, California Dept of Health Svcs. Center for Devices and Radiologic Health, Food and Drug Administration. Div of Field Svcs, Epidemiology Program Office; Respiratory Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Staphylococcus epidermidis and Staphylococcus aureus are the most common infecting organisms for postoperative endophthalmitis after corneal transplant surgeries, followed by gram-negative bacilli and various streptococci (6,7). Streptococcus pneumoniae has been reported as an infrequent cause of infection (8-10).

Gentamicin is the sole antibiotic supplement used in commercial cornea storage medium because it has been reported to be more effective than penicillin or cephalothin in reducing the colony counts of S. aureus and gram-negative bacilli in a buffered medium (11). However, streptococci are frequently resistant to gentamicin. Supplementation of the medium with gentamicin is intended to preserve the medium before use and not to sterilize corneal tissue. CDC in vitro studies reported here have demonstrated gentamicin to be ineffective in eliminating one of the infecting strains of S. pneumoniae from cornea storage medium within 11 days. In addition, the four patients reported here had received prophylactic gentamicin by the subconjunctival route. Thus, use of gentamicin alone in cornea storage media or as prophylaxis following corneal transplant surgery may not prevent the rare complication of pneumococcal endophthalmitis.

In the four cases described in this report, contamination of the corneal grafts with S. pneumoniae could have occurred before harvest, at harvest, during storage, or at time of transplantation. However, culture of donor corneoscleral tissue indicated that at least one of the grafts had been contaminated with S. pneumoniae before transplantation.

When cultured, a high proportion (12%-100%) of corneoscleral grafts have yielded contaminating organisms (2,12,13). Even though postoperative endophthalmitis is rare, the Eye Bank Association of America has recommended routine culture of the corneoscleral rim before and/or at the time of surgery (14); when there is clinical evidence of infection, the culture results can be used to guide initiation of appropriate and timely antimicrobial therapy.

Because of the need to further characterize the epidemiology of pneumococcal endophthalmitis following ocular surgery, physicians are asked to report such cases through state health departments to the Respiratory Diseases Branch, Division of Bacterial Diseases, Center for Infectious Diseases, CDC; telephone (404) 639-3021.

References

1. Baum JL. Current concepts in ophthalmology: ocular

infections. N Engl J Med 1978;299: 28-31.

2. Pardos GJ, Gallagher MA. Microbial contamination of donor eyes: a retrospective study. Arch Ophthalmol 1982;100:1611-3.

3. Eye Bank Association of America. 1988 Eye banking activity: a public accounting. Washington, DC: Eye Bank Association of America, 1989:1.

4. Matoba A, Moore MB, Merten JL, McCulley JP. Donor-to-host transmission of streptococcal infection by corneas stored in McCarey-Kaufman medium. Cornea 1984;3:105-8.

5. Khodadoust AA, Franklin RM. Transfer of bacterial infections by donor cornea in penetrating keratoplasty. Am J Ophthalmol 1979;87:130-2.

6. Baer JC, Nirankari VS, Glaros DS. Streptococcal endophthalmitis from contaminated donor corneas after keratoplasty: clinical and laboratory investigations. Arch Ophthalmol 1988;106:517-20.

7. Wilson LA. Acute bacterial infection of the eye: bacterial keratitis and endophthalmitis. Trans Ophthalmol Soc U K 1986;105:43-60.

8. Leveille AS, McMullan FD, Cavanagh HD. Endophthalmitis following penetrating keratoplasty. Ophthalmology 1983;90:38-9.

9. Shaw EL, Aquavella JV. Pneumococcal endophthalmitis following grafting of corneal tissue from a (cadaver) kidney donor. Ann Ophthalmol 1977;9:435-40. 10. Moore PJ, Linneman CC, Sanitato JJ, Binnion B. Pneumococcal endophthalmitis after corneal transplantation: control by modification of harvesting techniques. Infect Control Hosp Epidemiol 1989;10:102-5. 11. Baum J, Barza M, Kane A. Efficacy of penicillin G, cefazolin and gentamicin in M-K medium at 4SDC. Arch Ophthalmol 1978;96:1262-4. 12. Mathers WD, Lamp MA. Corneal rim cultures. Cornea 1987;6:231-3. 13. Hibberd PL, Baker AS. Dangers of eye-to-eye contact. Infect Control Hosp Epidemiol 1989;10:99-101. 14. Eye Bank Association of America. Medical standards. Washington, DC: Eye Bank Association of America, 1989.

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