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Asymptomatic bacteriuria and acute-onset endophthalmitis after cataract surgery

      Studies examining the variables associated with endophthalmitis after cataract surgery focus on surgical technique, antisepsis, and the use of prophylactic antibiotics.
      • Miller J.J.
      • Scott I.U.
      • Flynn Jr, H.W.
      • et al.
      Acute-onset endophthalmitis after cataract surgery (2000-2004): incidence, clinical settings, and visual acuity outcomes after treatment.
      • Taban M.
      • Behrens A.
      • Newcomb R.L.
      • et al.
      Acute endophthalmitis following cataract surgery: a systematic review of the literature.
      • Ng J.Q.
      • Morlet N.
      • Bulsara M.K.
      • Semmens J.B.
      Reducing the risk for endophthalmitis after cataract surgery: population based nested case-control study: endophthalmitis population study of Western Australia sixth report.
      • Cooper B.A.
      • Holekamp N.M.
      • Bohigian G.
      • Thompson P.A.
      Case-control study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wounds.
      Few patient predispositions to endophthalmitis have been identified. In this article, three cases of postoperative bacterial endophthalmitis are presented. They are noteworthy because the infections were caused by the same genus of organism identified in urine cultures in the months preceding surgery. Each patient was being observed with asymptomatic bacteriuria, and none had symptoms to suggest they were septic before surgery. Standard 5% povidone-iodine surgical preps were performed in each case; intracameral antibiotics were not used.

      Case Reports

      Case 1

      An 81-year-old male underwent uncomplicated clear-corneal cataract extraction with insertion of a posterior chamber intraocular lens (IOL). The patient had a suprapubic catheter for 1 year before surgery. Urine had grown Escherichia coli with > 105 colony-forming units (cfu)/mL on 3 occasions. He was treated with intravenous antibiotics only when the catheter was changed. A urine culture was not performed immediately before surgery. Severe inflammation on the first day after surgery was diagnosed as toxic anterior segment syndrome and treated with topical corticosteroids. By postoperative day 5, inflammation had not improved; a vitreous biopsy was performed and antibiotics were injected. The culture grew E coli. Inflammation progressed and the eye was eviscerated 3 days later. The vitreous, retina, and uveal tract were effaced with suppurative inflammation (Fig. 1A). A Gram stain showed sheets of gram-negative rods (Fig. 1A, inset).
      Figure thumbnail gr1
      Fig 1Histopathology of 3 eyes with postoperative endophthalmitis. (A) Vitreous from Patient 1 contains neutrophils with myriad bacterial forms at edge of cortical gel (arrows) (hematoxylin and eosin staining; scale bar = 120 µm). (A, inset) Gram stain reveals confluent mass of gram-negative rods. Bacteria are so thick the area blushes pink (scale bar = 12 µm). (B) Eye from Patient 2 with optic nerve (ON) at bottom shows vitreous cortex to the left filled with purulent exudate. The largely necrotic retina is barely discernable at this magnification (hematoxylin and eosin staining; scale bar = 3.1 mm). (C) Patient 3 eviscerated ocular tissue shows vitreous replaced with purulent exudate. Portions of retina are present peripherally (hematoxylin and eosin staining; scale bar = 1.4 mm).

      Case 2

      A 77-year-old male underwent uncomplicated clear-corneal incision cataract extraction with insertion of a posterior chamber IOL. Before surgery, the patient had a history of recurrent microscopic hematuria and bacteriuria, with few complaints referable to the urinary tract. Cultures on several occasions had grown Pseudomonas species, Klebsiella species, and Enterococcus faecalis in concentrations ranging from 2.5 × 104 cfu/mL to > 105 cfu/mL. A urologic evaluation was postponed until cataract surgery was completed. Urine was not cultured immediately before surgery. On postoperative day 6, the patient returned with a hypopyon. Later that day, a vitrectomy was performed and the eye was injected with antibiotics. Vitreous culture grew E faecalis. The eye became progressively more painful and was removed 15 days after surgery. The eye was acutely inflamed (Fig. 1B). No microorganisms were found with special stains.

      Case 3

      An 83-year-old female with diabetes mellitus underwent uncomplicated scleral-tunnel incision cataract extraction with insertion of a posterior chamber IOL. She had asymptomatic bacteriuria; several urine cultures in the preceding year grew E coli in concentrations > 105 cfu/ml. She had not been given antibiotics. No preoperative urinalysis or culture was performed. On postoperative day 4, clinicians suspected an intraocular infection. That day a vitreous biopsy and injection of antibiotics were performed. Culture grew E coli. The eye deteriorated and was eviscerated 8 days after surgery. Contents of the eye were severely, acutely inflamed (Fig. 1C). Organisms suspicious for gram-negative rods were seen with Gram stain.

      Discussion

      The association between urine pathogens and ocular infections in these patients suggests a possibly overlooked risk factor for endophthalmitis. In the seminal study by Schein et al.
      • Schein O.D.
      • Katz J.
      • Bass E.B.
      • Tielsch J.M.
      • et al.
      The value of routine preoperative medical testing before cataract surgery.
      that examined the value of routine preoperative medical testing before cataract surgery, urinalysis was not evaluated among preoperative tests, and endophthalmitis was not an outcome event. Subsequent studies investigating the impact of routine preoperative tests on outcome have not included urinalysis.
      • Keay L.
      • Lindsley K.
      • Tielsch J.
      • et al.
      Routine preoperative medical testing for cataract surgery.
      Numerous studies have examined risk factors for acute postoperative endophthalmitis. More than 40 variables have been systematically studied, but asymptomatic bacteriuria has not been one of them.
      • Cao H.
      • Zhang L.
      • Li L.
      • Lo S.
      Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis.
      • Li J.
      • Morlet N.
      • Ng J.Q.
      • et al.
      Significant nonsurgical risk factors for endophthalmitis after cataract surgery: EPSWA fourth report.
      Current guidelines for the prevention and treatment of endophthalmitis after cataract surgery do not address the subject of preoperative urinary tract infection.
      • Packer M.
      • Chang D.F.
      • Dewey S.H.
      • et al.
      Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis.
      To the author’s knowledge, only 2 case reports have described the association of asymptomatic bacteriuria with postoperative endophthalmitis.
      • Margo C.E.
      • Cole E.L.
      III. Postoperative endophthalmitis and asymptomatic bacteriuria caused by Group G Streptococcus.
      • Tsanaktsidis G.
      • Agarwal S.A.
      • Maloof A.J.
      • et al.
      Postoperative Morganella morganii endophthalmitis associated with subclinical urinary tract infection.
      Bacteria that most often thrive in urine, such as E coli, E faecalis, Pseudomonas species, and Klebsiella species, make up a minority of cases of postoperative endophthalmitis, but they are usually associated with a poor outcome. Patients with bacteriuria and urinary catheters harbor tens of thousands of potentially virulent intraocular pathogens in each millilitre of urine. These organisms are shed in high numbers and can exist on fingers and inanimate surfaces for days.
      • Linder K.A.
      • Hecker M.T.
      • Kundrapu S.
      • et al.
      Evaluation of patients’ skin, environmental surfaces, and urinary catheters as sources for transmission of urinary pathogens.
      • Kramer A.
      • Schwebke I.
      • Kampf G.
      How long do nosocomial pathogens persist on inanimate surfaces. A systematic review.

      Conclusions

      Eye surgeons may want to screen preoperative patients for histories of recurrent urinary tract infection, asymptomatic bacteriuria, or indwelling urinary catheters, and when indicated, obtain urinalysis and culture. Given the validated role that hand hygiene plays in reducing nosocomial infections in hospitals and infections in nonclinical settings,
      • Babeluk R.
      • Jutz S.
      • Merlitz S.
      • et al.
      Hand hygiene—evaluation of three disinfectant hand sanitizers in a community setting.
      surgical candidates may benefit from instructions on the proper use of disinfectant hand sanitizers after visiting the restroom or handling urinary catheters and urine bags. If high bacterial colony counts exist, the risks and benefits of systemic antibiotic treatment should be discussed with the patient and, if needed, appropriate clinical consultants. Although the Infectious Diseases Society of America and the U.S. Preventive Services Task Force recommend no treatment of asymptomatic bacteriuria in adults,
      • Nicolle L.E.
      • Bradley S.
      • Colgan R.
      • et al.
      Infectious Diseases Society of America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.
      the role of antibiotic treatment for urinary tract infection has never been addressed in the context of intraocular surgery.

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