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This is a retrospective study in consecutive cases with cultured-proven endogenous endophthalmitis (EE) treated at the largest tertiary medical center in middle Taiwan in the past 10 years. 83 eyes of 70 patients were enrolled. The mean interval between systemic diseases to the diagnosis of EE was 8.84 ± 6.94 days. The mean initial visual acuity (VA) in the logarithm of minimal angle of resolution (logMAR) was 1.63 ± 0.87. Type 2 diabetes mellitus was the most common predisposing medical illness (N = 53, 63.86%). The most common infectious sources were intra-abdominal abscess (N = 36, 43.37%), and the second most reason was urinary tract infection. The causative pathogen was Gram-negative predominant (N = 64, 77.11%). After aggressive treatment, 34.94% of eyes regain useful vision, and only six eyes underwent enucleation or evisceration. The binary multivariate logistic regression model revealed that female gender (95% CI 1.002–19.036, p = 0.05, OR 4.37), initial VA logMAR (95% CI 0.089–0.550, p = 0.01, OR 0.22), and more intravitreal injections (95% CI 0.368–0.927, p = 0.023, OR 0.58) were independent risk factors influencing final outcomes. Based on the results mentioned above, early diagnosis is recommended to gain better outcomes. The mean interval between systemic diseases to the diagnosis of EE was 8.84 ± 6.94 days in our sample population, clinicians should maintain a higher index of suspicion during this period when encountering patients with bacteremia or fungemia.

Taiwan is endemic for pyogenic liver abscess (PLA). Septic ocular or central nervous system (CNS) complications derived from PLA can result in catastrophic disability. We investigated the epidemiology and long-term prognosis of PLA patients with septic ocular or CNS complications over an 8-year period. We extracted 21,307 patients with newly diagnosed PLA from a nationwide health registry in Taiwan between 2000 and 2007. The frequency of and risk factors for PLA with septic ocular or CNS complications were determined. The 2-year survival of these patients was compared between those with and without septic ocular or CNS complications. Septic ocular or CNS complications accounted for 2.1% of all PLA patients. Age and the Charlson comorbidity index were significantly lower in PLA patients with ocular or CNS complications than those without. Diabetes and age <65 years were independent predictors of septic ocular or CNS complications. The 2-year mortality of patients with septic ocular or CNS complications was similar to those without complications (24.8% vs. 27.5%, p = 0.502). However, among patients <65 years old and a Charlson index ≤ 1, the 2-year mortality was significantly higher in those with than without complications (18.6% vs. 11.8%, p = 0.001). Physicians should recognize that catastrophic disability due to ocular or neurological complications from PLA could lead to a poor long-term prognosis, and should follow-up these patients more closely.

Few data exist on the etiology, presentation, prognosis, and management of fungal endophthalmitis (FE) in cancer patients. FE cases were identified by reviewing the ophthalmology reports and microbiology cultures of patients at The University of Texas M. D. Anderson Cancer Center. We retrospectively reviewed the medical records and obtained information related to malignancy, fungal infection and its management, visual outcome, and mortality. We compared FE caused by Candida spp. (CE) to FE caused by molds (ME). Of the 102 cancer patients with a fungal infection for whom an ophthalmology consult was requested, 23 met the criteria for definite ( N  = 6) or probable ( N  = 17) FE (8 with CE, 15 with ME). All of the patients with ME had hematologic malignancies, whereas half of the patients with CE had solid tumor ( P  = .008). Only patients with CE had a history of surgery within 30 days of FE diagnosis (38%, P  = .03). Fungal pneumonia [17 (74%)] and disseminated infection [14, (61%)] were common. The most common presenting symptoms were decreased vision [16 (70%)] and ocular pain [14 (61%)]. All treated patients received systemic antifungals (combination therapy in 72% of the cases). Seven patients (30%) underwent vitrectomy. Only one patient received intraocular injection of amphotericin B along with systemic antifungals. Four-week mortality was high [13 (57%)], especially in ME (73%, P  = .04). Among the eight surviving patients where visual acuity could be assessed, visual outcome improved or remained stable in five (63%). FE in cancer patients occurs in the setting of severe, frequently disseminated opportunistic mycoses, is caused predominantly by hyalohyphomycetes, and is a marker for high 4-week mortality.

Context Whether immunosuppressive treatment adversely affects survival is unclear.Objective To assess whether immunosuppressive drugs increase mortality.Design Retrospective cohort study evaluating overall and cancer mortality in relation to immunosuppressive drug exposure among patients with ocular inflammatory diseases. Demographic, clinical, and treatment data derived from medical records, and mortality results from United States National Death Index linkage. The cohort’s mortality risk was compared with US vital statistics using standardised mortality ratios. Overall and cancer mortality in relation to use or non-use of immunosuppressive drugs within the cohort was studied with survival analysis.Setting Five tertiary ocular inflammation clinics.Patients 7957 US residents with non-infectious ocular inflammation, 2340 of whom received immunosuppressive drugs during follow up.Exposures Use of antimetabolites, T cell inhibitors, alkylating agents, and tumour necrosis factor inhibitors.Main outcome measures Overall mortality, cancer mortality.Results Over 66 802 person years (17 316 after exposure to immunosuppressive drugs), 936 patients died (1.4/100 person years), 230 (24.6%) from cancer. For patients unexposed to immunosuppressive treatment, risks of death overall (standardised mortality ratio 1.02, 95% confidence interval [CI] 0.94 to 1.11) and from cancer (1.10, 0.93 to 1.29) were similar to those of the US population. Patients who used azathioprine, methotrexate, mycophenolate mofetil, ciclosporin, systemic corticosteroids, or dapsone had overall and cancer mortality similar to that of patients who never took immunosuppressive drugs. In patients who used cyclophosphamide, overall mortality was not increased and cancer mortality was non-significantly increased. Tumour necrosis factor inhibitors were associated with increased overall (adjusted hazard ratio [HR] 1.99, 95% CI 1.00 to 3.98) and cancer mortality (adjusted HR 3.83, 1.13 to 13.01).Conclusions Most commonly used immunosuppressive drugs do not seem to increase overall or cancer mortality. Our results suggesting that tumour necrosis factor inhibitors might increase mortality are less robust than the other findings; additional evidence is needed.

Purpose To present the different clinical manifestations of rhino-orbital mucormycosis (ROM) co-infection in severe COVID-19 patients. Study design Prospective observational clinical study Methods Among 32,814 patients hospitalized with the diagnosis of COVID-19 between March 2020 and December 2020 in our center, eleven microbiologically confirmed ROM co-infection cases in severe COVID-19 patients were evaluated. Results There were nine men and two women with a mean age of 73.1 ± 7.7 years. Eight patients had uncontrolled type 2 diabetes with a mean diagnosis duration of 12.1 ± 4.4 years. All patients had COVID-19-associated acute respiratory distress syndrome and received corticosteroids. The mean time interval between COVID-19 diagnosis and ROM diagnosis was 14.4 ± 4.3 days. Seven patients (63.6%) had orbital apex syndrome, and four patients (36.4%) presented with orbital cellulitis. Endophthalmitis was detected in 54.5% of patients, and two of these patients developed retinoschisis. CT scan/MRI revealed sino-orbital involvement in all patients, and three of these had cerebral involvement at initial presentation. All patients received intravenous and retrobulbar liposomal amphotericin B and had undergone radical debridement of involved sinuses. Intravitreal liposomal amphotericin B injected in patients with endophthalmitis. Despite all measures, 63.6% of patients expired. Conclusions Severe COVID-19 is associated with a significant incidence of ROM with higher mortality rates due to immune dysregulation and the widespread use of steroids. Physicians should be aware of the possibility of this infection in patients with COVID-19. An aggressive multidisciplinary approach can help to reduce mortality.

Purpose To explore how endophthalmitis presented from 2009 to 2019 in a West Virginia population particularly affected by the national opioid crisis. The analysis explores the relationship between the type of endophthalmitis and mortality, accounting for factors including age, gender, type of organism, and intravenous drug use (IVDU). Methods The electronic health record of West Virginia University (WVU) Medicine was queried for all patients managed for endophthalmitis from October 2009 to October 2019. For each of the included subjects, age, gender, history of IVDU, culture results, concomitant endocarditis, type of endophthalmitis, and the date of diagnosis were extracted. Mortality data were obtained from WVU’s electronic medical record, the Social Security Death Index, and public obituaries. Mortality results were represented by a Kaplan–Meier Survival curve following each patient for one year from the date of diagnosis. Results were analyzed using unadjusted and adjusted Cox Proportional Hazard models. Results One-year mortality was 14 out of 113 endogenous cases (12.4%) compared to 6 out of 173 exogenous cases (3.5%). Endogenous endophthalmitis cases had significantly higher mortality than exogenous ones within one year of diagnosis ( p  = 0.0034). The unadjusted Cox proportional hazards model revealed that the type of endophthalmitis (endogenous vs. exogenous) was the only variable with a significant impact on 1-year mortality with a hazard ratio of 3.78 ( p  = 0.01). However, the hazard ratio for endogenous infections rose to 10.91 (CI 3.544–33.595) when the other variables of age, gender, organism, and IVDU were controlled ( p  < 0.01). The Cox proportional hazard ratios for age group, gender, organism type, and history of IVDU were not significantly different when adjusted for all other variables. Conclusion Endogenous cases, which were significantly overrepresented in West Virginia, were associated with a significantly higher 1-year mortality rate than the exogenous ones. Age, gender, organism type, and history of IVDU have less, if any, modifying effect on mortality.

Background To study the epidemiology of patients with endogenous endophthalmitis in Denmark. Material and methods Retrospective and prospective case series of 59 eyes in patients with endogenous endophthalmitis in Denmark between 2000 and 2016. Results The age of the patients ranged from 28 to 90 years with a median of 66 years. Sixty-two percent of the eyes had a final VA (visual acuity) ≤ 0.1 while 8% had a final VA ≥ 1.0. Positive cultures were obtained in 51% of the cases from the blood and in 43% from the vitreous. Streptococcus species and Staphylococcus aureus were the most commonly identified microorganisms. The sources of endogenous endophthalmitis were diverse and were not identified in 36% of the patients. Diabetes (36%) was the most predisposing medical illness. A total of 15% of the patients died within the first year after surgery for endophthalmitis and half of the patients died during follow up. The mortality of patients was 22.6 times higher compared to a Danish background population. Culture positive patients had a higher mortality compared to culture negative patients. Conclusions Endogenous endophthalmitis is a heterogeneous condition which is reflected in the age, the visual outcome and the mortality of the patients. The epidemiology of the disease is very different in Scandinavia compared to Asia. The visual prognosis remains grave and the majority of the eyes lose useful vision.

Aims To identify the clinical features and prognostic factors of endogenous endophthalmitis caused by Klebsiella pneumoniae. Methods This is a retrospective case series of all patients with Klebsiella endophthalmitis managed from January 2006 to December 2015 by Kowloon East Ophthalmic Service. Statistical analysis involved hypothesis testing on the SPSS 18.0 software (SPSS). A significance level of P <0.05 was taken. Results In the 10-year period, K. pneumoniae accounted for 19 out of 39 cases of endogenous endophthalmitis (48.7%). The mean age of patients was 67.9 years. Bilateral involvement occurred in five patients (26.3%). More than half of the patients (10/19, 52.6%) had underlying diabetes mellitus. Most patients had concurrent liver abscess (18/19, 94.74%). Ten patients (52.6%) had disseminated intravascular coagulopathy. Eight patients (42.1%) were in shock. The overall mortality was 21.1% (4/19). Septic shock was associated with a significantly higher mortality (50.0 vs 0%, P =0.018). Among the 15 survivors, nine patients (60.0%) required evisceration and three patients (20.0%) had no light perception in an involved eye. Eyes with diffuse posterior involvement were less likely to have a final visual acuity of logMAR 0.30 or better than those with focal posterior involvement (4.76 vs 100% 4.76%, P =0.002). Patients with hypopyon were more likely to require evisceration (85.71 vs 25.00%, P =0.02). Conclusions Klebsiella endophthalmitis is associated with a high incidence of diabetes mellitus and liver abscess. Prognosis remains poor. Universal ocular screening and systemic control in patients with Klebsiella sepsis are recommended.

Flucytosine is an antifungal agent first licensed in the 1970’s. However, its clinical value has long been overlooked and its availability across the globe is limited. This review highlights the important clinical and pharmacological aspects of flucytosine. This a narrative review of the clinical and in vitro susceptibility literature, with a focus on clinical uses for flucytosine. Detailed literature review including early literature related to primary and acquired resistance to flucytosine. Flucytosine has good antifungal activity against Cryptococcus species, Candida species, and dematiaceous fungi. Its water solubility enables good penetration into the eye, urinary tract, central nervous system (CNS), cardiac vegetations and fungal biofilms. In combination with amphotericin B, it shows early fungicidal activity against Cryptococcus species, and this translates to ~20% improved survival in cryptococcal meningitis. Combination therapy also reduces the mortality of Candida meningitis, and should be used in neonatal candidiasis because of the high frequency of CNS infection. Monotherapy for urinary candidiasis is under-studied, but is usually effective. It is probably valuable in the treatment of Candida endocarditis and endophthalmitis: there are few data. It is not effective for aspergillosis or mucormycosis. Flucytosine monotherapy of urinary candidiasis resulted in 22% developing resistance on therapy and failing therapy, and in 29% of 21 patients with cryptococcosis. Certain regions of the world still do not have access to flucytosine compromising the management of certain severe fungal infections. Flucytosine has an important role in combination therapy for yeast and dematiaceous infections and probably as monotherapy for urinary candidiasis, with a modest risk of resistance emergence. Facilitating access to flucytosine in those regions (especially low-income countries) might alleviate the mortality of invasive fungal diseases

We present a case of bilateral endogenous endophthalmitis with an extremely rare etiology of Capnocytophaga canimorsus. A 42-year-old asplenic patient with bilateral deterioration of visual acuity presented to the Emergency Department. The sudden deterioration of visual acuity, which prompted the patient to visit the ophthalmologist, was the first sign of the onset of sepsis. The physicians’ attention, in addition to poor visual acuity and intense inflammation on ophthalmologic examination, was drawn to the reported flu-like symptoms. They were accompanied by high C-reactive protein results and abnormalities in echocardiography. A blood culture isolated the bacterium Capnocytophaga canimorsus. Immunocompromised patients are particularly susceptible to C. canimorsus infection. Endophthalmitis of this etiology has a very aggressive course, both ophthalmic and systemic. Therefore, quick diagnosis and initiation of adequate therapy are crucial.