Purpose: Staphylococcus epidermidis, a commensal, has emerged as an important opportunistic pathogen, particularly methicillin-resistant S. epidermidis (MRSE). The mechanism behind this transformation remains unclear. This study aimed to investigate the molecular and phenotypic characteristics of MRSE isolated from healthy conjunctiva and ocular infections. Methods: We collected MRSE isolates from two groups: healthy conjunctiva from patients undergoing cataract surgeries and ocular infections at our hospital. Genotypic analysis included pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), staphylococcal cassette chromosome mec (SCCmec), and biofilm-related genes (icaA, aap, and bhp). Additionally, phenotypic data on biofilm production and antibiotic susceptibility were recorded. Results: A total of 86 isolates, including 42 from healthy conjunctiva and 44 from ocular infections, were analyzed. MLST identified 21 sequence types (STs), with ST59 being the most frequent (n = 33, 39.5%), followed by ST130 (n = 10, 11.6%), ST57 (n = 6, 7.0%), and ST2 (n = 6, 7.0%). All isolates were categorized in 23 PFGE types, and SCCmec IV was the most prevalent SCCmec type (n = 52, 60.5%). The two sources of isolates exhibited overlapping molecular types and phenotypic traits, although the ocular infection isolates exhibited significantly higher multidrug resistance compared to healthy conjunctiva isolates (P = 0.032). When contrasting ST59 with non-ST59, ST59 displayed a significantly higher presence of aap (100%) and bhp (69.7%) while lacking icaA (0%). ST59 also showed lower susceptibility to fluoroquinolones compared to non-ST59 (42.4%–54.5% vs. 75.5%–83.0%; P < 0.01). Conclusions: MRSE isolates from healthy conjunctiva and ocular infections demonstrated a degree of resemblance. Specific strains, notably ST59, exhibited distinctive characterizations.
Paecilomyces/Purpureocillium species is an emerging pathogen of fungal keratitis; the risk factor, clinical course, and outcome of Paecilomyces/Purpureocillium keratitis need more exploration. We retrospectively reviewed 12 patients with culture-proven Paecilomyces/Purpureocillium keratitis in our hospital from 2003 to 2017 and combined them with 50 previous cases reported after the review conducted by Yuan et al. in 2009. Clinical features between the previously and newly reported cases were compared using the publication by Yuan et al. as a cutoff point. The mean age of the 62 newly reported patients with Paecilomyces/Purpureocillium keratitis was 52.7 years. Of these, contact lens wear was the most common predisposing factor (n = 32, 52%), followed by a preexisting corneal disease or previous ocular surgery (n = 12, 19%), and trauma (n = 8, 13%). Fifty eyes (81%) were treated with voriconazole, of which 31 (63%) were medically cured. Twenty-one of 62 eyes (34%) required therapeutic surgery. Compared with the 42 patients reported by Yuan et al., the patients were younger (P = .025); a higher proportion of the patients were contact lens wearers (P = .005); more patients were treated with voriconazole (P = .000); fewer patients required therapeutic surgery (P = .000) in recent reports. Contact lens use has become the major risk factor for Paecilomyces/Purpureocillium keratitis. The surgical rate has been significantly lower in recent publications, probably because of the prevalent use of voriconazole.
The monitoring of a sentinel monthly indicator ‘number of endophthalmitis post cataract surgery on total operations for cataract’ alerted the surgical and hygiene teams on the possible degradation of practical care: the usual rate of 0.2% became 0.9%: seven new cases in 5 months, becoming higher than the data from the literature (0.1 to 0.2%). This finding was part of a double context of surgery activity transfer in a new place and a significant increase in activity of Ophthalmology: 401 procedures in 2007 versus 801 in 2008. The objective of both teams was then to identify if new organisations and practices could reduce the occurrence of this type of infection.
Program
To reduce the occurrence of post-cataract endophthalmitis, objectified by reducing the infection rate for 100 procedures. After each new case, the hygiene team has coordinated a multi professionnal meeting including all stakeholders supporting the patient: Surgeons, the operating room nurse chief, hospital nurses, anaesthesiologists, manager, pharmacist in charge with sterilisation, biologist, biomedical engineering and technical services. At each meeting, the entire patient journey, from his pre-operative consultation, his surgeon sector arrival, his operating room stay, his surgeon sector return, until his home return was analysed by the ‘5M’ or Ishikawa method with dysfunctions search at every step. For each identified failure, corrective actions have been consensually proposed and then consensually implemented, such as: For each identified failure, corrective actions have been consensually proposed and then consensually implemented, such as: Equipment: buying single-use devices, Patient: improving the patient participation through information booklets on the preoperative shower and eye drops instillation art at home Environment: change air filter in the surgical room after a leak diagnosis Method: organisation of a pre operative nurse consultation dedicated to patient information, developing protocols for preparing the operative field, cleaning of the operating room and reusable instruments (microscope, slit lamp…), clarifying the circuit and behaviour of the professionals (changing surgical mask for the entire operating team between two interventions), prescriptions for home care for patients without autonomy. Manpower: formation of a dedicated staff to educate patients, manage and sterilise ophthalmic equipment.
Results
Establishing coordinated and concerted set of measures concerning the possible causes of these infections has helped to reduce the frequency of occurrence: one endophthalmitis since the last 12 months following the last analysis (for a stable activity).
Discussion
This work highlights the need to follow clinical indicators, although we need downturn although we can not say with certainty the relationship between the variation in time and the implementation of actions: Track reliable indicator as the method of ‘statistical process control’ could afford to sharpen the relationship between improvement rate and restructuring undertaken: it requires to introduce discipline into the evaluation of professional practice as well as required in clinical research, through the methodologists helps. To conclude, this program highlights the value of combining methods of assessment practices such as monitoring indicators and methodical research of causes described by J Reason, at all stages of patient journey, involving all stakeholders. It strengthened the relationship of trust and transparency among stakeholders. It can serve as an example to encourage other surgical teams to report and analyse their surgical site infections.
Contexte
La surveillance d9un indicateur sentinelle mensuel ‘nombre d9endophtalmie post chirurgie de la cataracte sur total d9interventions pour cataracte’ a alerté les équipes de chirurgie et d9hygiène sur la possible dégradation des pratiques de prise en charge: le taux habituel est passé de 0.2% à 0.9%: 7 nouveaux cas en 5 mois, devenant supérieur aux données de la littérature (0.1 à 0.2%). Ce constat s9inscrivait dans un double contexte de transfert de l9activité opératoire dans de nouveaux locaux et d9une importante augmentation de l9activité d9ophtalmologie: 401 interventions en 2007 versus 801 en 2008. L9objectif des deux équipes était alors d9identifier si de nouvelles pratiques et organisations pouvaient réduire la survenue de ce type d9infection.
Programme
Réduire la survenue d9endophtalmie post cataracte, objectivable par la réduction du taux d9infection pour 100 interventions. Après chaque nouveau cas, l9équipe d9hygiène a coordonné une réunion pluriprofessionnelle comprenant tous les acteurs de la prise en charge du patient: chirurgiens, cadre du bloc opératoire, infirmières d9hospitalisation, anesthésistes, représentant de la direction, pharmacien en charge de la stérilisation, biologiste, ingénieurs biomédical et des services techniques. A chaque réunion, l9ensemble du parcours du patient, depuis sa consultation pré opératoire, son arrivée dans le service de chirurgie ambulatoire, son passage au bloc opératoire, son retour dans le service, jusqu9à son retour à domicile était analysé par la méthode des ‘5M’ avec recherche de dysfonctionnements à chaque niveau. Pour chaque dysfonctionnement identifié, des actions correctives ont été proposées consensuellement puis mises en œuvre de façon concertée, telles que: Matériel: achat d9instruments à usage unique, Matière (patient): amélioration de sa participation via des plaquettes d9information sur la douche préopératoire et la technique d9instillation des collyres à domicile, Milieu: changement de filtre à air en salle d9intervention après diagnostic d9une fuite, Méthode: organisation d9une consultation infirmière pré opératoire dédiée à l9information du patient, protocolisation de la préparation du champ opératoire, de l9entretien des salles d9intervention et des instruments réutilisables (microscope, lampe à fente…), des circuit et comportement des professionnels au bloc (changement de masque chirurgical pour toute l9équipe opératoire entre deux interventions), prescription de soins à domicile pour les patients peu autonomes … Main d9œuvre: formation d9un personnel dédié pour informer les patients, gérer et stériliser le matériel d9ophtalmologie
Résultats
La mise en place coordonnée et concertée de l9ensemble des mesures portant sur les possibles causes profondes de ces infections a permis d9en réduire la fréquence de survenue: 1 endophtalmie en 12 mois depuis la dernière analyse (activité stable).
Discussion
ce travail met en évidence l9intérêt de suivre des indicateurs cliniques, malgré le peu de recul et quand bien même on ne peut affirmer avec certitude le lien entre la variation temporelle du taux et la mise en œuvre des actions: fiabiliser le suivi d9indicateur selon la méthode de “maîtrise statistique des processus” permettrait d9affiner la relation entre l9amélioration du taux et les réorganisations engagées: cela demande d9introduire dans l9évaluation des pratiques professionnelles la rigueur exigée en recherche clinique, via l9aide de méthodologistes. En conclusion ce programme témoigne de l9intérêt de combiner des méthodes d9évaluation des pratiques telles que le suivi d9indicateurs et la recherche méthodique des causes profondes décrites par J Reason, à toutes les étapes du parcours du patient, rassemblant tous les acteurs. Il a renforcé la relation de confiance et de transparence entre les acteurs. Il peut servir d9exemple pour inciter d9autres équipes chirurgicales à signaler et analyser leurs infections de site opératoire.
Purpose. Alternaria spp. are an uncommon cause of mycotic keratitis. Previous studies on Alternaria keratitis have generally been limited to case reports. We examined the clinical characteristics of Alternaria keratitis in this study. Methods. The characteristics and outcomes of 7 patients with culture-proven Alternaria keratitis treated in our hospital were compared with 25 previously reported cases. Results. The risk factors for Alternaria keratitis were trauma in 5 patients and soft contact lenses in 1 patient. Six patients with early diagnosis (<2 weeks) were cured with medical antimicrobial treatment; a patch graft was required in 1 patient with perforation. When incorporated with previous reports on Alternaria keratitis (n = 32), 14 (44%) infections followed trauma, 10 (31%) were associated with preexisting corneal disease or previous ocular surgery, and 5 (16%) occurred in soft contact lens wearers. Successful medical treatment was achieved in 23 (72%) patients, including 10 out of 21 eyes (48%) treated with natamycin and/or amphotericin B. Therapeutic penetrating keratoplasty was performed in 9 (28%) cases. Conclusions. Alternaria keratitis is generally associated with specific risk factors and responds to medical treatment when early diagnosis is performed and prompt antifungal treatment is initiated.
Staphylococcus aureus is an important pathogen for keratitis, a vision-threatening disease. We aimed to investigate the genotyping, antibiotic susceptibility, and clinical features of S. aureus keratitis, and to explore the possible role of Panton-Valentine leucocidin (PVL), a major virulence factor of S. aureus. We recruited 49 patients with culture-proven S. aureus keratitis between 2013 and 2017 at Chang Gung Memorial Hospital, Taiwan. PVL gene, multilocus sequence type (MLST), staphylococcal cassette chromosome mec (SCCmec), and pulsed-field gel electrophoresis (PFGE) were performed. Antibiotic susceptibility was verified using disk diffusion/E test. There were 49 patients with S. aureus keratitis; 17 (34.7%) were caused by methicillin-resistant S. aureus (MRSA) and 9 (18.4%) isolates had PVL genes. The predominant genotyping of MRSA isolates was CC59/PFGE type D/SCCmec VT/PVL (+). All methicillin-sensitive S. aureus (MSSA) and approximately 60% MRSA were susceptible to fluoroquinolones. No significant differences in clinical features, treatments, and visual outcomes were observed between MRSA/MSSA or PVL(+)/PVL(-) groups. In Taiwan, approximately one third of S. aureus keratitis was caused by MRSA, mainly community-associated MRSA. Although MRSA isolates were more resistant than MSSA, clinical characteristics were similar between two groups. Fluoroquinolones could be good empiric antibiotics for S. aureus keratitis.
To investigate the distribution, current trends, and antibiotic susceptibility profiles of bacterial keratitis isolates over 10 years.We retrospectively reviewed the microbiology records of all corneal scrapings undertaken for cultures at Chang Gung Memorial Hospital from 2003 through 2012. We identified bacterial isolates and verified antibiotic susceptibilities by using the disk diffusion method. The Mantel-Haenszel linear-by-linear association χ test was used to detect the trends.We collected 2012 corneal scrapings, and the culture was positive in 992 samples (49.3%), yielding 1282 isolates. Bacterial isolates were identified for 1039 isolates (81.1%), including 533 gram-positive and 506 gram-negative isolates. An increase in the percentage of gram-positive isolates was significant (P = 0.008), as was a decrease in that of gram-negative isolates (P = 0.002). The most common bacterial isolates were Pseudomonas aeruginosa (24.4%) and coagulase-negative Staphylococcus (16.6%). For gram-positive organisms, the susceptibilities were as follows: vancomycin 100%, ciprofloxacin 88.9%, sulfamethoxazole-trimethoprim 86.8%, clindamycin 73.2%, and oxacillin 56.5%. The susceptibility of gram-positive bacteria to clindamycin and oxacillin increased significantly (P = 0.009 and P = 0.001). For gram-negative organisms, the susceptibilities were as follows: ciprofloxacin 93.7%, piperacillin 91.9%, ceftazidime 90.9%, amikacin 88.3%, and gentamicin 84.7%. No change in trend occurred.In Taiwan, we documented an increasing trend in the percentage of gram-positive bacteria. Methicillin-resistant microorganisms accounted for 43.5% of all gram-positive bacteria, but the trend of resistance to oxacillin and clindamycin significantly decreased. Ciprofloxacin continued to be a good empiric antibiotic for treating bacterial keratitis.
Purpose: The relationship between Panton–Valentine leucocidin (PVL), a major virulence factor of Staphylococcus aureus, and disease severity and clinical outcomes remains unclear. We investigated the molecular characteristics and role of the PVL gene in methicillin-resistant S. aureus (MRSA) ocular infection in Taiwan. Methods: Patients with culture-proven S. aureus ocular infection in Chang Gung Memorial Hospital from 2010 to 2017 were included. The presence of the PVL gene was detected for all S. aureus isolates. MRSA isolates were characterized through pulsed-field gel electrophoresis (PFGE), staphylococcal multilocus sequence type, and staphylococcal cassette chromosome mec (SCCmec) typing. Drug susceptibility was examined using disk diffusion method and E-test. Patients’ demographics, diagnoses, and outcomes were collected. Results: There were 112 methicillin-sensitive S. aureus and 103 MRSA isolates. Among 50 PVL(+) S. aureus isolates, 43 were MRSA. CC59/PFGE type D/SCCmec IV, VT (38 of 43 isolates, 88%), and CC59/PFGE type C/SCCmec IV (27 of 60 isolates, 45%) were the predominant clones in the PVL(+) and PVL(−) MRSA isolates, respectively. When we compared the two CC59 strains, the patients with PVL(+)/CC59 MSRA infection were significantly younger than those with PVL(−)/CC59 MSRA (39.3 vs. 61.7 years; P = 0.001). PVL(+)/CC59 MSRA caused significantly more eyelid disorders (36.8% vs. 3.7%; P = 0.002) but less keratitis (23.7% vs. 51.9%; P = 0.034). The antibiograms of the two strains were similar. Conclusions: PVL(+) MRSA is significantly associated with eyelid infection, especially in young patients. Translational Relevance: PVL gene plays a role in clinical features of MRSA ocular infections.
Protein 70-1 (Hsp70-1) in Human Limbo-Corneal Epithelial Cells Cultivated on Amniotic Membrane: A Proteomic Study DAVID HUI-KANG MA,* JUI-YANG LAI, SZU-TZU YU, JIA-YE LIU, UNIQUE YANG, HUNG-CHI JESSE CHEN, LUNG-KUNG YEH, YI-JU HO, GRACE CHANG, SU-FANG WANG, JAN-KAN CHEN, AND KEN-KUO LIN Limbal Stem Cell Laboratory, Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan Department of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan Institute of Biochemical and Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan Biomedical Engineering Research Center, Chang Gung University, Taoyuan, Taiwan Department of Biology, University of California, Berkeley, California Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan Department of Biology, University of Oregon, Eugene, Oregon Department of Radiology, Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan Department of Physiology, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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