Risk Factors Predictive of Endogenous Endophthalmitis Among Hospitalized Patients With Hematogenous Infections in the United States

doi:10.1016/j.ajo.2014.11.032

American Journal of Ophthalmology

Volume 159, Issue 3, March 2015, Pages 498-504

https://doi.org/10.1016/j.ajo.2014.11.032 Get rights and content

Purpose

To identify potential risk factors associated with endogenous endophthalmitis among hospitalized patients with hematogenous infections.

Design

Retrospective cross-sectional study.

Methods

MarketScan Commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefit inpatient databases from the years 2007-2011 were obtained. Utilizing ICD-9 codes, logistic regression was used to identify potential predictors/comorbidities for developing endophthalmitis in patients with hematogenous infections.

Results

Among inpatients with hematogenous infections, the overall incidence rate of presumed endogenous endophthalmitis was 0.05%-0.4% among patients with fungemia and 0.04% among patients with bacteremia. Comorbid human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) (OR = 4.27; CI, 1.55-11.8; P = .005), tuberculosis (OR = 8.5; CI, 1.2-61.5; P = .03), endocarditis (OR = 8.3; CI, 4.9-13.9; P < .0001), bacterial meningitis (OR = 3.8; CI, 1.2-12.0; P = .023), fungal meningitis (OR = 59.1; CI, 14.1-247.8; P < .0001), internal organ abscess (OR = 2.9; CI, 1.2-6.4; P = .02), lymphoma/leukemia (OR = 2.9; CI, 1.6-5.3; P < .0001), skin abscess/cellulitis (OR = 1.75; CI, 1.1-2.8; P = .02), pyogenic arthritis (OR = 4.2; CI, 1.8-9.6; P = .001), diabetes with ophthalmic manifestations (OR = 7.0; CI, 1.7-28.3; P = .006), and urinary tract infection (OR = 0.04; CI, 0.3-0.9; P = .023) were each significantly associated with a diagnosis of endogenous endophthalmitis. Patients aged 0-17 years (OR = 2.61; CI, 1.2-5.7; P = .02), 45-54 years (OR = 3.4; CI, 2.0-5.4; P < .0001), and 55-64 years (OR = 2.9; CI, 1.8-4.8; P < .0001); those having length of stay of 3-10 days (OR = 1.9; CI, 1.1-3.3; P = .01), 11-30 days (OR = 3.1; CI, 1.8-5.5; P < .0001), and 31+ days (OR = 5.3; CI, 2.7-10.4; P < .0001); and those with intensive care unit/neonatal intensive care unit (ICU/NICU) admissions (OR = 1.5; CI, 1.4-1.6; P < .0001) were all more likely to be diagnosed with endogenous endophthalmitis.

Conclusions

Endogenous endophthalmitis is rare among hospitalized patients in the United States. Among patients with hematogenous infections, odds of endogenous endophthalmitis were higher for children and middle-aged patients, and for patients with endocarditis, bacterial meningitis, lymphoma/leukemia, HIV/AIDS, internal organ abscess, diabetes with ophthalmic manifestations, skin cellulitis/abscess, pyogenic arthritis, tuberculosis, longer hospital stays, and/or ICU/NICU admission.

Section snippets

Data Source

We performed a retrospective population-based cohort study utilizing the MarketScan Commercial Claims and Encounters, and the Medicare Supplemental and Coordination of Benefit inpatient databases from the years 2007 through 2011 (the most recent year the database was available). The MarketScan family of databases comprises the largest convenience-based proprietary database in the United States, annually encompassing approximately 40-50 million patients with employer-sponsored or supplemental

Prevalence and Clinical Characteristics

We identified a total of 11 396 085 unique hospitalized patients over the study period (Table 1). We found 258 092 patients with a diagnosis of bacteremia/septicemia, 3704 with a diagnosis of fungemia, and 1394 patients with a diagnosis of endophthalmitis. Of the total 261 796 patients diagnosed with hematogenous infections (2.3% of inpatients), 122 were identified with a comorbid diagnosis of endophthalmitis—implying an endogenous endophthalmitis incidence rate of 0.05% among patients with

Discussion

Endogenous endophthalmitis is an uncommon but potentially sight-threatening condition that can occur at any age and in either sex, via inoculation of the eye by infectious pathogens spread systemically through the bloodstream. It results in inflammation and, often, vision loss. Our results showed an incidence rate of 0.05% for presumed endogenous endophthalmitis among hospitalized patients with hematogenous infections. A higher proportion of patients with fungemia (0.4%) developed endogenous

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Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment.
Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.
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The Impact of Frailty Syndrome on Endogenous Endophthalmitis Development and Outcomes: A Population-Level Analysis
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Characterize the impact of frailty on endogenous endophthalmitis (EE) development and clinical outcomes among septicemic patients.
Population-level, retrospective cohort study.
Adult inpatients within the National Inpatient Sample (years 2002–2014) diagnosed with bacterial septicemia.
Septicemic patients were classified as frail or nonfrail using the previously validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, and diagnosis of EE was abstracted from International Classification of Diseases 9 codes. We used multivariable logistic regression to generate odds ratios (ORs) for rates of EE development and in-hospital mortality based on frailty status. We also examined the association between frailty and blood culture–proven organism class, inpatient length of stay, and total charges billed to insurance.
Incidence of EE among septicemic patients; rates of EE development among frail and nonfrail patients; blood culture–proven microbe type, length of stay, and total charges billed to insurance.
9294 of 18 470 658 (0.05%) inpatients with bacteremia developed EE, 2102 (22.6%) of whom had at least 1 frailty-defining feature (predominantly malnutrition [68%]). Odds of developing EE were 16.7% higher for frail patients (OR, 1.167; 95% confidence interval, 1.108–1.229) when controlling for age, sex, race, concomitant human immunodeficiency virus/AIDS, pyogenic liver abscess, infectious endocarditis, cirrhosis, and diabetes with chronic complications. Frail EE patients had a 27.9% increased odds of in-hospital death, independent of age, sex, race, and Elixhauser comorbidity score (OR, 1.279; 95% confidence interval, 1.056–1.549). Higher rates of methicillin-resistant Staphylococcus aureus bacteremia (14.3% vs. 10.9%, P = 0.000016), gram-negative bacteremia (7.6% vs. 4.9%, P = 0.000003), and concomitant candidemia (10.4% vs. 7.0%, P = 0.0000004) were associated with frailty. Hospital stays were significantly longer (median, 14 days; interquartile range, 19 days; P < 0.00001) and total charges billed to insurance were significantly greater (median, $96 398; interquartile range, $154,682; P < 0.00001) among frail EE patients.
Frailty syndrome is independently associated with development of EE in the setting of bacterial septicemia; frailty-associated EE may occur in patients with malnutrition and particular bacterial subtypes, and it predisposes to higher rates of in-hospital death and health care resource usage.
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To elucidate the linkage between organisms and visual outcome in cases of endogenous endophthalmitis.
Patients who presented with signs of endogenous endophthalmitis between January 2008 and December 2015 and underwent a vitreous tapping were enrolled. The patients’ demographics and clinical findings were recorded. The outcomes include visual acuity and enucleation.
A total of 175 consecutive patients with endogenous endophthalmitis were enrolled. Forty-four percent of the patients had a known distal focus of infection. The most common focus was liver abscess (24.6%), and the major intravitreal isolate was Klebsiella pneumoniae (34.4%). In this series, 51.4% of the intravitreal cultures were positive. The visual acuity of fungal ophthalmitis were better than in bacterial ophthalmitis. Multivariate logistic regression showed that Gram negative vitreous isolates, compared with the negative vitreous culture, were associated with higher risk of enucleation (Odds ratio [OR]: 10.424, 95% confidence interval [95% CI]: 3.019–35.995). The use of intravitreal antibiotics, compared non-users, was associated with a reduced risk of enucleation (OR:0.084, 95% CI: 0.026–0.268). Trans pars plana vitrectomy was not associated with risk of enucleation (OR: 0.307, 95% CI: 0.035–2.693). The post-treatment VA was positively correlated with the presenting VA (r = 0.718, p = 0.0001).
Our study demonstrated that liver abscess is the most common source of endogenous endophthalmitis in Taiwan. The visual outcome is good when the presenting visual acuity is relatively well preserved and when the infecting organism is fungus. The use of intra-vitreal antibiotics reduces the risk of enucleation.
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The epidemiology of infective endocarditis has evolved over the course of history. With the advent of new procedures, diagnostics, and therapies over time, there have been changes in the clinical presentation and overall prognosis of this illness. Pathogenesis involves a series of sequential steps that take into account underlying host conditions and epidemiological risk factors, which can then result in a multitude of clinical manifestations (both cardiac and extracardiac). Appreciation of the mechanisms by which pathogenesis occurs, the epidemiological risk factors that are involved, and the clinical presentations associated with infective endocarditis are important concepts in understanding the landscape of this infectious illness.

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Original articleRisk Factors Predictive of Endogenous Endophthalmitis Among Hospitalized Patients With Hematogenous Infections in the United States

Purpose

Design

Methods

Results

Conclusions

Section snippets

Data Source

Prevalence and Clinical Characteristics

Discussion

Surv Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Surv Ophthalmol

Endogenous endophthalmitis

Curr Opin Ophthalmol

Endogenous endophthalmitis: a 13-year review at a tertiary hospital in South Australia

Scand J Infect Dis

Endogenous fungal endophthalmitis: causative organisms, management strategies, and visual acuity outcomes

Am J Ophthalmol

Original article
Risk Factors Predictive of Endogenous Endophthalmitis Among Hospitalized Patients With Hematogenous Infections in the United States