Abstract
Purpose
To report Achromobacter xylosoxidans as a cause of both acute-onset and delayed-onset postoperative endophthalmitis after cataract surgery.
Methods
A non-comparative, consecutive case series of patients with culture-proven A. xylosoxidans endophthalmitis between 1970 and 2012. Cataract surgery and intraocular lens placement were performed in all patients prior to endophthalmitis. Positive cultures were obtained from the vitreous, capsular bag, and/or the removed intraocular lens.
Results
The clinical diagnosis was confirmed in 4 patients with positive cultures. Two endophthalmitis patients had a preliminary culture report of Pseudomonas species. In addition to receiving intravitreal antibiotics, all patients underwent capsulectomy and intraocular lens removal at the time of pars plana vitrectomy. Visual acuity at last follow up was 20/40 or better in 2 of 4 (50%) but the remaining 2 patients were 20/200 or worse.
Conclusion
A. xylosoxidans may be a cause of acute, recurrent, and delayed-onset postoperative endophthalmitis after cataract surgery. Complete capsulectomy and intraocular lens removal can be considered in recurrent and recalcitrant patients.
Keywords: Achromobacter xylosoxidans, Cataract surgery, Delayed-onset endophthalmitis, Recurrent endophthalmitis
Introduction
Achromobacter xylosoxidans is an aerobic, motile, gram-negative rod originally described by Yabuuchi and Ohyama in patients with chronic otitis media. [1] Achromobacter species is known to inhabit humid environments including well water, intravenous fluids, and water humidifiers. This organism is an important nosocomial pathogen frequently associated with immunocompromised patients. [2] In 1977, Holmes reported the first ocular infection by A. xylosoxidans, but the literature regarding A. xylosoxidans endophthalmitis is limited. [3] This organism is known to cause both acute-onset and delayed-onset postoperative endophthalmitis. [4–11] Previous reports have also documented A. xylosoxidans keratitis in contact lens wearers [12–13].
We report a case series of 4 patients who developed A. xylosoxidans endophthalmitis following cataract surgery. In the current study, two patients had preliminary cultures of Pseudomonas species but the correct culture diagnosis was made from cultures performed during the second vitrectomy. The time between repeat vitreous biopsies were 3 months and 1 week in the two cases. The clinical and microbiologic overlap between these two organisms can make it difficult to establish the culture diagnosis of A. xylosoxidans endophthalmitis.
Case Reports
Case 1
A 78-year-old hypertensive man underwent an uneventful extracapsular cataract surgery with posterior chamber intraocular lens implantation in the right eye. After surgery, the patient had postoperative inflammation and was managed with oral and topical corticosteroids. Four months after surgery, the patient complained of progressively hazy vision and monocular diplopia.
On initial examination, the right eye had a best-corrected visual acuity of 20/60, an intact corneal wound, moderate anterior chamber cellular reaction, posterior capsular opacification, and unremarkable posterior segment. Topical corticosteroid treatment was discontinued. However, 1 month after initial exam, his vision deteriorated in the right eye to 5/200 and there was a 1mm hypopyon, marked vitritis, and vitreous opacities. A diagnosis of chronic postoperative endophthalmitis was made.
The patient underwent pars plana vitrectomy, intraocular lens removal, and capsulectomy. A. xylosoxidans was isolated from cultured vitreous and intraocular lens. The organism was resistant to cefazolin, aztreonam, gentamycin, ciprofloxaxin, ceftriaxone, amikacin, tobramycin, ampicillin, and polymyxin B. It was sensitive to imipenem, sulfa-trimethoprim, ticarcillin, and ceftazidime. Intravitreal ceftazidime 2.25mg was injected. Two months after surgery, the patient had a best-corrected visual acuity of 20/40 with aphakic correction.
Case 2
A 62-year-old man underwent an uneventful phacoemulsification with posterior chamber intraocular lens implantation in the left eye. Ten days after surgery, the patient had an uncorrected 20/20 visual acuity in his left eye. Three weeks after surgery, the patient developed decreased visual acuity to 20/200 and a 1mm hypopyon was noted. Pars plana vitrectomy and vitreous cultures were performed. Intravitreal vancomycin and amikacin were injected. Pseudomonas paucimobilis was isolated from the vitreous specimen. The organism was sensitive to amikacin, ciprofloxacin, and gentamycin. The patient was then started on topical amikacin 8 mg/ml every 2 hours, prednisolone acetate 1% four times a day, and referred for a second opinion due to persistent intraocular inflammation.
On initial examination at our institution, the left eye had a best corrected visual acuity of hand motion, an intact corneal wound, moderate anterior chamber cellular reaction without hypopyon, well centered intraocular lens in the capsular bag, posterior capsular opacification with a retrolental membrane, and significant vitritis. Echographic examination revealed diffuse opacities. The patient was initially treated with topical vancomycin 50 mg/ml and prednisolone acetate 1%. Visual acuity improved to 20/30 with topical treatment at two months after initiating treatment.
Three months after initial exam, the patient returned because his visual acuity had dropped to 20/70 in the right eye with an associated 1mm hypopyon, marked vitritis, and vitreous opacities. A diagnosis of recurrent endophthalmitis was made. The patient underwent pars plana vitrectomy, intraocular lens removal, and capsulectomy. Intravitreal vancomycin 1 mg and dexamethasone 0.4 mg were injected. A. xylosoxidans was isolated from cultured vitreous and intraocular lens. The organism was resistant to ceftazidime and ceftriaxone but was sensitive to gentamycin, ciprofloxaxin, sulfa-trimethoprim, amikacin, tobramycin, and polymyxin B. Visual acuity was 20/200 one week after pars plana vitrectomy. The patient was then lost to follow up.
Case 3
A 67-year-old man underwent an extracapsular cataract extraction, anterior vitrectomy, and posterior chamber intraocular lens implantation in the right eye. Ten days after surgery, the patient had an uncorrected visual acuity of 20/30, but developed a macula on rhegmatogenous retinal detachment with a superior tear. The patient underwent scleral buckle and pars plana vitrectomy. Four months after posterior segment surgery, the patient had a quiet eye with uncorrected visual acuity of 20/30 visual acuity.
Five years after the initial cataract surgery, the patient was referred due to suspected endophthalmitis in his right eye. On initial examination, the right eye had visual acuity of light perception, purulent secretions on the conjuctiva and lid margins, an intact corneal wound, severe anterior chamber cellular reaction with fibrin and hypopyon, relative afferent pupillary defect, and poor visualization of the iris structures. Echographic examination revealed dense vitreous opacities and a localized retinal detachment.
The patient underwent pars plana vitrectomy, vitreous and buckle cultures, intraocular lens removal, and capsulectomy. The scleral buckle was not removed. Intravitreal gentamicin 0.1 mg and ceftriazone 2 mg were injected. The gram-stain was negative for bacteria. A. xylosoxidans was isolated from both vitreous and buckle cultures and Nocardia was isolated from vitreous cultures. A. xylosoxidans was resistant to gentamycin, ciprofloxaxin, ceftriaxone, sulfa-trimethoprim, and tobramycin. It was sensitive to carbenicillin, cefoperazone, imipenem, and piperacillin. Blood cultures were performed due to the possibility of an endogenous source; however, results were negative. Chest X-ray and urinalysis were unremarkable. No systemic signs of infection were present. Because of his painful blind eye with severe inflammation, the right eye was enucleated.
Case 4
A 59-year-old female underwent an uneventful extracapsular cataract surgery with posterior chamber intraocular lens implantation in the left eye. The day after surgery, the patient presented with a visual acuity of 20/400 and a red eye. Treatment with frequent topical and oral moxifloxacin and topical corticosteroids did not achieve clinical improvement. Pars plana vitrectomy without capsulectomy was performed two weeks after the initial surgery. Pseudomonas species was isolated from the vitreous sample. The patient then underwent intravitreal ceftazidime injection 2mg/0.1ml and referred to our institution.
On initial examination, the left eye had a visual acuity of hand motion, an intact corneal wound, moderate anterior chamber cellular reaction with a 1 mm hypopyon, segmental posterior capsule opacity with a well centered posterior chamber intraocular lens and poor visualization of the posterior segment (Figure 1). Echographic examination revealed diffuse vitreous opacities.
Figure 1.
Anterior segment photograph of Case 4 presenting an intact corneal wound, ciliary hyperemia, moderate anterior chamber cellular reaction with a 1 mm hypopyon, with segmental posterior capsule opacity and a well placed posterior chamber intraocular lens.
The patient underwent pars plana vitrectomy, vitreous culture, intraocular lens removal, and capsulectomy. Intravitreal vancomycin 1mg, ceftazidime 2.25mg, and dexamethasone 0.4 mg were injected. Histopathologic examination of the lens capsule showed gram-negative rods (Figure 2). A. xylosoxidans was isolated from the vitreous specimen and the intraocular lens. The organism was resistant to ciprofloxaxin, sulfa-trimethoprim, amikacin, gentamycin, and tobramycin. It was sensitive to imipenem, piperacillin, and ceftazidime. Three weeks after surgery, the patient had a quiet eye with a best-corrected visual acuity of 20/40 using aphakic correction and unremarkable posterior segment.
Figure 2.
(A) Histopathologic analysis demonstrating gram-negative rods on inner aspect of anterior capsule and (B) on inner aspect of posterior capsule.
Discussion
A. xylosoxidans, formerly called Alcaligenes xylosoxidans, is part of the normal flora of the ear and gastrointestinal tract. [14] Although it is thought to be uncommon, it may be a cause of both acute and chronic-onset postoperative endophthalmitis. [4, 8, 11].
In cases 2 and 4, the cultures were initially reported as a Pseudomonas species prior to consultation to our institution as seen in Table 1. Differentiation between Pseudomonas species and A. xylosoxidans can be a challenge because both are aerobic gram-negative nonfermentative rods, thrive in moist environments, and are opportunistic pathogens. However, Pseudomonas is not part of the normal human flora. Both pathogens may have very similar antibiotic resistance patters. Siegman et al. suggested that colonial morphology and antibiotic sensitivity pattern are not specific enough for the differentiation. [15] Pseudomonas has one or more polar flagella. However, the peritrichous flagella in A. xylosoxidans is the key distinguishing factor. [15] This may account for the few reportings of this organism and the preliminary diagnosis of Pseudomonas enophthalmitis in the current series. The generally indolent course of A. xylosoxidans endophthalmitis contrasts with the more fulminant Pseudomonas species. However, in the current study one patient developed A. xylosoxidans endophthalmitis by postoperative day number 1.
Table 1.
Clinical features of Achromobacter xylosoxidans endophthalmitis following cataract surgery
| Case 1 | Case 2 | Case 3 | Case 4 | |
|---|---|---|---|---|
| Cefazolin | r | - | - | - |
| Aztreonam | r | - | - | - |
| Gentamycin | r | s | r | r |
| Ciprofloxacin | r | s | r | r |
| Ceftriaxone | r | r | r | - |
| Amikacin | r | s | - | r |
| Tobramycin | r | s | r | r |
| Ampicillin | r | - | - | - |
| Polymyxin B | r | s | - | - |
| Imipenem | s | - | s | s |
| Sulfa-Trimethoprim | s | s | r | r |
| Ticarcillin | s | - | - | - |
| Ceftazidime | s | r | - | s |
| Carbanicillin | - | - | s | - |
| Cefoperazone | - | - | s | - |
| Piperacillin | - | - | s | s |
s = sensitive
r = resistant
In the current report, all patients that had resolution of the infection were treated with pars plana vitrectomy, capsulectomy, and intraocular lens removal. Cases 2 and 4 did not resolve after initial treatment with pars plana vitrectomy alone and intravitreal injection of susceptible antibiotics. Shirodkar et al. reported that recurrence of the infectious process in cases of delayed-onset endophtahlmitis is significantly decreased with pars plana vitrectomy, capsulectomy, and intraocular lens removal because of the removal of indolent organisms that remain in the capsular bag and on the intraocular lens. [16] The Achromobacter species have been shown to create a biofilm to survive otherwise toxic environments. [17] To our knowledge, this is the first report that shows histopathologic evidence of A. xylosoxidans on the lens capsule.
A retrospective study by Reddy and colleagues suggests that ceftazidime and amikacin are antibiotics of choice for the management of ocular infections by A. xylosoxidans. [18] In contrast to older generation cephalosporins, ceftazidime’s molecular structure confers extra stability to beta-lactamases that are usually present in gram negatives. However, in the current series, one isolate was resistant to ceftazidime and two isolates were resistant to amikacin in the laboratory microbiologic analysis (Table 2). No resistance was found for imipenem or ureidopenicillins.
Table 2.
Antibiotic sensisitivity and resistance patterns of Achromobacter xylosoxidans endophthalmitis after cataract surgery.
| Case | Age/Gender | Presenting VA | Final VA | Time after cataract surgery | Comments |
|---|---|---|---|---|---|
| 1 | 78M | 5/200 | 20/40 | 5 months | - |
| 2 | 62M | 20/200 | 20/200* | 3 weeks | Initial culture diagnosis Pseudomonas paucimobilis |
| 3 | 67M | LP | NLP | 5 years | - |
| 4 | 59F | 20/400 | 20/40 | 1 day | Initial culture diagnosis Pseudomonas species |
Lost to follow up
A recent study by Robert and associates reported 5 cases in which A. xylosoxidans endophthalmitis developed within 24 hours of uncomplicated cataract surgery. [19] All patients except 1 achieved a visual acuity better than 20/60 at 12 months after initial endophthalmitis treatment. Similarly in the current series, Case 4, which developed endophthalmitis within the first day, achieved a visual acuity of 20/40. Cases of A. xylosoxidans endophthalmitis that develop within the first 24 hours may have a more favorable prognosis.
All patients in the current study were immunocompetent. However, previous studies suggest that A. xylosoxidans infections are more common in immunocompromised hosts, especially those with renal insufficiency, diabetes mellitus, carcinoma, alcoholism, tuberculosis, or endogenous immunosuppression. [2, 20] Previous studies have also reported ocular infections by A. xylosoxidans in immunocompetent patients. [5, 8, 10, 12–13, 19] Cataract surgery was the only risk factor associated in the current study. Therefore, there were no known risk factors to distinguish between ocular infections with A. xylosoxidans versus other more common isolates.
The incidence of A. xylosoxidans ocular infections may be underestimated due to relatively higher proportions of Pseudomonas species infections in ocular tissues and laboratory reports. The optimal treatment for A. xylosoxidans endophthalmitis after cataract surgery remains controversial. Because of the high rate of recurrence, current treatment often consists of pars plana vitrectomy, capsulectomy, intraocular lens removal, and intravitreal injection of antibiotics.
Summary Statement.
Achromobacter xylosoxidans was isolated from vitreous specimens in 4 patients with both acute-onset and delayed-onset endophthalmitis after cataract surgery. In spite of successful treatment of the infection, visual outcomes were variable.
Acknowledgments
Supported in part by the National Institute of Health, Bethesda, Maryland, grant P30-EY014801, and an unrestricted grant to the University of Miami from Research to Prevent Blindness, New York, New York, USA.
Footnotes
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