Title: Current Characteristics of Infectious Keratitis at a Tertiary Referral Center in South Korea
1Current Characteristics of Infectious Keratitis
at a Tertiary Referral Center in South Korea
2008 ASCRSPoster No. P-139
Sang Beom Han, MD, Tae Hyoung LIm, MD, Won Ryang
Wee, MD,PhD, Jin Hak Lee, MD,PhD, Mee Kum Kim,
MD,PhD Department of Ophthalmology Seoul
National University College of Medicine Seoul
National University Hospital, Korea
2Financial Disclosure
- None of the authors has a financial
- interest in any material or method in
- the study.
3Introduction
- The profiles of infectious keratitis vary
according to age, climate, geographic factors,
socioeconomic status, and patients general
condition. - The level of ophthalmologic center (primary,
secondary, and tertiary referral center) could
also be one of important factors which determine
the clinical features of infectious keratitis. - The clinical manifestation of the disease has
changed with time. - For example, due to widespread use of contact
lens, - Contact lens wear has emerged to be the main risk
factor - The proportion of youngster in age distribution
has increased.
4Introduction
- Understanding the recent trend of infectious
keratitis, including predisposing factors,
microbiological profile, clinical manifestation,
and response to treatment is essential in the
treatment of the disease. - The current trend in South Korea has not yet been
reported.
5Purpose
- To identify risk factors and causative agents,
and to investigate demographic and clinical
features of infectious keratitis at a tertiary
referral center in South Korea.
6Materials Methods
- Review of medical records of 56 patients with
culture-proven bacterial or fungal keratitis - at Seoul National University Hospital.
- from January 1, 2003 to December 31, 2007.
- The diagnosis of bacterial or fungal keratitis
was made when there was acute corneal epithelial
defect and suppurative corneal infiltrate
associated with identified causative bacteria or
fungus. - Data such as demographics, predisposing factors,
microbiological profile, sensitivity to
antibiotics, and healing time were collected and
analyzed.
7Materials Methods
- Healing was defined as complete disappearance of
epithelial defect and inactivation of stromal
infiltrate accompanied with absence of anterior
chamber reaction in medically controlled cases. - Healing time was defined as the term from when
the patient first received treatment with
antibiotics or antifungal agents after diagnosed
as infectious keratitis in our or another
facility to the point of epithelial closure. - Cases which led to therapeutic penetrating
keratoplasty(PKP) or evisceration were regarded
as treatment failure, and were excluded from the
analysis of healing time.
8Materials Methods
- All patients were divided into two groups
according to the outcome. - Cases with healing 4 weeks were included in the
better outcome group (Group 1). - Poor outcome was defined when healing time was
longer than 4 weeks, or surgical intervention
such as therapeutic PKP or evisceration was
needed (Group 2). - The time point of four weeks was set based on the
finding that the median healing time was 4 weeks,
and 24 of 45 (53) medically controlled cases
showed healing time of four weeks or less. - Twenty-five (45) patients were included in the
better outcome group (Group 1), 28 (50) were in
the poorer outcome group (Group 2), and the
remaining three (5.4) were lost during
following-up.
9Materials Methods
- The possible effect of age, prior empirical
treatment, diabetes mellitus(DM), hypertension,
and the sizes of epithelial defect and stromal
infiltration on the outcome was investigated
using Pearsons chi-square test and Fishers
exact test. - Resistance to antibiotics was investigated.
10Results
- The number of patients with culture-proven
infectious keratitis has been increasing every
year
11Results - Demographics
- 33 male (59) and 23 female (41)
- The average age was 46.927.7 years, and 33
patients (59) were 50 years or older. - the peak at 0th decade was mainly due to the
outbreak of secondary bacterial keratitis after
epidemic keratoconjunctivitis in neonatal
intensive care unit (NICU).
12Results Predisposing Factors
- Ocular surface disease was the most common
predisposing factor, followed by corneal trauma
and contact lens wear. - The proportion of patients who were 50 years or
older tends to be higher in corneal trauma than
in ocular surface disease and contact lens wear. - ?All patients with history of
ocular surface surgery are also included in the
group with - history of ocular surface
disease.
13Results Microbiological profiles
- 49 cases were infection with single organism,
while two or more organisms were identified in 7
cases. - In cases infection with single organism
- Gram () bacteria were most common 25 patients
(51) - Staphylococcus species were the most frequently
found Gram ()bacteria with 15 cases(30) - S. aureus was found in 9 of those cases,
including six outbreak cases in NICU in which
MRSA was identified. - Fungus were cultured in 12 patients. (25)
- Seven of them (14) were Candida species,
followed by Aspergillus species, and Fusarium
species. - Gram (-) bacteria was found in 11 patients (22).
- Pseudomonas aeruginosa and Serratia marcescens
were found in three cases, respectively.
14Results Microbiological profiles
- Seven cases of mixed infection
G() Gram positive bacteria G(-)Gram
negative bacteria Fungus fungus
15Resistance to antibiotics
- High resistance of Gram () bacteria to
penicillin, cefazolin and - erythromycin. (although the number of cases in
which the sensitivity test to - cefazolin was too small)
- High resistance of Gram (-) bacteria to
gentamicin and tobramicin. - However, quinolone showed low resistance to both
Gram () and (-) - bacteria.
16Results - Outcome
- 45 cases were controlled with medical treatment.
- The average healing time was 5.1 2.8 wk (1 to
12 wk) - 4 patients underwent therapeutic PKP, and four
cases led to evisceration. - The remaining 3 patients were lost during
follow-ups. - In 17 out of 42patients (40) whose visual acuity
was measured, the visual acuity improved by 1
line or more.
17Outcome
- The contribution of factors to the clinical
outcome
- Significant correlation between the outcome and
the size of infiltration and epithelial defect
was found.
Odds Ratio (Poorer outcome/ Better outcome) CI
Confidence interval Extreme age was defined as
age yonger than 10 years or older than 60
years. Pearsons chi-square test Fishers
exact test
18Outcome
- The difference in clinical outcome according to
causative microorganisms
Odds Ratio (Poorer prognosis / Better
prognosis) CI Confidence interval Fishers
exact test
- Keratitis caused by Gram() bacteria showed
significantly better outcome than that due to
fungus, and tended to have better outcome than
that due to Gram(-) bacteria, although the
difference was not statistically significant.
19Dicussion
- The age profile showed two peaks in 0s and 60s.
- 6 cases of outbreak in NICU caused bias in age
distribution - Low proportion of contact lens (CL)-related
keratitis (9, 5 patients) and low proportion of
patients in 20s and 30s - most CL-related cases might be have been
cured before referral to tertiary center. (most
CL wearers are youngsters who have more competent
immune system than elderly) - The resistance to ofloxacin and ciprofloxacin was
shown to be low in spite of the widespread
empirical use, suggesting that monotherapy with
topical quinolones can still be considered as
primary treatment of bacterial keratitis.
20Discussion
- The result that Gram () bacteria was the most
frequently identified pathogen, and
Staphylococcus species was the most common in
them. - Low proportion of G(-) bacteria might be due to
low incidence of CL-related keratitis. - Infection with Gram () bacteria showed
statistically significant better outcome than
that with fungus, and tended to have better
outcome than that with Gram (-) bacteria,
although the result was not statistically
significant.
21Discussion
- The severity of corneal inflammation is an
important prognostic factor. Based on the
findings that there was significant correlation
between the outcome and the size of infiltration
and epithelial defect, this contention is in good
agreement with previous reports. - Although this study has a limitation that the
size of study patients were small, and only
culture-proven cases of only one tertiary center
were included, we believe that this study
provided updated data of infectious keratitis in
South Korea to some extent. These data are
expected to be useful in upcoming multi-center
study with larger patients group.
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