SMALL CASE SERIES

phate, 2 mg. Postoperatively, the pa- Vitek 2 system; BioMe´rieux, Inc). Quinupristin/Dalfopristin tient received topical besifloxacin, The second set of cultures showed in Vancomycin-Resistant 0.6%, prednisolone acetate, 1%, and similar growth. Oral linezolid, 600 Staphylococcus aureus bromfenac sodium, 0.09%. mg, and minocycline hydrochlo- Endophthalmitis At 2 weeks postoperatively, the ride, 100 mg, were given for 21 days patient had pain, decreased visual followed by rifampin and minocy- Postoperative bacterial endophthal- acuity to hand motions, a Seidel- cline for a total of 3 months. Visual mitis is the most dreaded complica- positive cataract incision, plasmoid acuity improved to 20/80 at 1 week. tion of any eye surgery. Once infec- anterior chamber (AC) reaction, pos- Complete resolution of vitreous and tion is suspected, prompt treatment terior synechia, keratic precipi- AC inflammation as well as return by vitreous tap and biopsy or by vi- tates, and intraocular pressure of 8 to visual acuity of 20/50 occurred trectomy and injection of intravit- mm Hg OS. There was no retained over 3 months. real antibiotics is instituted prior to lens material or plaque present. Af- Case 2. A 78-year-old man with identifying the specific bacteria and ter review of the literature and in- a history of hypertension, cardiac dis- its antibiotic sensitivities. Of the 70% formed consent for off-label medi- ease, adult-onset diabetes, chronic of cases that were culture positive in cation use with the patient, allergist, obstructive lung disease, multiple the Endophthalmitis Vitrectomy infectious disease specialist, and hospitalizations, and previously Study (EVS), 94% were gram- pharmacist, the patient was treated treated methicillin-resistant S au- positive organisms that were all sen- with pars plana vitrectomy, AC reus skin abscess had cataract sur- sitive to vancomycin.1 The recent washout, suture of cataract inci- gery of the right eye through clear Antibiotic Resistance Monitoring in sion, and injection of intravitreal qui- corneal incision. The surgery was Ocular micRorganisms 2009 study nupristin/dalfopristin (0.4 mg/0.1 complicated by rupture of the pos- reported that 39% of Staphylococ- mL) and ceftazidime (2.25 mg/0.1 terior lens capsule. Because of a 30- cus aureus isolates were resistant to mL). He received oral linezolid, 600 year history of central retinal vein methicillin, but all were still sensi- mg. Gram staining showed gram- occlusion in the right eye, his pre- tive to vancomycin.2 Several recent positive cocci in clusters, and the operative visual acuity was count- cases of endophthalmitis due to van- bacteria were coagulase positive. ing fingers. At the conclusion of comycin-resistant S aureus and Thirty-six hours later, he had recur- surgery, the patient received sub- Enterococcus have also been re- rent pain, decreased vision, and re- conjunctival cefazolin sodium, 100 ported.3-5 Of the few antibiotics ef- accumulation of vitreous opacities mg, and dexamethasone sodium fective against vancomycin-resistant and hypopyon. S aureus was iso- phosphate, 2 mg. Postoperatively, the bacteria, only intravitreal quinupris- lated from the vitreous and AC but patient received topical gatifloxa- tin/dalfopristin has been reported sensitivities were pending. Follow- cin, 0.5%, prednisolone acetate, 1%, previously in a single human eye.6 In ing EVS guidelines for reinjection and ketorolac tromethamine. the current series, 2 additional cases ([1] visual acuity Ͻ1.5/60 but Ͼlight Three days postoperatively, the are reported with successful treat- perception, [2] red reflex absent or patient had pain, decreased visual ment of vancomycin-resistant S au- increased media opacification com- acuity to light perception, Seidel- reus endophthalmitis with intravit- pared with the initial manifesta- positive test results, superior cor- real quinupristin/dalfopristin. tion, [3] at least an equivocal growth neal infiltrate, keratic precipitates, seen in the initial culture, and [4] Ն1 30% hypopyon, and intraocular pres- Report of Cases. Case 1. An 83-year- of the following: [A] a 1-mm in- sure of 32 mm Hg. The patient was old man with a history of hyperten- crease in the height of the hypo- treated with pars plana vitrectomy, sion, cardiac arrhythmia, prostate pyon, [B] a corneal ring infiltrate, AC washout, and suture placement cancer, multiple hospitalizations for and [C] worsening pain), vitrec- in the clear corneal incision. Cul- infections, and previous anaphylac- tomy with intravitreal quinupristin/ tures were obtained from the AC and tic reaction to vancomycin had cata- dalfopristin (0.4 mg/0.1 mL) and vitreous. The patient received intra- ract surgery in his left eye 2 weeks ceftazidime (2.25 mg/0.1 mL) was vitreal vancomycin hydrochloride prior to the diagnosis of endoph- performed. The next day, the ini- (1 mg/0.1 mL) and ceftazidime thalmitis. Surgery was performed via tial vitreous and AC cultures iden- (2.25 mg/0.1 mL) as well as subcon- scleral tunnel and was complicated tified S aureus resistant to methicil- junctival vancomycin and ceftazi- by rupture of the posterior lens cap- lin, vancomycin, moxifloxacin, dime. Every 2 hours beginning on the sule. At the conclusion of surgery, clindamycin, imipenem, and tetra- day after surgery, topical vancomy- the patient received subconjuncti- cycline but sensitive to chloram- cin and ceftazidime were adminis- val cefazolin sodium, 100 mg, and phenicol, quinupristin/dalfopris- tered every 2 hours. Gram staining dexamethasone sodium phos- tin, and linezolid (determined by showed gram-positive cocci in clus-

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 ters, and the bacteria were partially tericidal. Linezolid is an oxazolidi- Financial Disclosure: None re- identified as coagulase positive the none antibiotic that inhibits protein ported. next day. synthesis by binding to the 50S ri- 1. Endophthalmitis Vitrectomy Study Group. Thirty-six hours later, he had re- bosomal subunit. It is bacterio- Results of the Endophthalmitis Vitrectomy Study: current pain, decreased vision, reac- static and has potential adverse ef- a randomized trial of immediate vitrectomy and cumulation of vitreous opacities, and of intravenous antibiotics for the treatment of fects of irreversible optic neuropathy postoperative bacterial endophthalmitis. Arch 30% hypopyon. Following the EVS from systemic use, which could po- Ophthalmol. 1995;113(12):1479-1496. guidelines for reinjection, pars plana tentially be even greater with intra- 2. Haas W, Pillar CM, Torres M, Morris TW, Sahm DF. Monitoring antibiotic resistance in ocular vitrectomy was performed and intra- vitreal use, although to our knowl- microorganisms: results from the Antibiotic Re- vitreal antibiotics were adminis- edge this has not been studied. sistance Monitoring in Ocular micRorganisms tered. The next day, the initial vitre- (ARMOR) 2009 surveillance study. Am Antibiotic resistance is evolution- J Ophthalmol. 2011;152(4):567-574, e3. ous and AC cultures identified S ary and the genes responsible can be 3. Tang CW, Cheng CK, Lee TS. Community- aureus resistant to methicillin, van- transferred between bacteria, lead- acquired bleb-related endophthalmitis caused by comycin, ciprofloxacin, levofloxa- 8 vancomycin-resistant enterococci. Can ing to increased resistance. If resis- J Ophthalmol. 2007;42(3):477-478. cin, and tetracycline but sensitive to tance to established antibiotics 4. Bains HS, Weinberg DV, Feder RS, Noskin GA. chloramphenicol, quinupristin/ Postoperative vancomycin-resistant Enterococ- becomes more common, newer cus faecium endophthalmitis. Arch Ophthalmol. dalfopristin, and linezolid (deter- treatment regimens need to be con- 2007;125(9):1292-1293. mined by Vitek 2 system; BioMe´rieux, sidered for continued successful 5. Sharma S, Desai RU, Pass AB, Saffra NA. Van- Inc). He had persistent pain, worse comycin-resistant enterococcal endophthalmitis. treatment or there will be poor out- Arch Ophthalmol. 2010;128(6):794-795. vision, and recurrent 20% hypo- comes in those resistant cases. The 6. Hernandez-Da Mota SE. Quinupristin/dalfo- pyon. After informed consent for off- EVS showed that intravitreal anti- pristin in Staphylococcus aureus endophthalmi- label use, intravitreal quinupristin/ tis: a case report. J Med Case Rep. 2011;5(1):130. biotics are effective with or with- 7. Finch RG. Antibacterial activity of quinupristin/ dalfopristin (0.4 mg/0.1 mL) and out use of systemic antibiotics for dalfopristin: rationale for clinical use. Drugs. amikacin sulfate (0.4 mg/0.1 mL) bacterial endophthalmitis. Clini- 1996;51(suppl 1):31-37. were administered. Oral linezolid, 8. Jones DB. Emerging vancomycin resistance: what cians should be aware of alterna- are we waiting for? Arch Ophthalmol. 2010;128 600 mg, and minocycline hydrochlo- tive intravitreal antibiotics when (6):789-791. ride, 100 mg, were given for 21 days vancomycin-resistant bacteria are followed by rifampin and minocy- present or highly suspected. Al- cline for a total of 3 months. Within though prolonged oral antibiotics Spectral-Domain Optical 2 days there was significant clearing have not been necessary in endoph- Coherence Tomographic of vitreous debris and view of sec- thalmitis, a 3-month course of sys- Characteristics of ondary vessels. During the next 3 temic therapy was recommended in Autosomal Recessive months there was complete resolu- these cases of vancomycin-resis- Isolated Foveal Hypoplasia tion of vitreous, AC, and corneal in- tant organisms to eradicate any flammation and return of visual acu- nonocular reservoir of remaining ity to his baseline of counting fingers. Foveal hypoplasia, also referred to bacteria. The timing of ocular im- as foveal planum, is a congential con- provement in these patients dem- Comment. Antibiotic treatment for dition that can be associated with onstrates that the effectiveness of in- bacterial endophthalmitis must be other ocular abnormalities such as travitreal treatments is more rapid aniridia, albinism, microphthal- started promptly for optimal suc- 1 cess, and the empirical antibiotic than the reported cases treated by mos, and achromatopsia. Isolated chosen should be active against the oral linezolid alone. In conclusion, foveal hypoplasia (IFH) is an even suspected bacteria even though sen- 2 cases of vancomycin-resistant en- rarer disorder, with similar clinical sitivities may not be available for up dophthalmitis were successfully findings in the fovea. The charac- to 72 hours later. Clinicians need to treated with intravitreal quinupris- teristic findings of patients with IFH be knowledgeable of the likely causes tin/dalfopristin and oral antibiot- and sensitivity patterns of the sus- ics. Clinicians should consider in- Videos available online at pected bacteria because delay in treat- travitreal quinupristin/dalfopristin www.archophthalmol.com ment can lead to poor outcomes. for vancomycin-resistant bacterial While all of the gram-positive bac- endophthalmitis. are nystagmus, poor visual acuity, teria in the EVS were sensitive to van- Edward M. Stroh, MD absent or abnormal maculofoveal re- comycin, recent resistant organisms flexes on ophthalmoscopy, and vari- have been reported with increased fre- Author Affiliations: Department of able and incomplete filtering of the quency and are a concern. Ophthalmology, Mercy Medical choroidal fluorescence in the macu- Synercid is a streptogramin anti- Center, Rockville Centre, and De- lar area on fluorescein angiogra- microbial resulting from the com- partment of Ophthalmology, Hof- phy. No single hereditary pattern has bination of semisynthetic pristina- stra University School of Medicine, been established for patients with mycin derivatives, quinupristin and Hempstead, New York. IFH. Reported cases include pa- dalfopristin, in a 3:7 ratio.7 The com- Correspondence: Dr Stroh, Retina tients with autosomal dominant and bination targets both early and late Consultants of Long Island, 165 N autosomal recessive inheritance pat- stages of protein synthesis, result- Village Ave, Ste 203, Rockville Cen- terns as well as sporadic cases.1-5 Only ing in synergistic activity, and is bac- tre, NY 11570 ([email protected]). recently has a grading system for the

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