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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 24-29

Post-operative infections at a Tertiary Eye Hospital: A 5-year retrospective study


Department of Ophthalmology, Nethradhama Super Speciality Eye Hospital, Bengaluru, Karnataka, India

Date of Web Publication18-Aug-2017

Correspondence Address:
Namita C Anagol
Nethradhama Super Speciality Eye Hospital, No 256/14, Kanakapura Main Road, 7th Block, Jayanagar, Bengaluru - 560 082, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_4_17

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  Abstract 


Purpose: The purpose of this study is to evaluate and assess the incidence and outcomes of post-operative infections after eye surgeries.
Materials and Methods: A 5-year retrospective study of all the post-operative infections was conducted at our institute with a detailed clinical and microbiological evaluation. All cases were treated with topical, systemic and/or intravitreal antibiotics. In addition to medical management, 7 eyes underwent pars plana vitrectomy, 3 underwent Keraring explantation and 1 underwent a secondary retinal detachment (RD) surgery.
Results: Out of 54,359 surgeries done in the past 5 years, 19 cases of post-operative infections were recorded with 14 of them being endophthalmitis and the rest 5 were superficial infections (3 Keraring associated infiltrates, 1 corneal ulcer and 1 orbital cellulitis). Post-operative infection rate and post-operative endophthalmitis rate were found to be 0.0349' and 0.0257', respectively. Four (21') cases were culture positive - 2 cases of Staphylococcus aureus, 1 methicillin-resistant S. aureus and 1 Staphylococcus epidermidis. Twelve cases of endophthalmitis were acute in onset, and 2 were chronic onset endophthalmitis. Final visual outcome recorded at 1 month showed that 15 (79') patients recovered with good vision, whereas 4 (21') had a poor visual outcome. Of the 15 patients with good visual outcome, 6 (31.5') patients had final best-corrected vision >0.3 logMAR while 9 (47.3') had best-corrected vision of 0.3–1 logMAR. Four (21') patients with poor visual outcome had final vision <1 logMAR.
Conclusions: A significantly low incidence of post-operative infections can be attributed to adherence of strict pre- and post-operative protocols as per the Hospital Infection Control guidelines. Early and prompt treatment reduced the risk of severe visual morbidity.

Keywords: Cellulitis, corneal ulcer, endophthalmitis, keraring, pars plana vitrectomy


How to cite this article:
Anagol NC, Nisha D S, Ganesh S, Shree S. Post-operative infections at a Tertiary Eye Hospital: A 5-year retrospective study. J Patient Saf Infect Control 2017;5:24-9

How to cite this URL:
Anagol NC, Nisha D S, Ganesh S, Shree S. Post-operative infections at a Tertiary Eye Hospital: A 5-year retrospective study. J Patient Saf Infect Control [serial online] 2017 [cited 2017 Sep 21];5:24-9. Available from: http://www.jpsiconline.com/text.asp?2017/5/1/24/213285




  Introduction Top


Post-operative infections are a cause of concern to every operating surgeon due to its associated morbidity, mortality and medico-legal implications. Standard guidelines and preferred practice patterns have been put forth to reduce the incidence of post-operative infections. Post-operative infections in ocular surgeries may either be superficial or deep. Superficial infections can be in the form of suture tract infections, Keratitis or soft tissue involvement. However, deeper infections such as endophthalmitis are a major concern because visual loss and debilitation caused by it can be severe and irreversible.

Amongst all the post-operative infections, endophthalmitis remains one of the most devastating and most dreaded vision-threatening complications of any eye surgery. Clinically, it may occur either as an isolated event or as a cluster of infections in the form of a surgical epidemic. Cluster infections have been commonly known to occur due to breach in the operating room asepsis and also by the use of contaminated fluids and viscoelastics intraoperatively.[1] Common sources of such infections are the patient's own ocular surface flora, pre-operative risk factors like blepharitis, dacryocystitis, ocular inflammation, surgical complications, poor or delayed wound healing, use of contaminated surgical instruments, tubings or an unsterile surgical environment. The most commonly isolated organisms are coagulase-negative Staphylococcus, Staphylococcus aureus, Streptococcus, Enterococci and Fungi.[2],[10],[11],[12]

Maintenance of asepsis and sterility of the surgical environment is imperative to minimise the incidence of post-operative infection and its dreaded consequences. Sterile operating room protocols, better instrumentation and surgical techniques, use of prophylactic antibiotics and pre-operative patient preparation with povidone–iodine combined with a better understanding of asepsis have significantly reduced their incidence. Our main aim should be to prevent the occurrence and reduce the incidence of such infections and keep it to a minimum. Prevention of post-operative endophthalmitis requires strict adherence to operating room norms, with all the involved personnel discharging their assigned roles faithfully.

For any eye hospital, the occurrence of endophthalmitis is a cause of concern and needs a thorough evaluation of the root cause and assessment of any breach in the existing infection control protocols of the hospital. Many studies have been conducted so as to provide standard operating guidelines for hospital infection control (HIC). Our main aim of doing this study was to benchmark our self with respect to the national and international standards in HIC and also to evaluate the implementation of our HIC protocols by the medical and paramedical hospital staff.


  Materials and Methods Top


This was a 5-year retrospective study conducted at a single centre. All 54,359 ocular surgeries performed in the past 5 years were included in this study. All patients presenting with post-operative infections underwent a thorough clinical and microbiological workup which included microscopy and culture sensitivity. In cases presenting with corneal lesions, corneal scrapings were taken while vitreous samples were sent for laboratory investigations in cases of endophthalmitis. Presenting signs, symptoms, best-corrected visual acuity before and after treatment, type of ocular surgery, duration of onset and duration of full recovery were all recorded. All samples were sent for microbiological investigations which included Gram-staining, KOH mount and culture. All superficial infections were treated with topical fortified antibiotic drops with explantation of the corneal implant when necessary, while post-operative orbital cellulitis was treated with systemic antibiotics. All cases of endophthalmitis were started on intravitreal antibiotic injections, and the number of doses were titrated depending on the response to treatment. Seven of the fourteen patients who failed to respond to intravitreal injections underwent pars plana vitrectomy. Subsequent complications such as retinal detachment were tackled surgically.


  Results Top


Out of 54,359 surgeries done in the past 5 years, 19 cases of post-operative infections were recorded with an incidence of 0.0349% [Table 1]. Of these, 14 cases developed post-operative endophthalmitis, whereas 5 cases presented with superficial infections (3 cases of Keraring-associated infiltrates, 1 case of corneal ulcer and 1 case of orbital cellulitis) [Figure 1]. Four (21%) of the cases were culture positive - 2 were S. aureus, 1 was methicillin-resistant S. aureus and 1 was Staphylococcus epidermidis [Figure 2].
Figure 1: Incidence of post-operative infections

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Figure 2: Microbial analysis

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Table 1: Incidence of post-operative infections

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Incidence of endophthalmitis was found to be 0.0257% [Table 2]. Twelve of these cases were acute in onset while 2 cases were of chronic onset [Figure 3].
Figure 3: Post-operative endophthalmitis

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Table 2: Incidence of post-operative endophthalmitis

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Final visual outcome recorded at 1 month showed that 15 (79%) patients recovered with good vision, while 4 (21%) had a poor visual outcome. Of the 15 patients with good visual outcome, 6 (31.5%) patients had final best-corrected vision >0.3 logMAR while 9 (47.3%) had best-corrected vision of 0.3–1 logMAR. Four (21%) patients with poor visual outcome had final vision <1 logMAR [Figure 4].
Figure 4: Visual outcome

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  Discussion Top


Although all groups of bacteria have been implicated in endophthalmitis, the most predominant was Gram-positive organisms constituting 90%–95% of all the post-surgical endophthalmitis. According to the endophthalmitis vitrectomy study, Gram-negative isolates were obtained in only around 6% of post-operative endophthalmitis cases.[3] Of the Gram-positive organisms, the most common infecting organism was found to be S. epidermidis, although in most cases, the causative organism could not be identified conclusively.

The incidence of post-operative endophthalmitis also depends on the type of intraocular surgery and the criteria for diagnosis (clinical, laboratory culture and duration of follow-up). In a case series reported by Kattan et al. (30,002 cases), the incidence of culture-positive endophthalmitis following cataract surgery, secondary intraocular lens implantation, penetrating keratoplasty, filtering surgery and pars plana vitrectomy was found to be 0.072%, 0.3%, 0.11%, 0.061% and 0.051%, respectively.[4] Less commonly endophthalmitis can also occur following suture removal and after laser capsulotomy.

Various means of controlling the incidence of post-operative infections were implemented and tried. One of the landmark studies was conducted by a group of Swedish surgeons who started the practice of administering intracameral injection of cefuroxime at the end of each cataract surgery.[5] This study was conducted with the main aim of reducing the incidence of post-operative endophthalmitis, which was well achieved.

According to the landmark ESCRS study, the incidence of post-operative endophthalmitis in the group with intracameral use of cefuroxime and in those with no intracameral cefuroxime was found to be 0.05% and 0.35%, respectively.[6],[13] The Swedish national study reported endophthalmitis rates of 0.027% and 0.039% with and without the use of intracameral cefuroxime.[7]

At the national level, two landmark studies were conducted - one by Aravind Eye Hospital, Pondicherry and another by LV Prasad Eye Hospital, Bhubaneshwar. Aravind Eye Hospital, Pondicherry, reported an endophthalmitis incidence of 0.09%.[8],[14] LV Prasad Eye Institute, Bhubaneswar, concluded that 43% of the total endophthalmitis cases at their institute could be attributed to a previous intraocular surgery.[9]

In the present study, we found significantly low incidence rates of post-operative infections at our institute. Our post-operative endophthalmitis rates of 0.0257% were comparable to those recorded in the Swedish national study despite the fact that we did not use prophylactic intracameral cefuroxime. We found that all of the culture-positive cases were Gram-positive organisms which was in accordance to the results of the endophthalmitis vitrectomy study which documented Gram-positive isolates in 90%–95% of endophthalmitis occurring in patients following cataract surgery.[3]

Low incidence rates at our institute can be attributed to various measures taken by our institute to curb post-operative infections [Figure 5]. Some of them are listed below.
Figure 5: Sterilisation process flow chart

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  • Operating room asepsis – use of laminar airflow systems and high-efficiency particulate air filters
  • Surgical safety checklist [Figure 6]
  • Strict adherence to hand washing and hand scrubbing techniques
  • Use of disposable consumables with a single use policy
  • One way flow of traffic – sterile instruments and used instruments are transported in and out of the operating room through separate routes
  • Regular monitoring of autoclaving and sterilisation using chemical indicators for each cycle of autoclaving, biological indicators for weekly monitoring and use of process challenge devices
  • Monthly monitoring of the sterility of the surgical environment, instruments, water source, etc., with regular cultures
  • Monthly cleaning of the water supply tank and microbiological sampling of water in our laboratory
  • Quarterly water culture samples are sent outside to other NABL (National Accreditation Board for Testing and Calibration Laboratories) accredited laboratories for external quality control
  • Pre-operatively – All patients are given 5% povidone–iodine eye wash
  • Intraoperative – Use of vancomycin in the irrigating fluid. According to the 2007 American Society of Cataract and Refractive Surgery member committee survey, there was a 50%–50% split between those using prophylactic antibiotics in the irrigating fluids to those injecting it directly and vancomycin was the most commonly used antibiotic. Although there are very few cases of macular ischaemia following intracameral use of vancomycin, the benefits outnumber the side effects
  • Post-operative – A course of topical antibiotic eye drops is prescribed for 1 week following surgery. The most commonly used topical antibiotic is moxifloxacin 0.5% eye drops.
Figure 6: Surgical Safety checklist

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Lack of polymerase chain reaction (PCR) analysis to support our findings was the limitation of our study. PCR being a highly sensitive and specific investigation could have probably helped us in isolating more organisms in cases where culture results did not detect any growth. This would have aided to ascertain the aetiology and would also give us in-depth knowledge of the epidemiology of post-operative infections following various ocular surgeries.


  Conclusions Top


Low incidence of post-operative infections at our institute can be attributed to strict adherence of pre- and post-operative protocols as per our Hospital infection committee guidelines and regular monitoring of the same by our HIC Committee. Early diagnosis and prompt treatment aided in faster recovery and also reduced the risk of severe visual morbidity and the devastating complications and sequelae of post-operative infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ram J, Kaushik S, Brar GS, Taneja N, Gupta A. Prevention of postoperative infections in ophthalmic surgery. Indian J Ophthalmol 2001;49:59-69.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Safneck JR. Endophthalmitis: A review of recent trends. Saudi J Ophthalmol 2012;26:181-9.  Back to cited text no. 2
    
3.
Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479-96.  Back to cited text no. 3
    
4.
Kattan HM, Flynn HW Jr, Pflugfelder SC, Robertson C, Forster RK. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. Ophthalmology 1991;98:227-38.  Back to cited text no. 4
    
5.
Chang DF, Braga-Mele R, Henderson BA, Mamalis N, Vasavada A; ASCRS Cataract Clinical Committee. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg 2015;41:1300-5.  Back to cited text no. 5
    
6.
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33:978-88.  Back to cited text no. 6
    
7.
Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg 2013;39:15-21.  Back to cited text no. 7
    
8.
Sharma S, Padhi TR, Basu S, Kar S, Roy A, Das T. Endophthalmitis patients seen in a tertiary eye care centre in Odisha: A clinico-microbiological analysis. Indian J Med Res 2014;139:91-8.  Back to cited text no. 8
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9.
Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: Outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009;35:629-36.  Back to cited text no. 9
    
10.
Kunimoto DY, Das T, Sharma S, Jalali S, Majji AB, Gopinathan U, et al. Microbiologic spectrum and susceptibility of isolates: Part I. Postoperative endophthalmitis. Endophthalmitis Research Group. Am J Ophthalmol 1999;128:240-2.  Back to cited text no. 10
    
11.
Anand AR, Therese KL, Madhavan HN. Spectrum of aetiological agents of postoperative endophthalmitis and antibiotic susceptibility of bacterial isolates. Indian J Ophthalmol 2000;48:123-8.  Back to cited text no. 11
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12.
Gupta A, Gupta V, Gupta A, Dogra MR, Pandav SS, Ray P, et al. Spectrum and clinical profile of post cataract surgery endophthalmitis in North India. Indian J Ophthalmol 2003;51:139-45.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmitis following cataract surgery: Results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33:978-88.  Back to cited text no. 13
    
14.
Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: Outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg 2009;35:629-36.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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