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MRSA Keratitis and Conjunctivitis: What Does It Mean Practically?

  • Ocular Microbiology and Immunology (B Jeng and L Schocket, Section Editors)
  • Published:
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Abstract

Purpose of Review

This paper aims to review the epidemiology and clinical spectrum of two of the most common ophthalmic manifestations of methicillin-resistant Staphylococcus aureus (MRSA) infection, conjunctivitis, and keratitis. Recent data on antimicrobial resistance patterns and its clinical implications will be reviewed, as well as strategies for ophthalmologists to adequately treat infections and curtail the progress of resistance.

Recent Findings

There have been reports that the prevalence of MRSA ocular infections has been increasing and is associated with an increase in resistance to fluoroquinolones based on systemic standards. Notably, with community-acquired MRSA (CA-MRSA) on the rise, colonization and infection with MRSA is no longer exclusive to those with traditional risk factors.

Summary

Key strategies including culture-directed treatment with potent antimicrobials, effective antimicrobial dosing, empirical treatment based on local trends, and utilization of antiseptic strategies and antibiotic cycling should be utilized by clinicians to limit the spread of MRSA ophthalmic infections.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Mainous A. Nasal carriage of Staphylococcus aureus and methicillin-resistant S aureus in the United States, 2001-2002. Ann Fam Med. 2006;4:132–7. https://doi.org/10.1370/afm.526.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Klevens RM. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298:1763–71. https://doi.org/10.1001/jama.298.15.1763.

    Article  CAS  PubMed  Google Scholar 

  3. Amato M, Pershing S, Walvick M, Tanaka S. Trends in ophthalmic manifestations of methicillin-resistant Staphylococcus aureus (MRSA) in a northern California pediatric population. J AAPOS. 2013;17:243–7. https://doi.org/10.1016/j.jaapos.2012.12.151.

    Article  PubMed  Google Scholar 

  4. Solomon R, Donnenfeld ED, Holland EJ, Yoo SH, Daya S, Güell JL, et al. Microbial keratitis trends following refractive surgery: results of the ASCRS infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg. 2011;37:1343–50. https://doi.org/10.1016/j.jcrs.2011.05.006.

    Article  PubMed  Google Scholar 

  5. Blomquist PH. Methicillin-resistant staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006;104:322–45.

    PubMed  PubMed Central  Google Scholar 

  6. Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, Mcdougal LK, Carey RB, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. NEJM. 2006;355:666–74. https://doi.org/10.1056/NEJMoa055356.

    Article  CAS  PubMed  Google Scholar 

  7. Choo EJ. Community-associated methicillin-resistant Staphylococcus aureus in nosocomial infections. Infect Chemother. 2017;49:158–9. https://doi.org/10.3947/ic.2017.49.2.158.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Figueiredo AMS. What is behind the epidemiological difference between community-acquired and health-care associated methicillin-resistant Staphylococcus aureus? Virulence. 2017;8:640–2. https://doi.org/10.1080/21505594.2017.1335847.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Elam AR, Kowalski TA, Romanowski EG, Kowalski RP. The origin of Staphylococcus aureus isolated from blepharitis based on panton-valentine leucocidin and antibiotic susceptibility testing. J Ocul Dis Thera. 2014;2:4–8.

    Article  CAS  Google Scholar 

  10. CLSI. Performance standards for antimicrobial disk susceptibility tests, CLSI standard M02. 13th ed. Wayne: Clinical and Laboratory Standards Institute; 2018.

    Google Scholar 

  11. David MZ, Taylor A, Lynfield R, Boxrud DJ, Short G, Zychowski D, et al. Comparing pulsed-field gel electrophoresis with multilocus sequence typing, spa typing, staphylococcal cassette chromosome mec (SCCmec) typing, and PCR for panton-valentine leukocidin, arcA, and opp3 in methicillin-resistant Staphylococcus aureus isolates at a U.S. Medical Center. J Clin Microbiol. 2012;51:814–9. https://doi.org/10.1128/JCM.02429-12.

    Article  PubMed  Google Scholar 

  12. Pierre DJ, Tang J. Bleb associated endophthalmitis with methicillin-resistant Staphylococcus aureus. Br J Ophthalmol. 2010;94:390–2. https://doi.org/10.1136/bjo.2009.163774.

    Article  PubMed  Google Scholar 

  13. Wu KI, Liu KR, Chien HW. Methicillin-resistant Staphylococcus aureus buckle infection complicated by endophthalmitis and presumed choroidal abscess in a patient with ulcerative colitis. Taiwan J Ophthalmol. 2016;6:98–100. https://doi.org/10.1016/j.tjo.2015.07.002.

    Article  PubMed  Google Scholar 

  14. Lee JE, Oum BS, Choi HY, Lee JS. Methicillin-resistant Staphylococcus aureus sclerokeratitis after pterygium excision. Cornea. 2007;26:744–6. https://doi.org/10.1097/ICO.0b013e31804e45ba.

    Article  PubMed  Google Scholar 

  15. Oakey Z, Thai K, Garg S. Bilateral corneal perforation due to MRSA keratitis in a crosslinking patient. GMS Ophthalmol Cases. 2017;7. https://doi.org/10.3205/oc000072.

  16. Kenneth Teow KL, Nor Akmal B, Jamalia R, Safinaz MK. A rare complication of MRSA lid abscess and orbital abscess following strabismus surgery in a child. J Surg Acad. 2018;8:32–5.

    Google Scholar 

  17. Oteyza GGD, Laiseca A, Sauvageot P, Toledo JÁD. Methicillin-resistant Staphylococcus aureus acute keratitis after intracorneal ring segment implantation. Ophthalmol Ther. 2017;6:367–71. https://doi.org/10.1007/s40123-017-0103-9.

    Article  Google Scholar 

  18. Fasciani R, Agresta A, Caristia A, Mosca L, Scupola A, Caporossi A. Methicillin-resistant Staphylococcus aureus ocular infection after corneal cross-linking for keratoconus: potential association with atopic dermatitis. Case Rep Ophthalmol Med. 2015;2015:1–6.

    Article  Google Scholar 

  19. Chou T, Prabhu. Clinical course and management of postoperative methicillin-resistant Staphylococcus aureus keratitis in immunocompromised patients: two case reports. Clin Ophthalmol. 2011;5:1789–93. https://doi.org/10.2147/OPTH.S23201.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Pansegrau ML, Mengarelli E, Dersu II. Complication of an Ahmed glaucoma valve implant: tube exposure with methicillin-resistant Staphylococcus aureus infection. Digit J Ophthalmol. 2015;21:1–9. https://doi.org/10.5693/djo.02.2015.04.005.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Labowsky M, Lim M, Aboobakar IF, Freedman SF. Red eye after strabismus surgery: community-acquired MRSA periocular infection. J AAPOS. 2016;20:448–448.e2. https://doi.org/10.1016/j.jaapos.2016.05.017.

    Article  PubMed  Google Scholar 

  22. Miyamoto T, Eguchi H, Tserennadmid E, Mitamura-Aizawa S, Hotta F, Mitamura Y. Methicillin-resistant Staphylococcus aureus keratitis after Descemet’s stripping automated endothelial keratoplasty. Case Rep Ophthalmol. 2013;4:269–73. https://doi.org/10.1159/000357170.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Asbell PA, Sahm DF, Shaw M, Draghi DC, Brown NP. Increasing prevalence of methicillin resistance in serious ocular infections caused by Staphylococcus aureus in the United States: 2000 to 2005. J Cataract Refract Surg. 2008;34:814–8. https://doi.org/10.1016/j.jcrs.2008.01.016.

    Article  PubMed  Google Scholar 

  24. • Chang VS, Dhaliwal DK, Raju L, Kowalski RP. Antibiotic resistance in the treatment of Staphylococcus aureus keratitis. Cornea. 2015;34:698–703. https://doi.org/10.1097/ICO.0000000000000431. This 20-year review provides information on the regional incidence and resistance patterns of a large number of culture-proven MRSA keratitis isolates at an ophthalmic microbiology laboratory in Western Pennsylvania.

    Article  PubMed  PubMed Central  Google Scholar 

  25. • Peng MY, Cevallos V, Mcleod SD, Lietman TM, Rose-Nussbaumer J. Bacterial Keratitis: Isolated organisms and antibiotic resistance patterns in San Francisco. Cornea. 2018;37:84–7. https://doi.org/10.1097/ICO.0000000000001417. This 19-year review tracked regional trends in the bacteriological profiles of a large sample of corneal cultures and their in vitro antibiotic resistance patterns in Northern California.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Rutar T, Chambers HF, Crawford JB, Perdreau-Remington F, Zwick OM, Karr M, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. 2006;113:1455–62. https://doi.org/10.1016/j.ophtha.2006.03.031.

    Article  PubMed  Google Scholar 

  27. Hsiao CH, Chuang CC, Tan HY, Ma DH, Lin KK, Chang CJ, et al. Methicillin-resistant Staphylococcus aureus ocular infection: a 10-year hospital-based study. Ophthalmology. 2012;119:522–7. https://doi.org/10.1016/j.ophtha.2011.08.038.

    Article  PubMed  Google Scholar 

  28. • Wong ES, Chow CWY, Luk WK, Fung KSC, Li KKW. A 10-year review of ocular methicillin-resistant Staphylococcus aureus infections. Cornea. 2017;36:92–7. https://doi.org/10.1097/ICO.0000000000001048. This review describes epidemiological data, distinctive clinical features, and antibiotic susceptibility profiles of ocular MRSA infections in Hong Kong stratified by CA- and HA-MRSA isolates.

    Article  PubMed  Google Scholar 

  29. Rarey K, Shanks RMQ, Romanowski EG, Mah FS, Gondaira F, Kowalski RP. Staphylococcus aureus from endophthalmitis are hospital-acquired based on PVL and antibiotic susceptibility testing. J Ocul Pharmacol Ther. 2012;28:12–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Shukla SK, Karow ME, Brady JM, Stemper ME, Kislow J, Moore N, et al. Virulence genes and genotypic associations in nasal carriage, community-associated methicillin-susceptible and methicillin-resistant USA400 Staphylococcus aureus isolates. J Clin Microbiol. 2010;48:3582–92. https://doi.org/10.1128/JCM.00657-10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Chuang CC, Hsiao CH, Tan HY, Ma DHK, Lin KK, Chang CJ, et al. Staphylococcus aureus ocular infection: methicillin-resistance, clinical features, and antibiotic susceptibilities. PLoS One. 2012;7:e42437. https://doi.org/10.1371/journal.pone.0042437.

    Article  CAS  PubMed Central  Google Scholar 

  32. Ong SJ, Huang YC, Tan HY, Ma DHK, Lin HC, Yeh LK, et al. Staphylococcus aureus keratitis: a review of hospital cases. PLoS One. 2013;8:e80119. https://doi.org/10.1371/journal.pone.0080119.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP, Margolis TP. Spectrum of eye disease caused by methicillin-resistant staphylococcus aureus. Am J Ophthal. 2007;144:313–5. https://doi.org/10.1016/j.ajo.2007.03.032.

    Article  PubMed  Google Scholar 

  34. Lever J, Eubanks E, Gupta C, Barmettler A, Servat JJ, Nesi-Eloff F. Giant fornix syndrome with chronic methicillin resistant staphylococcus aureus conjunctivitis causing nasal lacrimal duct obstruction. Invest Ophthalmol Vis Sci. 2013;54:5348.35.

    Google Scholar 

  35. Rose GE. The giant fornix syndrome: an unrecognized cause of chronic, relapsing, grossly purulent conjunctivitis. Ophthalmol. 2004;111:1539–45.

    Article  Google Scholar 

  36. Turaka K, Penne RB, Rapuano CJ, Ayres BD, Abazari A, Eagle RC, et al. Giant fornix syndrome: a case series. Ophthalmic Plast Reconstr Surg. 2012;28:4–6.

    Article  PubMed  Google Scholar 

  37. Deramo VA, Lai JC, Winokur J, Luchs J, Udell IJ. Visual outcome and bacterial sensitivity after methicillin-resistant Staphylococcus aureus–associated acute endophthalmitis. Am J Ophthalmol. 2008;145:413–7. https://doi.org/10.1016/j.ajo.2007.10.020.

    Article  PubMed  Google Scholar 

  38. Speaker MG, Milch FA, Shah MK, Eisner W, Kreiswirth BN. Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis. Ophthalmology. 1991;98:639–50.

    Article  CAS  PubMed  Google Scholar 

  39. Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hosp Infect. 1995;31:13–24.

    Article  CAS  PubMed  Google Scholar 

  40. Ritterband D. Methicillin-resistant Staphylococcus aureus and the eye: current concepts and management strategies. Curr Ophthalmol Rep. 2013;1:151–60.

    Article  Google Scholar 

  41. Olson, Donnenfeld E, Bucci, Price, Raizman, Solomon, et al. Methicillin resistance of Staphylococcus species among health care and nonhealth care workers undergoing cataract surgery. Clin Ophthalmol. 2010:1505. https://doi.org/10.2147/OPTH.S14333.

  42. Cadena J, Walter E, Frei CR, Thinwa J. Risk factors for the development of active methicillin-resistant Staphylococcus aureus (MRSA) infection in patients colonized with MRSA at hospital admission. Am J Infect Control. 2016;44:1617–21. https://doi.org/10.1016/j.ajic.2016.05.009.

    Article  PubMed  Google Scholar 

  43. Hsiao CH, Ong SJ, Chuang CC, Ma DH, Huang YC. A comparison of clinical features between community-associated and healthcare-associated methicillin-resistant Staphylococcus aureus keratitis. J Ophthalmol. 2015;2015:1–7. https://doi.org/10.1155/2015/923941.

    Article  CAS  Google Scholar 

  44. Gupta K, Martinello RA, Young M, Strymish J, Cho K, Lawler E. MRSA nasal carriage patterns and the subsequent risk of conversion between patterns, infection, and death. PLoS One. 2013;8.

  45. Kimura N, Sotozono C, Higashihara H, Inatomi T, Yokoi N, Kinoshita S. Relationship between ocular surface infection or colonization of methicillin-resistant Staphylococcus aureus and nasal carriage. Nippon Ganka Gakkai Zasshi. 2007;111:504–8.

    PubMed  Google Scholar 

  46. Alexandrou TJ, Hariprasad SM, Benevento J, Rubin MP, Saidel M, Ksiazek S, et al. Reduction of preoperative conjunctival bacterial flora with the use of mupirocin nasal ointment. Trans Am Ophthalmol Soc. 2006;104:196–201.

    PubMed  PubMed Central  Google Scholar 

  47. Sato KI. External ocular infections due to methicillin-resistant Staphylococcus aureus and medical history. Can J Ophthalmol. 2015;50:e97–9.

    Article  PubMed  Google Scholar 

  48. Crum NF, Barrozo CP, Chapman FA, Ryan MAK, Russell KL. An outbreak of conjunctivitis due to a novel unencapsulated Streptococcus pneumoniae among military trainees. Clin Infect Dis. 2004;39:1148–54.

    Article  PubMed  Google Scholar 

  49. Lichtenstein SJ, Dorfman M, Kennedy R, Stroman D. Controlling contagious bacterial conjunctivitis. J Pediatr Ophthalmol Strabismus. 2006;43:19–26.

    PubMed  Google Scholar 

  50. Schwartz B, Harrison LH, Motter JS, Motter RN, Hightower AW, Broome CV. Investigation of an outbreak of Moraxella conjunctivitis at a Navajo boarding school. Am J Ophthalmol. 1989;107:341–7.

    Article  CAS  PubMed  Google Scholar 

  51. Trottier S, Stenberg K, Von Rosen IA, Svanborg C. Haemophilus influenzae causing conjunctivitis in day-care children. Pediatr Infect Dis J. 1991;10:578–84.

    Article  CAS  PubMed  Google Scholar 

  52. Rutledge S. Methicillin-resistant Staphylococcus aureus outbreak in the neonatal intensive care unit. Am J Infect Control. 2012;40:e109–10.

    Article  Google Scholar 

  53. Kowalski RP, Romanowski EG, Mah FS, Sasaki H, Fukuda M, Gordon YJ. A comparison of moxifloxacin and levofloxacin topical prophylaxis in a fluoroquinolone-resistant Staphylococcus aureus rabbit model. Jpn J Ophthalmol. 2008;52:211–6. https://doi.org/10.1007/s10384-008-0530-1.

    Article  CAS  PubMed  Google Scholar 

  54. Romanowski EG, Mah FS, Kowalski RP, Yates KA, Gordon YJ. Benzalkonium chloride enhances the antibacterial efficacy of gatifloxacin in an experimental rabbit model of intrastromal keratitis. J Ocul Pharmacol Ther. 2008;24:380–4. https://doi.org/10.1089/jop.2008.0017.

    Article  CAS  PubMed  Google Scholar 

  55. Asbell PA, Colby KA, Deng S, Mcdonnell P, Meisler DM, Raizman MB, et al. Ocular TRUST: nationwide antimicrobial susceptibility patterns in ocular isolates. Am J Ophthalmol. 2008;145:951–958.e1. https://doi.org/10.1016/j.ajo.2008.01.025.

    Article  PubMed  Google Scholar 

  56. Major JC, Engelbert M, Flynn HW, Miller D, Smiddy WE, Davis JL. Staphylococcus aureus endophthalmitis: antibiotic susceptibilities, methicillin resistance, and clinical outcomes. Am J Ophthalmol. 2010;149:278–283.e1.

    Article  CAS  PubMed  Google Scholar 

  57. Vola ME, Moriyama AS, Lisboa R, Vola MM, Hirai FE, Bispo PJM, et al. Prevalence and antibiotic susceptibility of methicillin-resistant Staphylococcus aureus in ocular infections. Arq Bras Oftalmol. 2013;76:350–3.

    Article  PubMed  Google Scholar 

  58. Kotlus BS, Wymbs RA, Vellozzi EM, Udell IJ. In vitro activity of fluoroquinolones, vancomycin, and gentamicin against methicillin-resistant Staphylococcus aureus ocular isolates. Am J Ophthalmol. 2006;142:726–9.

    Article  CAS  PubMed  Google Scholar 

  59. Croghan C, Lockington D. Management of MRSA-positive eye swabs and the potential advantages of chloramphenicol availability in the United Kingdom. Eye. 2017;32:157–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. • Asbell PA, Sanfilippo CM. Antibiotic resistance trends among ocular pathogens in the US—cumulative results from the antibiotic resistance monitoring in ocular microorganisms (ARMOR) surveillance study. US Ophthalmic Rev. 2017;10:35–8. The Bausch + Lomb-sponsored study is the only multicenter, nationwide surveillance study of antibiotic resistance patterns specific to ophthalmology.

    Article  Google Scholar 

  61. Mah FS, Sanfilippo CM. Besifloxacin: efficacy and safety in treatment and prevention of ocular bacterial infections. Ophthalmol Ther. 2016;5:1–20. https://doi.org/10.1007/s40123-016-0046-6.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Sanfilippo CM, Allaire CM, Decory HH. Besifloxacin ophthalmic suspension 0.6% compared with gatifloxacin ophthalmic solution 0.3% for the treatment of bacterial conjunctivitis in neonates. Drugs R D. 2017;17:167–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Ohnsman CM. Exclusion of students with conjunctivitis from school: policies of state departments of health. J Pediatr Ophthalmol Strabismus. 2007;44:101–5.

    PubMed  Google Scholar 

  64. Hutnik C, Cheema. Bacterial conjunctivitis. Clin Ophthalmol. 2010;4:1451–7.

    Article  PubMed  PubMed Central  Google Scholar 

  65. • Silvester A, Neal T, Czanner G, Briggs M, Harding S, Kaye S. Adult bacterial conjunctivitis: resistance patterns over 12 years in patients attending a large primary eye care centre in the UK. BMJ Open Ophthalmol. 2016:1. https://doi.org/10.1136/bmjophth-2016-000006. This large retrospective study addressed the important concern regarding rate of resistance to chloramphenicol after being made available over the counter in the UK. This evidence contributes to the larger discussion of revisiting the use of chloramphenicol.

  66. Price FW, Dobbins K, Zeh W. Penetration of topically administered ofloxacin and trimethoprim into aqueous humor. J Ocul Pharmacol Ther. 2002;18:445–53.

    Article  CAS  PubMed  Google Scholar 

  67. Kowalski RP. Is antibiotic resistance a problem in the treatment of ophthalmic infections? Expert Rev Ophthalmol. 2013;8:119–26.

    Article  CAS  Google Scholar 

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Correspondence to Tarika Thareja.

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Thareja, T., Kowalski, R.P., Jhanji, V. et al. MRSA Keratitis and Conjunctivitis: What Does It Mean Practically?. Curr Ophthalmol Rep 7, 110–117 (2019). https://doi.org/10.1007/s40135-019-00206-z

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