Extensively and pan-drug resistant Pseudomonas aeruginosa keratitis: clinical features, risk factors, and outcome

  • Merle Fernandes
  • Divya Vira
  • Radhika Medikonda
  • Nagendra Kumar



Emergence of multi-drug resistant (MDR), extensively drug resistant (XDR), and pan-drug resistant (PDR) strains of Pseudomonas aeruginosa pose a significant therapeutic challenge. Managing XDR and PDR Pseudomonas aeruginosa keratitis would be extremely difficult due to paucity of safe and effective topical medications. We aim to describe the clinical features, risk factors, and outcome of XDR and PDR Pseudomonas aeruginosa keratitis.


A retrospective chart review of consecutive cases of XDR and PDR Pseudomonas aeruginosa keratitis were identified from Ocular Microbiology Department. XDR and PDR were defined based on criteria established by Centers for Disease Control and European Centre for Disease Prevention and Control. The following data was collected: age, gender, occupation, symptom duration, systemic and ocular risk factors, infiltrate characteristics, antimicrobial susceptibility, complications, surgical interventions, presenting, and final visual acuity and final outcome. Complete success was defined as resolution of the infiltrate with scar formation on medical treatment alone. Partial success was the resolution following tissue adhesive application. Failure was an inadequate response to medical therapy with progressive increase in infiltrate, corneal melting, and/or perforation necessitating one or more therapeutic penetrating keratoplasties or evisceration.


Fifteen eyes of 13 patients were included. Seven (53.8 %) were male with left eye involvement in nine (60 %) cases. Most common risk factors were bandage contact lens (6, 40 %), topical steroids (5, 33.3 %), previous therapeutic graft (4, 26.6 %), and ocular surface disorder (OSD) following Stevens Johnson Syndrome (SJS) (4, 26.6 %). Of 15 isolates, six (40 %) were sensitive only to imipenem, three (20 %) to colistin, two (13.3 %) to neomycin, one (6.7 %) each to imipenem and colistin, imipenem and ceftazidime, and azithromycin respectively. One isolate was resistant to all antibiotics. Complete success was noted in two (16.67 %), partial success in three (25 %) and failure in seven (58.33 %) eyes. Five (33.3 %) eyes healed on imipenem (three eyes), azithromycin (one eye), and imipenem and colistin (one eye).


XDR and PDR Pseudomonas aeruginosa keratitis are extremely difficult to treat. Globe salvage was possible in all cases; however, more than half required therapeutic grafts. Close monitoring of patients with known ocular and systemic factors is warranted.


Pseudomonas aeruginosa Microbial keratitis Extensive drug resistance Multi-drug resistance Pan-drug resistance 



We would like to acknowledge Dr. Savitri Sharma, MD, Jhaveri Centre for Microbiology, L V Prasad Eye Institute, Hyderabad for reviewing the manuscript and providing feedback.

We would also like to acknowledge Mr. Mohammed Hasnat Ali, MBA, Biostatistician, L V Prasad Eye Institute, Hyderabad for inputs on the statistical analysis.

Compliance with ethical standards


No funding was received for this research.

Conflict of Interest

All authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. In this retrospective study formal consent was not required. There is no identifying information available in the article.


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Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Merle Fernandes
    • 1
  • Divya Vira
    • 1
  • Radhika Medikonda
    • 1
  • Nagendra Kumar
    • 2
  1. 1.Cornea and Anterior Segment ServicesL. V. Prasad Eye InstituteVisakhapatnamIndia
  2. 2.Ocular Microbiology DepartmentL. V. Prasad Eye InstituteVisakhapatnamIndia

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