Molecular and Phenotypic Characterization of Ocular Methicillin-Resistant Staphylococcus epidermidis Isolates in Taiwan.

Purpose: Staphylococcus epidermidis, a commensal, has emerged as an important opportunistic pathogen, particularly methicillin-resistant S. epidermidis (MRSE). The mechanism behind this transformation remains unclear. This study aimed to investigate the molecular and phenotypic characteristics of MRSE isolated from healthy conjunctiva and ocular infections. Methods: We collected MRSE isolates from two groups: healthy conjunctiva from patients undergoing cataract surgeries and ocular infections at our hospital. Genotypic analysis included pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), staphylococcal cassette chromosome mec (SCCmec), and biofilm-related genes (icaA, aap, and bhp). Additionally, phenotypic data on biofilm production and antibiotic susceptibility were recorded. Results: A total of 86 isolates, including 42 from healthy conjunctiva and 44 from ocular infections, were analyzed. MLST identified 21 sequence types (STs), with ST59 being the most frequent (n = 33, 39.5%), followed by ST130 (n = 10, 11.6%), ST57 (n = 6, 7.0%), and ST2 (n = 6, 7.0%). All isolates were categorized in 23 PFGE types, and SCCmec IV was the most prevalent SCCmec type (n = 52, 60.5%). The two sources of isolates exhibited overlapping molecular types and phenotypic traits, although the ocular infection isolates exhibited significantly higher multidrug resistance compared to healthy conjunctiva isolates (P = 0.032). When contrasting ST59 with non-ST59, ST59 displayed a significantly higher presence of aap (100%) and bhp (69.7%) while lacking icaA (0%). ST59 also showed lower susceptibility to fluoroquinolones compared to non-ST59 (42.4%-54.5% vs. 75.5%-83.0%; P < 0.01). Conclusions: MRSE isolates from healthy conjunctiva and ocular infections demonstrated a degree of resemblance. Specific strains, notably ST59, exhibited distinctive characterizations.

Methicillin-Resistant Staphylococcus aureus Ocular Infection in Taiwan: Potential Role of Panton-Valentine Leukocidin Gene.

Purpose: The relationship between Panton-Valentine leucocidin (PVL), a major virulence factor of Staphylococcus aureus, and disease severity and clinical outcomes remains unclear. We investigated the molecular characteristics and role of the PVL gene in methicillin-resistant S. aureus (MRSA) ocular infection in Taiwan. Methods: Patients with culture-proven S. aureus ocular infection in Chang Gung Memorial Hospital from 2010 to 2017 were included. The presence of the PVL gene was detected for all S. aureus isolates. MRSA isolates were characterized through pulsed-field gel electrophoresis (PFGE), staphylococcal multilocus sequence type, and staphylococcal cassette chromosome mec (SCCmec) typing. Drug susceptibility was examined using disk diffusion method and E-test. Patients' demographics, diagnoses, and outcomes were collected. Results: There were 112 methicillin-sensitive S. aureus and 103 MRSA isolates. Among 50 PVL(+) S. aureus isolates, 43 were MRSA. CC59/PFGE type D/SCCmec IV, VT (38 of 43 isolates, 88%), and CC59/PFGE type C/SCCmec IV (27 of 60 isolates, 45%) were the predominant clones in the PVL(+) and PVL(-) MRSA isolates, respectively. When we compared the two CC59 strains, the patients with PVL(+)/CC59 MSRA infection were significantly younger than those with PVL(-)/CC59 MSRA (39.3 vs. 61.7 years; P = 0.001). PVL(+)/CC59 MSRA caused significantly more eyelid disorders (36.8% vs. 3.7%; P = 0.002) but less keratitis (23.7% vs. 51.9%; P = 0.034). The antibiograms of the two strains were similar. Conclusions: PVL(+) MRSA is significantly associated with eyelid infection, especially in young patients. Translational Relevance: PVL gene plays a role in clinical features of MRSA ocular infections.

Staphylococcus aureus Keratitis in Taiwan: Genotyping, Antibiotic Susceptibility, and Clinical Features.

Staphylococcus aureus is an important pathogen for keratitis, a vision-threatening disease. We aimed to investigate the genotyping, antibiotic susceptibility, and clinical features of S. aureus keratitis, and to explore the possible role of Panton-Valentine leucocidin (PVL), a major virulence factor of S. aureus. We recruited 49 patients with culture-proven S. aureus keratitis between 2013 and 2017 at Chang Gung Memorial Hospital, Taiwan. PVL gene, multilocus sequence type (MLST), staphylococcal cassette chromosome mec (SCCmec), and pulsed-field gel electrophoresis (PFGE) were performed. Antibiotic susceptibility was verified using disk diffusion/E test. There were 49 patients with S. aureus keratitis; 17 (34.7%) were caused by methicillin-resistant S. aureus (MRSA) and 9 (18.4%) isolates had PVL genes. The predominant genotyping of MRSA isolates was CC59/PFGE type D/SCCmec VT/PVL (+). All methicillin-sensitive S. aureus (MSSA) and approximately 60% MRSA were susceptible to fluoroquinolones. No significant differences in clinical features, treatments, and visual outcomes were observed between MRSA/MSSA or PVL(+)/PVL(-) groups. In Taiwan, approximately one third of S. aureus keratitis was caused by MRSA, mainly community-associated MRSA. Although MRSA isolates were more resistant than MSSA, clinical characteristics were similar between two groups. Fluoroquinolones could be good empiric antibiotics for S. aureus keratitis.

Human leucocyte antigen association of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis with severe ocular complications in Han Chinese.

BACKGROUND/AIMS: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) induced by cold medicine (CM) may result in severe ocular complications (SOCs). The purpose of this study was to investigate the human leucocyte antigen (HLA) polymorphism pattern in CM-induced patients with SJS/TEN developing SOCs. METHODS: All participants, including patients with SJS/TEN (n=33) and control patients (n=98), were enrolled through visits to the clinic from 2016 to 2017. SOCs were diagnosed (n=26) via a chart review or eye examination. Patient saliva was collected with commercialised kits and genotyped with PCR assays followed by hybridisation with sequence-specific oligonucleotide (SSO) probes (PCR-SSO) using commercial bead-based typing kits. RESULTS: In all patients with SJS/TEN with SOCs, the HLA-A*02:07 carrier frequency was significantly higher than that in controls (OR=3.24, 95% CI=1.09 to 9.60, p=0.049), as was the genotype frequency (OR=3.89, 95% CI=1.49 to 10.16, p=0.007). In patients with CM-SJS/TEN with SOCs, the HLA-A*02:07 carrier frequency was higher than that in controls (OR=5.56, 95% CI=1.52 to 20.00, p=0.016), as was the allele frequency (OR=6.67, 95% CI=2.33 to 20.00, p=0.001). In patients with CM-SJS/TEN with SOCs, the HLA-B*46:01 allele frequency was significantly higher than that in controls (OR=3.85, 95% CI=1.52 to 10.00, p=0.008). CONCLUSIONS: The HLA-A*02:07 and HLA-B*46:01 alleles were significantly associated with SOCs among Han Chinese patients with CM-SJS/TEN. These findings demonstrate the genetic diversity in SJS pathogenesis among different ethnic groups.

Clinical Features and Molecular Characteristics of Methicillin-Susceptible Staphylococcus aureus Ocular Infection in Taiwan.

This study analyzed the clinical features and molecular characteristics of methicillin-susceptible Staphylococcus aureus (MSSA) ocular infections in Taiwan and compared them between community-associated (CA) and health-care-associated (HA) infections. We collected S. aureus ocular isolates from patients at Chang Gung Memorial Hospital between 2010 and 2017. The infections were classified as CA or HA using epidemiological criteria, and the isolates were molecularly characterized using pulsed-field gel electrophoresis, multilocus sequence typing, and Panton-Valentine leukocidin (PVL) gene detection. Antibiotic susceptibility was evaluated using disk diffusion and an E test. A total of 104 MSSA ocular isolates were identified; 46 (44.2%) were CA-MSSA and 58 (55.8%) were HA-MSSA. Compared with HA-MSSA strains, CA-MSSA strains caused a significantly higher rate of keratitis, but a lower rate of conjunctivitis. We identified 14 pulsotypes. ST 7/pulsotype BA was frequently identified in both CA-MSSA (28.3%) and HA-MSSA (37.9%) cases. PVL genes were identified in seven isolates (6.7%). Both CA-MSSA and HA-MSSA isolates were highly susceptible to vancomycin, teicoplanin, tigecycline, sulfamethoxazole-trimethoprim, and fluoroquinolones. The most common ocular manifestations were keratitis and conjunctivitis for CA-MSSA and HA-MSSA, respectively. The MSSA ocular isolates had diverse molecular characteristics; no specific genotype differentiated CA-MSSA from HA-MSSA. Both strains exhibited similar antibiotic susceptibility.

Clinico-microbiological profile of Burkholderia cepacia keratitis: a case series.

BACKGROUND: Burkholderia cepacia, an opportunistic pathogen mainly affecting patients with cystic fibrosis or immunocompromised, has rarely been documented as a cause of corneal infection. The clinical and microbiological profiles of B. cepacia keratitis are reported herein. METHODS: We retrospectively reviewed the medical record of 17 patients with culture-proven B. cepacia keratitis, treated between 2000 and 2019 at Chang Gung Memorial Hospital, Taiwan. Our data included predisposing factors, clinical presentations, treatments, and visual outcomes of B. cepacia keratitis as well as the drug susceptibility of the causative agent. RESULTS: The most common predisposing factor for B. cepacia keratitis was preexisting ocular disease (seven, 41.2%), particularly herpetic keratitis (five). Polymicrobial infection was detected in seven (41.2%) eyes. All B. cepacia isolates were susceptible to ceftazidime. Main medical treatments included levofloxacin or ceftazidime. Surgical treatment was required in five (29.4%) patients. Only four (23.5%) patients exhibited final visual acuity better than 20/200. CONCLUSIONS: B. cepacia keratitis primarily affects patients with preexisting ocular disease, particularly herpetic keratitis, and responds well to ceftazidime or fluoroquinolones. However, the visual outcomes are generally poor.

Paecilomyces/Purpureocillium keratitis: A consecutive study with a case series and literature review.

Paecilomyces/Purpureocillium species is an emerging pathogen of fungal keratitis; the risk factor, clinical course, and outcome of Paecilomyces/Purpureocillium keratitis need more exploration. We retrospectively reviewed 12 patients with culture-proven Paecilomyces/Purpureocillium keratitis in our hospital from 2003 to 2017 and combined them with 50 previous cases reported after the review conducted by Yuan et al. in 2009. Clinical features between the previously and newly reported cases were compared using the publication by Yuan et al. as a cutoff point. The mean age of the 62 newly reported patients with Paecilomyces/Purpureocillium keratitis was 52.7 years. Of these, contact lens wear was the most common predisposing factor (n = 32, 52%), followed by a preexisting corneal disease or previous ocular surgery (n = 12, 19%), and trauma (n = 8, 13%). Fifty eyes (81%) were treated with voriconazole, of which 31 (63%) were medically cured. Twenty-one of 62 eyes (34%) required therapeutic surgery. Compared with the 42 patients reported by Yuan et al., the patients were younger (P = .025); a higher proportion of the patients were contact lens wearers (P = .005); more patients were treated with voriconazole (P = .000); fewer patients required therapeutic surgery (P = .000) in recent reports. Contact lens use has become the major risk factor for Paecilomyces/Purpureocillium keratitis. The surgical rate has been significantly lower in recent publications, probably because of the prevalent use of voriconazole.

Prevalence and clinical consequences of cytomegalovirus DNA in the aqueous humour and corneal transplants.

AIM: To determine the prevalence and clinical consequences of cytomegalovirus (CMV) DNA in the aqueous and corneal tissues obtained at the time of corneal transplantation to evaluate the diagnostic value of PCR analysis in identifying patients at risk of postkeratoplasty CMV endotheliitis. METHODS: Thirty patients who underwent corneal transplantation were included in 2011. The aqueous, excised recipient corneas and donor corneoscleral rims were analysed by PCR for the presence of CMV DNA. The medical records of the patients were retrospectively reviewed and linked with PCR results. RESULTS: CMV DNA was detected in three (10%) aqueous, eight (26.7%) recipient corneas and six (20.0%) donor corneas obtained during keratoplasty from the 30 patients. Postoperatively, four patients, who had CMV DNA in either aqueous (3) or recipient cornea (1), were diagnosed with CMV endotheliitis based on clinical features and repeat aqueous tapping for real-time PCR analysis. At the median 60.5 months follow-up, 8 (72.7%), including 4 with postkeratoplasty CMV endotheliitis, of the 11 patients with CMV positivity in any one sample had graft failure, while 9 (47.3%) of the 19 patients without evidence of CMV DNA experienced graft failure. CONCLUSIONS: We found a relatively high prevalence of CMV DNA in the aqueous and corneas obtained during keratoplasty. All the patients who had CMV positivity in aqueous developed CMV endotheliitis postoperatively and experienced graft failure eventually. Aqueous tapping at the time of corneal transplantation for PCR analysis may help to improve the diagnosis and follow-up management of postkeratoplasty CMV endotheliitis.

Clinical Characteristics of Stenotrophomonas maltophilia Keratitis.

PURPOSE: Stenotrophomonas maltophilia is an important opportunistic pathogen but an uncommon cause of corneal infections. This study aimed to report the clinical features, antibiotic susceptibility, treatments, and visual outcomes of S. maltophilia keratitis. METHODS: The medical records of 21 patients with culture-proven S. maltophilia-associated infectious keratitis in our hospital between January 1, 2003, and December 31, 2014, were retrospectively reviewed. The clinical features of patients with S. maltophilia keratitis were compared with those of patients from 17 previously reported cases. RESULTS: The most common risk factors for S. maltophilia keratitis were preexisting corneal disease or previous corneal surgery (16), followed by soft contact lens wear (9). Nine patients (42.9%) were multifactorial. Polymicrobial infections was detected in 12 eyes (57.1%). All S. maltophilia isolates were susceptible to levofloxacin and moxifloxacin. A total of 17 of 21 patients (81.0%) had favorable responses to topical antimicrobial treatment, and 10 (47.6%) required surgical intervention for promotion of reepithelialization (6) and corneal perforation (4). Final vision ranged from light perception to 20/20. The clinical features of S. maltophilia keratitis in our cases and in previously reported cases were similar. CONCLUSIONS: S. maltophilia keratitis primarily affects patients with compromised ocular surfaces. S. maltophilia demonstrates in vitro susceptibility and a strong clinical response to fluoroquinolones.

Shifting Trends in Bacterial Keratitis in Taiwan: A 10-Year Review in a Tertiary-Care Hospital.

PURPOSE: To investigate the distribution, current trends, and antibiotic susceptibility profiles of bacterial keratitis isolates over 10 years. METHODS: We retrospectively reviewed the microbiology records of all corneal scrapings undertaken for cultures at Chang Gung Memorial Hospital from 2003 through 2012. We identified bacterial isolates and verified antibiotic susceptibilities by using the disk diffusion method. The Mantel-Haenszel linear-by-linear association χ test was used to detect the trends. RESULTS: We collected 2012 corneal scrapings, and the culture was positive in 992 samples (49.3%), yielding 1282 isolates. Bacterial isolates were identified for 1039 isolates (81.1%), including 533 gram-positive and 506 gram-negative isolates. An increase in the percentage of gram-positive isolates was significant (P = 0.008), as was a decrease in that of gram-negative isolates (P = 0.002). The most common bacterial isolates were Pseudomonas aeruginosa (24.4%) and coagulase-negative Staphylococcus (16.6%). For gram-positive organisms, the susceptibilities were as follows: vancomycin 100%, ciprofloxacin 88.9%, sulfamethoxazole-trimethoprim 86.8%, clindamycin 73.2%, and oxacillin 56.5%. The susceptibility of gram-positive bacteria to clindamycin and oxacillin increased significantly (P = 0.009 and P = 0.001). For gram-negative organisms, the susceptibilities were as follows: ciprofloxacin 93.7%, piperacillin 91.9%, ceftazidime 90.9%, amikacin 88.3%, and gentamicin 84.7%. No change in trend occurred. CONCLUSIONS: In Taiwan, we documented an increasing trend in the percentage of gram-positive bacteria. Methicillin-resistant microorganisms accounted for 43.5% of all gram-positive bacteria, but the trend of resistance to oxacillin and clindamycin significantly decreased. Ciprofloxacin continued to be a good empiric antibiotic for treating bacterial keratitis.

Methicillin-Resistant Staphylococcus aureus Ocular Infection in Taiwan: Clinical Features, Genotying, and Antibiotic Susceptibility.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is an important public health issue. This observational study aimed to characterize clinical features, antibiotic susceptibility, and genotypes of ocular infections caused by MRSA based on the clinical and molecular definitions of community-associated (CA) and healthcare-associated (HA) strains.Fifty-nine patients with culture-proven S aureus ocular infection were enrolled from January 1, 2010 to December 31, 2011 at Chang Gung Memorial Hospital, Taiwan. Antibiotic susceptibility was verified using disk diffusion/E test. For characterization, staphylococcal cassette chromosome mec (SCCmec), pulsed-field gel electrophoresis (PFGE), multilocus sequence type (MLST), and Panton-Valentine leukocidin (PVL) gene, were performed. MRSA isolates from the patients with HA factors were classified as clinically defined HA-MRSA, and those carrying SCCmec type I to III as molecularly defined HA-MRSA.Thirty-four patients with MRSA ocular infection were identified. The most common clone of CA-MRSA and HA-MRSA isolates was ST59/PFGE type D/SCCmec IV,VT/PVL (+) (n = 12) and CC 239/PFGE type A/SCCmec III, IIIA/PVL(-) (n = 10), respectively. All the 11 patients with molecularly defined HA-MRSA infections and 50% of the 22 patients with molecularly defined CA-MRSA infections were found to have HA factors (P = .005). CA-MRSA tended to cause lid infections, whereas HA-MRSA tended to cause corneal infections. Contrary to HA-MRSA isolates, nearly all the CA-MRSA isolates were susceptible to trimethoprim/sulfamethoxazole and fluoroquinolones under either clinical or molecular classifications.In Taiwan, CA-MRSA isolates exhibited considerably higher susceptibility to fluoroquinolones when compared with HA-MRSA isolates. A strong correlation was observed between the HA factors and molecularly defined HA-MRSA isolates.

A Comparison of Clinical Features between Community-Associated and Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Keratitis.

Purpose. To compare the clinical features of community-associated (CA) and healthcare-associated (HA) methicillin-resistant Staphylococcus aureus (MRSA) keratitis. Methods. Patients presenting with culture-proven MRSA keratitis between January 1, 2006, and December 31, 2010, at Chang Gung Memorial Hospital, Taiwan, were included in this study. The patients' demographic and clinical information were reviewed retrospectively. Antibiotic susceptibility was verified using the disk diffusion method. Results. Information on 26 patients with MRSA keratitis was collected, including 12 cases of CA-MRSA and 14 cases of HA-MRSA. All MRSA isolates were susceptible to vancomycin; the only difference in drug susceptibility was that CA-MRSA isolates were more susceptible to trimethoprim/sulfamethoxazole than HA-MRSA (P = .034). The most common risk factor for MRSA keratitis was ocular surface disease. No significant differences were observed between the 2 groups in terms of clinical features, treatments, and visual outcomes. Conclusion. In Taiwan, CA-MRSA rivals HA-MRSA as a critical cause of MRSA keratitis. Furthermore, CA-MRSA isolates are multidrug resistant. CA-MRSA and HA-MRSA keratitis are clinically indistinguishable, although larger studies are warranted to further evaluate this association.

Clinical characteristics of alternaria keratitis.

Purpose. Alternaria spp. are an uncommon cause of mycotic keratitis. Previous studies on Alternaria keratitis have generally been limited to case reports. We examined the clinical characteristics of Alternaria keratitis in this study. Methods. The characteristics and outcomes of 7 patients with culture-proven Alternaria keratitis treated in our hospital were compared with 25 previously reported cases. Results. The risk factors for Alternaria keratitis were trauma in 5 patients and soft contact lenses in 1 patient. Six patients with early diagnosis (<2 weeks) were cured with medical antimicrobial treatment; a patch graft was required in 1 patient with perforation. When incorporated with previous reports on Alternaria keratitis (n = 32), 14 (44%) infections followed trauma, 10 (31%) were associated with preexisting corneal disease or previous ocular surgery, and 5 (16%) occurred in soft contact lens wearers. Successful medical treatment was achieved in 23 (72%) patients, including 10 out of 21 eyes (48%) treated with natamycin and/or amphotericin B. Therapeutic penetrating keratoplasty was performed in 9 (28%) cases. Conclusions. Alternaria keratitis is generally associated with specific risk factors and responds to medical treatment when early diagnosis is performed and prompt antifungal treatment is initiated.

Pediatric microbial keratitis in Taiwan: clinical and microbiological profiles, 1998-2002 versus 2008-2012.

PURPOSE: To identify the change in clinical and microbiological profiles of pediatric microbial keratitis in Taiwan between 1998-2002 and 2008-2012. DESIGN: Retrospective, observational study. METHOD: setting: Chang Gung Memorial Hospital, a referral center in Taiwan. patient population: We retrospectively reviewed the medical records of 68 eyes of 67 children aged 16 years or younger who were diagnosed with microbial keratitis and treated at our hospital between July 2008 and December 2012. main outcomes and measures: Predisposing factors, isolated organisms, antibiotic susceptibility, and clinical outcomes. The findings were compared with the results of our previous study conducted between July 1998 and December 2002. RESULTS: As in 1998-2002, the leading risk factor for microbial keratitis during 2008-2012 was contact lens use, and the infection rate significantly increased from 40.7% to 52.9% (P = .024), which was mainly attributable to the recent increase in the rate of orthokeratology-related keratitis from 9.9% to 19.1% (P = .011). Pseudomonas aeruginosa remained the most commonly isolated organism (30.6%), but the number of isolated coagulase-negative Staphylococcus cases increased significantly in the 2008-2012 cases (P = .04). Antibiotic susceptibility of organisms did not change significantly between the 2 study periods. By using multiple linear stepwise regression analysis, we found that gram-negative bacterial infection played a crucial role in poor visual outcome. CONCLUSIONS: Contact lens-related microbial keratitis increased in Taiwanese children over time, especially because of the use of overnight orthokeratology. Clinicians must understand the infection background and pay further attention to contact lens use in pediatric patients.

Staphylococcus aureus keratitis: a review of hospital cases.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infection is an important public health issue. The study aimed to characterize the patient demographics, clinical features, antibiotic susceptibility, and clinical outcomes of keratitis caused by S. aureus, and to make a comparison between MRSA and methicillin-sensitive S. aureus (MSSA) isolates. METHODOLOGY/PRINCIPAL FINDINGS: Patients (n = 59) with culture-proven S. aureus keratitis treated in Chang Gung Memorial Hospital between January 1, 2006, and December 31, 2010, were included in our study. Patients' demographic and clinical data were retrospectively reviewed. Twenty-six MRSA (44%) and 33 MSSA (56%) isolates were collected. The MRSA keratitis was significantly more common among the patients with healthcare exposure (P = 0.038), but 46.2% (12/26) of patients with MRSA keratitis were considered to have community-associated infections. All isolates were susceptible to vancomycin. MRSA isolates were significantly more resistant to clindamycin, erythromycin, and sulfamethoxazole/trimethoprim. Ocular surface disease was a significant risk factor for MRSA keratitis (P = 0.011). Visual outcome did not differ significantly between the MRSA and MSSA groups. However, age (B = 0.01, P = 0.035, 95% confidence interval [CI]: 0.001-0.019) and visual acuity at presentation (B = 0.749, P<0.001, 95% CI: 0.573-0.926) were significantly correlated with visual outcome. CONCLUSIONS/SIGNIFICANCE: Ocular surface disease is an important predisposing factor for S. aureus keratitis, especially for MRSA infections. Advanced age and poor visual acuity at presentation are important prognostic indicators for poor visual outcome in S. aureus keratitis. Oxacillin resistance may not be a significant prognostic indicator.

Methicillin-resistant Staphylococcus aureus ocular infection: a 10-year hospital-based study.

PURPOSE: To characterize the patient demographics, clinical features, and antibiotic susceptibility of ocular infections caused by methicillin-resistant Staphylococcus aureus (MRSA), including community-associated (CA) and healthcare-associated (HA) isolates. DESIGN: Retrospective, observational study. PARTICIPANTS: Patients (n = 519) with culture-proven S. aureus ocular infections seen between January 1, 1999, and December 31, 2008, in Chang Gung Memorial Hospital. METHODS: Data collected included patient demographics and clinical information. Antibiotic susceptibility was verified by disc diffusion method. MAIN OUTCOME MEASURES: Proportion of MRSA in S. aureus ocular infections and the clinical characteristics, diagnoses, and antibiotic susceptibility patterns of CA-MRSA versus HA-MRSA ocular infections. RESULTS: We identified 274 patients with MRSA ocular infections, which comprised 181 CA-MRSA and 93 HA-MRSA isolates. The average rate of MRSA in S. aureus infections was 52.8% with a stable trend, whereas the annual ratio of CA-MRSA in ocular MRSA infections averaged 66.1% and tended to increase over the 10-year interval. Patients with ocular CA-MRSA were younger. Lid and lacrimal system disorders were more common, but keratitis, endophthalmitis, and wound infection were less common among CA-MRSA cases than HA-MRSA cases. Both CA-MRSA and HA-MRSA isolates were resistant to clindamycin and erythromycin, but CA-MRSA was more susceptible to sulfamethoxazole/trimethoprim. CONCLUSIONS: Community-associated MRSA is an important pathogen of ocular infections; CA-MRSA and HA-MRSA ocular infections differ demographically and clinically, but both strains were multi-resistant in Chang Gung Memorial Hospital, one of the biggest referral centers in Taiwan. In a country with a high prevalence of MRSA, ophthalmologists should be aware of such epidemiologic information.

The successful medical treatment of a case of Paecilomyces lilacinus keratitis.

PURPOSE: To report the successful medical treatment of Paecilomyces lilacinus keratitis case with topical voriconazole. METHODS: A 72-year-old male farmer developed a corneal infection in the left eye and corneal culture revealed Paecilomyces lilacinus. Infection was progressive despite initial treatment with hourly topical amphotericin B (1.5 mg/mL) and topical 5% natamycin. Treatment was switched to hourly topical voriconazole (10 mg/mL). RESULTS: The infection responded well to topical voriconazole and resolved within 1 month without any surgical intervention. The patient's best-corrected visual acuity was 20/200 secondary to central corneal scarring and a cataract in the left eye at the 10-month follow-up. CONCLUSION: Voriconazole may be effective in the treatment of Paecilomyces lilacinus keratitis refractory to standard antifungal agents. Early organism detection and appropriate treatment are necessary to eradicate such an infection.

Pediatric herpes simplex virus keratitis.

PURPOSE: To report the clinical characteristics and visual outcomes of pediatric herpes simplex virus (HSV) keratitis. METHODS: The medical records of 29 patients younger than 16 years with HSV keratitis who were diagnosed and treated at Chang Gung Memorial Hospital, Taoyuan, Taiwan, between 1996 and 2004 were retrospectively reviewed. The diagnosis of HSV keratitis was proven by a positive viral culture and/or real-time quantitative polymerase chain reaction or by a clear history of dendritic keratitis or herpetic kerato-uveitis. Type of HSV keratitis, recurrence rate, and visual outcome were analyzed. RESULTS: The average age at the entry into the study was 5.7 years (range: 7 months to 15 years). Mean follow-up time was 35.3 months (range: 2-69 months). Epithelial keratitis including dendritic and geographic ulcers was noted in 14 eyes, stromal keratitis in 2 eyes, stromal keratitis concurrent with epithelial keratitis in 8 eyes, and endotheliitis in 6 eyes. One patient had sequential involvement of both eyes. Thirteen patients (45%) developed recurrent HSV keratitis after the first documented episode. Female gender (but not age or the type of keratitis) was significantly associated with recurrences. Five patients who were maintained on oral valacyclovir prophylaxis up to 1 year had no recurrence during the period. Fifteen of 21 patients younger than 8 years of age had best-corrected visual acuity available at last follow-up, and 10 patients developed amblyopia. CONCLUSIONS: Children with HSV keratitis are at risk for recurrent keratitis and amblyopia. Prolonged systemic antiviral prophylaxis may help to prevent such consequences.