Nocardia keratitis: species, drug sensitivities, and clinical correlation.

PURPOSE: To correlate the clinical presentation and treatment outcome of Nocardia keratitis with the time to diagnosis, different species and with the drug sensitivity pattern. METHOD: Patients with Nocardia corneal ulcers were studied at a tertiary eye care center. Speciation of Nocardia isolates was done by sequencing the 16s rRNA gene. Clinical response to treatment was assessed by chart review. RESULTS: Twenty one (65.3%) patients presented within 15 days of the onset of symptoms with typical clinical features of Nocardia keratitis, ie, a ring-like distribution of superficial infiltrates in a wreath pattern. Eight patients (25%) who presented after 15 days and within 30 days had an ulcer resembling fungal keratitis. N. Cyriacigeorgica (n = 11; 34.37%), N. asteroides (n = 9; 28%), N. farcinica (n = 7; 22%,) and N. Otitidiscaviarum (n = 5; 16%). All the species had 100% sensitivity to amikacin, sulphamethoxazole, imipenem and co-trimoxazole. Time to diagnosis of the infection was significantly associated with the different types of clinical presentation; those presenting early having the typical clinical picture (P = 0.004). Patients (73%) presenting within 15 days showed a highest recovery rate. (P = 0.045). The recovery time of the patients when compared with species showed those who were infected with N. cyriageorgica had a healing time of less than 15 days. Clinically, healing was faster when treated with 2% amikacin. Visual outcome improved in fourteen patients (44%) and sixteen (50%) patients remained the same (P = 0.0001). CONCLUSION: Characteristic clinical picture of Nocardia is dependant on early presentation. It could be mistaken for fungal keratitis. Microbiological confirmation is important. Drug of choice for Nocardia keratitis is amikacin.

Clinico-microbiological profile and visual outcomes of post-traumatic endophthalmitis at a tertiary eye care center in South India.

PURPOSE: To analyze the clinical and microbiological characteristics of eyes with post-traumatic endophthalmitis and factors influencing the visual outcomes in these cases. METHODS: We performed a retrospective chart analysis of the clinical and microbiological data of 97 consecutive patients with post-traumatic endophthalmitis presenting to a tertiary eye care hospital in South India. RESULTS: Thirty-nine (40.2%) cases were culture-positive, gram-positive cocci (n=24/42, 57.1%) being the commonest isolates. Staphylococcus epidermidis and Pseudomonas aeuruginosa were the commonest single isolates (n=10; 23.8%). Majority of the organisms were sensitive to chloramphenicol (n=27) or ciprofloxacin (n=26). Susceptibility to vancomycin (n=3) and amikacin (n=4) was poor. Cases with negative cultures at presentation were more likely to have improvement in visual acuity compared with culture-positive cases (on multivariate analysis, OR: 3.2, 95% CI: 1.1, 9.0). CONCLUSIONS: In this series of post-traumatic endophthalmitis, a high prevalence of resistance of the culture isolates to vancomycin and amikacin was observed.

Postcataract endophthalmitis in South India incidence and outcome.

OBJECTIVE: To determine the incidence of acute-onset postcataract endophthalmitis, identify risk factors, and determine clinical outcomes in a tertiary eye care center in South India. DESIGN: Retrospective, interventional, observational case series. PARTICIPANTS: All patients who underwent cataract extraction from January 2002 to December 2003 at Aravind Eye Hospital, Madurai. METHODS: The records of patients with acute endophthalmitis after cataract surgery were reviewed. MAIN OUTCOME MEASURES: Acute-onset postcataract endophthalmitis, incidence rates, risk factors, organisms cultured, and visual acuity outcomes after treatment. RESULTS: During the study period, 36072 cataract surgeries were performed; these included 22294 cases of phacoemulsification and 9503 cases of extracapsular cataract extraction. A total of 19 eyes developed acute endophthalmitis after cataract surgery (average 2-year incidence, 0.05%). Ten cases were culture positive (average 2-year incidence, 0.03%). In multivariate analysis, increased risk of endophthalmitis was associated with intraoperative complications, such as posterior capsular rent and vitreous loss (relative risk [RR], 6.57; 95% confidence interval [CI], 1.5-28.5; P = 0.05) for all endophthalmitis cases, age >60 years for culture-positive endophthalmitis cases (RR, 6; 95% CI, 0.7-47.8; P = 0.04), and an extracapsular cataract extraction technique for culture-positive endophthalmitis cases (RR, 4.9; 95% CI, 1.2-19.3; P = 0.001). After follow-up of 37 days, 5 (29.41%) of the 17 patients achieved a best-corrected visual acuity (BCVA) of 20/40, and the remaining 7 (32.3%) had a BCVA better than 20/200. Of the culture-positive cases, Nocardia species was the most common organism isolated, accounting for more than half of these cases (6/10 [60%]). CONCLUSIONS: This study found the incidence of acute postoperative endophthalmitis after cataract surgery to be 0.05%. Extracapsular cataract extraction technique and the occurrence of intraoperative complications are major risk factors for developing endophthalmitis. Visual outcome after endophthalmitis was generally poor. Nocardia is a lesser-known but virulent organism causing endophthalmitis, the management of which still poses a therapeutic dilemma.

Newborn vitamin A dosing reduces the case fatality but not incidence of common childhood morbidities in South India.

Vitamin A supplementation reduces mortality in young children in areas of endemic vitamin A deficiency. However, it has no impact on the incidence of common morbidities. This discrepancy has been explained by an impact on case fatality, although with the exception of hospitalized measles cases, there is little direct evidence to support this hypothesis. We assessed the impact of newborn dosing with vitamin A on the incidence and case fatality of common childhood morbidities in early infancy in a community-based, randomized trial in South India. Morbidity for each day in the previous 2 wk was assessed for the first 6 mo of life. A total of 11,619 live-born infants were enrolled and randomized to receive either 48,000 IU (50.4 micromol retinol) of oral vitamin A or placebo following delivery. There was no difference between treatment groups in the incidence of acute or chronic diarrhea, dysentery, or fever but a small increased incidence of acute respiratory illness (ARI). Case fatality for diarrhea and fever were significantly reduced in the vitamin A group compared with placebo (relative case fatality [95% CI] of 0.50 [0.27, 0.90] and 0.60 [0.40, 0.88], respectively). There was a trend in reduction of case fatality for various definitions of ARI, but the evidence for this effect was modest. Survival analysis among those with morbid episodes confirmed the case fatality analysis. This trial demonstrated that the reduction in overall mortality due to newborn vitamin A dosing was driven primarily by a reduction in case fatality among infants.

Rubella serosurveys at three Aravind Eye Hospitals in Tamil Nadu, India.

OBJECTIVE: To determine the susceptibility of female eye hospital staff to rubella infection and the potential risk for hospital-based rubella outbreaks. METHODS: A prospective cohort study on the seroprevalence of rubella IgG antibodies was conducted at three large eye hospitals in Coimbatore, Madurai and Tirunelveli, Tamil Nadu, India, where young children with eye abnormalities attributable to congenital rubella are treated. A total of 1000 female hospital employees aged 18-40 years agreed to participate and gave written informed consent. FINDINGS: The proportions of rubella-seronegative women were: 11.7% at Coimbatore, with a 95% confidence interval (CI) of 8.1-16.5; 15% at Madurai (95% CI = 12.3-18.1), and 20.8 at Tirunelveli (95% CI = 14.7-28.6). For the entire cohort the proportion seronegative was significantly higher among married women (21.5%) than among single women (14.0%) (P = 0.02). Rates of seronegativity were highest among physicians and lowest among housekeepers. All 150 seronegative women in the study sample accepted a dose of rubella vaccine. CONCLUSION: These are the first rubella serosurveys to have been reported from eye hospitals in any country. The relatively high rate of susceptibility indicated a risk of a rubella outbreak, and this was reduced by vaccinating all seronegative women. A policy has been established at all three hospitals for the provision of rubella vaccine to new employees. Other hospitals, especially eye hospitals and hospitals in countries without routine rubella immunization, should consider the rubella susceptibility of staff and the risk of hospital-based rubella outbreaks.

Impact of supplementing newborn infants with vitamin A on early infant mortality: community based randomised trial in southern India.

OBJECTIVE: To assess the impact of supplementing newborn infants with vitamin A on mortality at age 6 months. DESIGN: Community based, randomised, double blind, placebo controlled trial. SETTING: Two rural districts of Tamil Nadu, southern India. PARTICIPANTS: 11 619 newborn infants allocated 24 000 IU oral vitamin A or placebo on days 1 and 2 after delivery. MAIN OUTCOME MEASURE: Primary outcome measure was mortality at age 6 months. RESULTS: Infants in the vitamin A group had a 22% reduction in total mortality (95% confidence interval 4% to 37%) compared with those in the placebo group. Vitamin A had an impact on mortality between two weeks and three months after treatment, with no additional impact after three months. CONCLUSION: Supplementing newborn infants with vitamin A can significantly reduce early infant mortality.