Elizabeth Ciociola Kelly, Russell Calderon, Peter Weng, Anthony Gonzales, Aunika Zheng, Evan Lau, Justin Bai, Richmond Woodward, Walter Duy, Gabriel Gomide, Ahmed Alshaikhsalama, Krista Thompson, Bita Momenaei, Thomas Jenkins, Peter Fioramonti, Lauren Dimalanta, Joel Epling, Tina Liu, David Hinkle, Alice Yang Zhang, Mark P Breazzano, Sunir Garg, Angeline L Wang, Royce Chen, Margaret Greven, Sharon Fekrat, J Fernando Arevalo
In this multicenter cohort, organism groups were associated with distinct presentations, sources, management, and outcomes. Low intraocular culture yield and imperfect concordance with blood cultures complicate pathogen-directed therapy. Presenting VA is the dominant prognostic factor, but gram-negative infections-particularly Serratia-carry markedly higher risk of globe loss. These findings support organism-informed clinical decision-making and highlight the need for improved intraocular diagnostics and targeted interventions.
OBJECTIVE: Evaluate differences in presentation, management, and outcomes of culture-positive endogenous endophthalmitis by microbial pathogen.
DESIGN: Retrospective multicenter clinical cohort study PARTICIPANTS: Eyes with a clinical diagnosis of endogenous endophthalmitis that underwent anterior chamber paracentesis, intravitreal aspiration, or pars plana vitrectomy (PPV) and intravitreal injection of antimicrobials with no recent exogenous risk factors.
METHODS: Clinical presentation, culture characteristics, treatment and outcomes for culture-positive endogenous endophthalmitis from 2012-2024 at nine academic tertiary referral centers stratified by microbial pathogen were reported. Multivariable mixed-effects models were used to determine predictors of final visual acuity (VA).
MAIN OUTCOMES AND MEASURES: Final VA, retinal detachment, enucleation.
RESULTS: 305 eyes from 261 patients were included: Staphylococcus aureus 115 (37.7%), Streptococcus 41 (13.4%), other gram-positive 29 (9.5%), gram-negative 47 (15.4%), fungal 59 (19.3%), and polymicrobial 14 (4.6%) infections. Blood cultures were positive in 202/305 eyes (66.2%), vitreous in 95 (31.1%), and aqueous in 27 (8.9%); concordant organism growth in paired blood and eye cultures occurred in 24/39 cases (62%). Fungal cases had higher rates of immunosuppression and intravenous drug use (p<0.05), while gram-negative cases more often had urinary sources (p<0.001). Presenting and final VA varied across groups (presenting mean logMAR 1.78-2.14 for most bacteria vs 1.30 for fungal, p<0.001; final mean logMAR 1.31-1.75 for bacteria vs 1.13 for fungal, p=0.06). Retinal detachment was most frequent with Staphylococcus aureus and Streptococcus. Enucleation was highest with gram-negative organisms (27.7%), driven by Serratia (85.7%, p=0.05). In adjusted mixed-effects models, worse presenting VA was the most consistent predictor of poorer final VA across groups; in Staphylococcus aureus and Streptococcus infections, systemic infection source, culture positivity, and need for PPV were predictors of final VA.
CONCLUSIONS: In this multicenter cohort, organism groups were associated with distinct presentations, sources, management, and outcomes. Low intraocular culture yield and imperfect concordance with blood cultures complicate pathogen-directed therapy. Presenting VA is the dominant prognostic factor, but gram-negative infections-particularly Serratia-carry markedly higher risk of globe loss. These findings support organism-informed clinical decision-making and highlight the need for improved intraocular diagnostics and targeted interventions.