Pharmacist-Led Management of Elizabethkingia Keratitis: Precision Therapy Guided by Culture and mNGS to Improve Clinical Outcomes and Efficiency.

PURPOSE: This study evaluated the clinical efficacy of a pharmacist-led antimicrobial stewardship program augmented by metagenomic next-generation sequencing (mNGS) for managing rare, multidrug-resistant Elizabethkingia keratitis. METHODS: We conducted a retrospective case series of 5 male patients (mean age 56.4 years) diagnosed with Elizabethkingia keratitis (3 E. meningoseptica, 2 Elizabethkingia anophelis) between 2020 and 2025. Initial microbiological identification relied on corneal scraping culture and MALDI-TOF MS, while mNGS was strategically used in 1 complex case to identify potential copathogens. Clinical pharmacists provided interventions including minimum inhibitory concentration-guided therapy and the extemporaneous preparation of fortified antibiotic eye drops, such as 2% amikacin and 10% piperacillin/tazobactam. We assessed clinical outcomes, visual acuity (LogMAR), and the length of hospital stay. RESULTS: Although conventional culture confirmed Elizabethkingia species in all cases, mNGS offered critical genomic insights in 1 complex case by detecting culture-negative co-pathogens Nocardia pneumoniae and Fusarium proliferatum, which directly guided the addition of targeted antifungal and antibacterial therapy. All Elizabethkingia isolates demonstrated extensive resistance to carbapenems and cephalosporins. After pharmacist-led interventions, mean visual acuity improved significantly from 1.56 ± 0.77 to 0.90 ± 0.25 LogMAR. Furthermore, the length of hospital stay decreased markedly from 40 days in the index case to an average of 10.7 ± 4.9 days in the final 3 cases as diagnostic and therapeutic protocols were refined. CONCLUSIONS: Integrating clinical pharmacists within a multidisciplinary team, supported by mNGS for comprehensive polymicrobial detection, enables precision pharmacotherapy for multidrug-resistant Elizabethkingia keratitis. This approach promotes successful ocular salvage and visual recovery while substantially improving clinical efficiency through shortened hospitalization.