Elizabethkingia menigoseptica has reduced susceptibility to a broad range of antimicrobials, including beta lactams, aminoglycosides and chloramphenicol. It is an opportunistic pathogen being most often associated with meningitis and septicemia in a pediatric (especially neonatal) population. It has also been identified as a cause of healthcare-associated pneumonia, sepsis and meningitis in adults, particularly in immunocompromised patients, those with indwelling central venous catheters and those with long hospital stays. Mortality in patients with E. meningoseptica bacteraemia or meningitis may be high (>50%) depending on the population studied [7, 14, 15].
To date, there have only been two case reports on E. meningoseptica-related endophthalmitis, both exogenous in nature, in contrast to our patient who had an endogenous cause [12, 13]. One was a case of deliberate ocular penetration with an unsterile sewing needle in a patient with depressive illness, while the other was a case of penetrating eye injury caused by a truck tyre explosion resulting in a self-sealing full thickness corneal wound with two metallic posterior segment foreign bodies . While the above two cases differ from ours in the nature of the infection, there are similarities in all cases: the infection in the eye occurred acutely, progressed very quickly from one to three days, behaved virulently and produced an intense fibrinous reaction in the anterior and posterior segments of the eye. E. meningoseptica cultured from the vitreous, like those from other parts of the body, was found to be resistant to many antibiotics. Ciprofloxacin was one antibiotic to which it was sensitive to in all three cases, and hence may be considered as first-line therapy (systemic and intravitreal) in future cases of E. meningoseptica related endophthalmitis.
There have been no previous reports of E. meningoseptica causing endogenous endophthalmitis, which occurs when organisms reach the eye via the bloodstream, and enter the internal ocular spaces by crossing the blood–ocular barrier. Endogenous bacterial endophthalmitis is treated seriously because they are serious infections with poor visual outcomes . The outcomes worsen with several factors: delay in diagnosis, use of inappropriate antibiotics, diffuse infection of the vitreous and retina or panophthalmitis, poor vision at presentation, infection with virulent organisms and gram negative infection . Gram negative endophthalmitis is more common in East Asian hospitals, with the most common bacteria being Klebsiella spp, Escherichia coli, Pseudomonas aeruginosa, Neisseria meningitides and Serratia marscescens. In fact because of its virulence and prevalence, it has become routine, in our local hospitals, to refer all patients with Klebsiella bacteraemia to ophthalmologists for screening for endophthalmitis.
Elizabethkingia menigoseptica, like Klebsiella spp, has shown to behave in a virulent manner in the eye. With its increasing prevalence in health care settings, especially in intensive care environments due to its propensity to form biofilms, it is of utmost importance for physicians to have a high vigilance for this opportunistic pathogen. While its presence in the blood may not necessarily require an automatic referral for eye screening, they should consider an early eye referral if the patient has any signs (conjunctival injection or chemosis, periocular redness and swelling, hazy cornea, hypopyon in anterior chamber, reduced or absent red reflex) or symptoms (floaters, blurring of vision, eye pain, tearing, redness) of an eye infection. However, in view of the aggressiveness and virulence of this bacteria, and the likelihood of misdiagnosis or missed diagnosis of endogenous endophthalmitis especially given its low incidence, we may want to consider screening all cases of E. menigoseptica bloodstream infections for endophthalmitis in future.
This case also brings up the issue of potential contamination of taps and aerators within ICUs as important sources of E. meningoseptica infection as may have been in this case [6, 8, 10]. E. meningoseptica is an opportunistic pathogen that is well adapted to the intensive care environment due to its intrinsic resistance to antimicrobials commonly used in the ICU setting and its propensity to form biofilms. The latter are difficult to eradicate, particularly where the organism has established on an indwelling device such as a vascular line or endotracheal tube.
Previous outbreaks have shown a multitude of potential sources of the bacteria, including sink drains, taps, aerators, catheters, blood and respiratory specimens, hand cultures, infant formula, electrical buttons, a computer keyboards, phone, doorknobs, Ambu bags etc. [6–10]. Beyond the potential contribution of E. meningoseptica to the deterioration of the severely ill adult patient, transmission of E. meningoseptica from environmental reservoirs to neonates is a known infection outbreak scenario. Infection control personnel in acute care hospitals must be aware of E. meningoseptica in chronically ill patients, especially those on mechanical ventilation in ICUs. Attention should also be paid to non-adherence to existing policies regarding disposal of patient secretions and cleaning of re-usable patient care items, time pressures and distance between patient rooms and ward utility rooms notwithstanding.
Design of wards particularly within the critical care setting must consider physical and personnel requirements to facilitate safe delivery of care, and staff workflows must be optimized to facilitate patient safety and avoid inadvertently putting patients at risk with lapses in safety procedures .