Biradar, Nigudgi, Doddamani, and Kollur: Microbiological profile of infective keratitis in a tertiary care hospital in north Karnataka


Introduction

Infective keratitis is one of the leading cause of monocular blindness in developing countries in Asia and Africa.1 Corneal ulcer is infective condition of cornea which is a vision threatening disorder. Corneal blindness is seen worldwide with 1.5 to 2 million new cases reported every year and approximately there are 6.8 million cases of corneal blindness in India.2 Infective keratitis affects both male and females of all age group.1, 2

Infective keratitis leading to corneal ulcers are caused by various causative agents both bacterial and fungal. The bacterial causes such as staphylococcus aureus, streptococuus pneumoniae, streptococcus viridians and psedudomonas. The fungal causes are Fusarium spp, Aspergillus spp, curvularia, and unclassified fungi.3

Infective keratitis are commonly caused by trauma mainly in people engaged in agricultural, manual labourers usually dealing with plant or vegetative matter that causes infection which ulcerate and leads to corneal blindness if left untreated. Most of the fungal keratitis are associated with various predisposing factors such as trauma, surgical ocular condition, use of contact lens, diabetes and use of steroids.3, 4

Present study was conducted to systematically determine the microbiological profile of infective keratitis in this region and its antibiotic sensitivity pattern, early diagnosis and treatment not only will prevent the corneal blindness but also to reduce the morbidity associated with it.

Material and Methods5, 6, 7, 8, 9

The present study was conducted as a retrospective study for a period of one year starting from March 2018 in a tertiary care hospital attached to MR Medical College, Kalaburagi in north Karnataka.

Present study was conducted by Dept. of microbiology and ophthalmology department of MR medical college. Total samples collected were 109 from clinically diagnosed cases of infective keratitis.

Inclusion criteria

All clinically diagnosed cases of infective keratitis of all age groups belonging to both sexes.

Exclusion criteria

Patients diagnosed as viral or protozoal keratitis were not included in the study.

Specimen collection

Corneal scrappings were collected by the ophthalmologist after anesthetizing the affected eye by tropical lignocaine. Corneal scrapings were collected from the edge and base of the ulcer. For bacterial, the received samples were inoculated on sheep blood agar Mac Conkeys agar. Blood agar plate and macconkey agar plates incubated for 370c for 24-28hrs. Further identification was based on colony morphology, grams stain and battery of biochemical tests done as per standard protocol. Antibiotic sensitivity testing of bacterial isolates was done by modified Kirby Buer’s disc diffusion method as per CLSI guidelines. HiMedia antibiotic discs used for gram positive and gram negative bacilli.

Fungal keratitis was diagnosed by doing a KOH mount of specimen and cultured on sabourauds dextrose agar incubated at 250c. Fungal cultures were identified by colony morphology and LPCB mount.

Results

Total Clinically diagnosed cases were 109 out of which 67 were bacterial corneal ulcer and 24 were fungal corneal ulcers, 18 samples didn’t give any growth (Table 1)

Infective keratitis is usually Bacterial(61.4%) in origin than fungal(22%).

Table 1

Types of infective keratitis

S. No.

Type of infection

Number of cases(%)

1

Bacterial isolates

67 (61.46%)

2

Fungal isolates

24(22.01%)

No bacterial or fungal growth(clinically diagnosed)

18(16.51%)

Total

109

Infectious keratitis most commonly seen in Males than females with ratio 2.2:1.

Table 2

Distribution of cases based on sex

S.No.

Sex

Number of cases

1

Male

75(68.8%)

2

Female

34(31.2%)

Total

109

21-40 age group(45%) are most commonly affected followed by 41-60yrs (33%)

Table 3

Age wise distribution of cases

S.No.

Age

Number of cases

Percentage of cases

1

0-20

09

9.1%

2

21-40

49

44.95%

3

41-60

36

33.02%

4

61-80

15

13.76%

Agriculturists (50.3%) are found to be the most commonly affected followed by Manual labour(16.51%), carpenter(13.56%) & others(14.67%).

Table 4

Occupational distribution of cases

S.No.

Occupation of patients

Number of cases

Percentage of cases

1

Agriculture

55

50.3

2

Manual labour

18

16.51

3

Carpenter

15

13.76

4

Welders/blacksmith

06

5.5

5

others

16

14.67

6

Total

109

100

Trauma(54.1%) found to be the most common predisposing factor followed by diabetes(34.86%), other ocular diseases (4.58%), surgery(3.66%) & corticosteroid therapy(2.75%).

Table 5

Case distribution based on preexisting factors

S.No.

Pre-existing condition in patients

Number of cases

Percentage of cases

1

Corneal Trauma

59

54.12

2

Diabetes

38

34.86

3

Ocular diseases

05

4.58

4

Post ocular surgery

04

3.66

5

Corticosteroid therapy

03

2.75

Total

109

100

Corneal trauma with the vegetative material (54.25%) is most common in causing infective keratitis.

Table 6

Nature of material causing corneal trauma

S.No

Nature of material causing corneal trauma

Number of cases

Percentage of cases

1

Vegetative material

32

54.25

2

Sand/dust

09

15.25

3

Finger nails

5

08.47

4

Stone pieces/metal pieces

5

08.47

5

Wood dust

4

06.77

6

Cloth

1

1.69

7

Miscellaneous (Insect, cow tail/ acid)

3

5.08

Total

59

100

Table 7 Total of 67 bacterial isolates was seen in the study out of which 46 were gram positive, 21 gram negative bacteria and 24 were fungal isolates. Staphylococcus aureus is most common gram positive bacteria followed by Streptococcus pneumoniae, Staphylococcus epidermidis, Corynebacterium spp & Micrococcus species. Among gram negative bacterias Pseudomonas is the most common followed by Klebsiella, Haemophilus, Moraxella & Acinetobacter.

Table 7

S.No.

Gram positive bacterial isolates

Number of cases

Percentage

1

Streptococcus pneumoniae

23

34.3%

2

Staphylococcus aureus

12

17.9%

3

Staphylococcus epidermidis

05

7.46%

4

Corynebacterium spp

03

4.47%

5

Micrococcus spp

03

4.47%

Total gram positive bacteria

46

68.6%

S.No

Gram negative bacterial isolates

Number of cases

Percentage

1

Pseudomonas aeruginosa

12

17.9%

2

Klebsiella pneumoniae

03

4.47%

3

Haemophilus influenzae

03

4.47%

4

Morexella spp

02

2.98%

5

Acinetobacter baumannii

01

1.49%

Total gram negative bacteria

21

31.34%

Mycotic keratitis is mainly caused by Fusarium (37.5%) followed by aspergillus (37.4%), curvularia (8.33%) & candida (4.16%).

Table 8

Fungal isolates

S.No

Fungal isolates

Number of cases

Percentage

1

Fusarium species

09

37.5%

2

Aspergillus flavus

05

20.83%

3

Aspergillus fumigatus

04

16.66%

4

Curvularia

02

8.33%

5

Candida species

01

4.16%

6

Unidentified fungus

03

12.5%

Total fungal isolates

24

100%

Antibiotic sensitivity pattern of bacterial isolates showed Amikacin as the best antibiotic with higher sensitivity. The antibiotic sensitivity is as shown in Table 9, Table 10. Antibiotic sensitivity of gram positive bacteria.

Table 9

Antibiotic sensitivity of gram positive bacteria

Organism

No. tested

Ampicillin

Amikacin

Erythromycin

Gentamicin

Ofloxacin

Ciprofloxacin

No.

No.

No.

No.

No.

No.

%

%

%

%

%

%

Streptococcus pneumoniae

23

23

23

23

23

15

16

100

100

100

100

65.2

69.5

Staphylococcus aureus

12

6

12

3

11

5

3

50

100

25

91.6

41.6

25

Staphylococcus epidermidis

5

4

5

2

5

5

4

80

100

40

100

100

80

Corynebacterium spp.

3

3

3

3

3

2

2

100

100

100

100

66.6

66.6

Micrococcus sp.

3

3

3

3

3

3

3

100

100

100

100

100

100.00

Total

46

39

46

34

44

30

28

-

-

-

-

-

-

Table 10

Antibiotic sensitivity of gram negative bacteria

Organism

No. tested

No. of strain sensitive and percentage

Ampicillin

Amikacin

Gentamicin

Ofloxacin

Ciprofloxin

Polymyxin B

Cephalexin

Pip-taz

imipenem

No

No

No

No

No

No

No

No

No

%

%

%

%

%

%

%

%

%

Pseudomonas aeruginosa

16

-

16

15

14

11

14

8

15

12

-

100

93.7

87.5

68.7

87.5

50

93.7%

75%

Haemophilus influenzae

3

3

3

3

3

2

-

1

-

-

100

100

100

100

-

Morexella sp.

2

2

2

2

2

2

-

2

-

-

100

100

100

100

-

100

Acinetobacter baumannii

1

1

1

1

-

-

1

1

1

1

100

100

100

100

100

100

Total

21

5

28

25

26

18

16

11

16

13

-

-

-

-

-

-

-

Discussion

Present study was conducted for period of two year at hospital attached to MR Medical college, Kalaburagi in north Karnataka to determine the microbiological profile of infective keratitis prevalent in the region.

In the present study incidence of corneal ulcer was seen most common in age group 21-40 years with 44.9% followed by 41-60years with 33.02% Which is supposed to be comparable with studies conducted by Amrutha KB et al,10 Waghmare AS et al,11 Sharmila Raut et al,12 Metha S et al,13 Gotekar R. B et al,14 where as Vasudha CL15 study had 41-50 years as most common age group with 38.8%, Gotekar R.B et al14 study stated 56-70 years as most affected age group with 35%.

Present study the percentage of males affected 68.8% compared to females affected 31.2% and male female ratio 2.2:1, males were more affected may be due to more exposure outdoors and hard labour in dry dusty areas. This was in accordance with studies done by Waghmare AS et al,11 Metha S et al,13 Jayashree MP et al.16

Agricultural workers (50.3%) were most affected people in the present study due to exposure to the vegetative injuries because of nature of work, this was in line with studies done by Metha S et al13 Vasudha CL,15 Jayashree MP et al. 16

Predisposing factors such as corneal trauma in our study was 54.12% followed by diabetes 34%, this finding was comparable with studies done by Waghmare AS et al.,11 Sharmila Raut et al.,12 Metha S et al.,13 Suwal S,17 Gotekar R. B et al.,14 Jayashree MP et al,16 Tarekegn Wuletaw et al.18

Percentage of vegetative trauma was 54.25% followed by Sand and dust 15.2%. Similar findings are seen in most of the studies done. In a study done by Vasudha CL15 vegetative trauma was 27.7% diabetes 16.6%, Waghmare AS et al., 11 Sharmila Raut et al.12 30% and 36% respectively.

Our study showed bacterial isolates were 61.4% and fungal isolates 22% whereas 18 (16.4%) samples from clinically diagnosed cases didn’t show any growth, this was in accordance with studies done by Amal Ibrahim Abouzeid et al.19 showed that 40% of samples didn’t grow any type of isolates, Gotekar R.B et al.14 showed 39.7% no growth.

Most common bacterial isolate was streptococcus pneumoniae(34.3%) followed by staphylococcus aureus (17.9%) which was comparable with Vasudha CL,15 Jayashree MP et al.,16 whereas study done by Reena Anie Jose et al.20 showed staphylococcus epidermidis and Waghmare AS et al.11 showed staphylococcus aureus to be the most common bacterial isolate.

Most common fungal isolate was fusarium followed by aspergillus spp similar findings were seen in studies conducted by Vasudha CL et al,15 Waghmare AS et al,11 while Sharmila Raut et al12 study showed aspergillus as most common fungal isolate with 39.3%

Conclusion

Infective keratitis whether bacterial or fungal are more common in working males, agriculturist who are exposed to vegetative trauma. North Karnataka is known for farming which is the main occupation where vegetative injuries are more common. The prevalence of streptococcus pneumoniae and fusarium infections are more compared to other causative microorganisms. Immediate diagnosis is helpful in the detection of the type of microorganisms by Gram stain and KOH mount of corneal scrapings. Early detection and treatment with proper antibacterials or antifungals is important to prevent ocular problems and scarring of cornea.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest.

Acknowledgment

Our team would like to thank each and every patient and staff who contributed to our study, a special thanks to Ophthalmology and Microbiology departments without their cooperation this study could not be done.

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Received : 26-06-2021

Accepted : 08-07-2021

Available online : 30-07-2021


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https://doi.org/10.18231/j.ijmr.2021.035


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