Background: The elucidation of the routes of transmission of a pathogen is crucial for the prevention of infectious diseases caused by bacteria that are not a resident in human tissue. The purpose of this report is to describe a case of suture-related conjunctivitis caused by Pseudomonas aeruginosa for which we identified the transmission route using pulsed-field gel electrophoresis (PFGE).
Case presentation: A 38-year-old man, who had undergone surgery for glaucoma 2 years ago previously, presented with redness, discomfort, and mucopurulent discharge in the right eye. A 9–0 silk suture had been left on the conjunctiva. A strain of P. aeruginosa was isolated from a culture obtained from the suture, and the patient was therefore diagnosed with suture-related conjunctivitis caused by P. aeruginosa. The conjunctivitis was cured by the application of an antimicrobial ophthalmic solution and removal of the suture. We used PFGE to survey of the indoor and outdoor environments around the patient’s house and office in order to elucidate the route of transmission of the infection. Three strains of P. aeruginosa were isolated from the patient’s indoor environment, and the isolate obtained from the patient’s bathroom was identical to that from the suture.
Conclusion: The case highlights the fact that an indoor environmental strain of P. aeruginosa can cause ocular infections

Eguchi, Hiroshi

Kuwahara, Tomomi

Mitamura, Sayaka

Mitamura, Yoshinori

Miyamoto, Tatsuro

English

Tokushima University Institutional Repository

Eguchi et al. BMC Research Notes 2013, 6:245http://www.biomedcentral.com/1756-0500/6/245CASE REPORT Open AccessInfectious conjunctivitis caused by Pseudomonasaeruginosa isolated from a bathroomHiroshi Eguchi1*, Tatsuro Miyamoto1, Tomomi Kuwahara2, Sayaka Mitamura1 and Yoshinori Mitamura1AbstractBackground: The elucidation of the routes of transmission of a pathogen is crucial for the prevention of infectiousdiseases caused by bacteria that are not a resident in human tissue. The purpose of this report is to describe a caseof suture-related conjunctivitis caused by Pseudomonas aeruginosa for which we identified the transmission routeusing pulsed-field gel electrophoresis (PFGE).Case presentation: A 38-year-old man, who had undergone surgery for glaucoma 2 years ago previously,presented with redness, discomfort, and mucopurulent discharge in the right eye. A 9–0 silk suture had been lefton the conjunctiva. A strain of P. aeruginosa was isolated from a culture obtained from the suture, and the patientwas therefore diagnosed with suture-related conjunctivitis caused by P. aeruginosa. The conjunctivitis was cured bythe application of an antimicrobial ophthalmic solution and removal of the suture. We used PFGE to survey of theindoor and outdoor environments around the patient’s house and office in order to elucidate the route oftransmission of the infection. Three strains of P. aeruginosa were isolated from the patient’s indoor environment,and the isolate obtained from the patient’s bathroom was identical to that from the suture.Conclusion: The case highlights the fact that an indoor environmental strain of P. aeruginosa can cause ocularinfections.Keywords: Pseudomonas aeruginosa, Conjunctivitis, Bathroom, Pulsed-field Gel ElectrophoresisBackgroundThe bacterium Pseudomonas aeruginosa is a Gram-negative rod that is commonly isolated from aquatic andterrestrial environments. It is an established nosocomialpathogen in the field of hospital infection control [1-3].The routes of transmission are well investigated epidemio-logically, because it is responsible for severe infections inimmunocompromised patients. However, in clinical oph-thalmology, the transmission route of Pseudomonasaeruginos is not well investigated, even it is known to beable to cause keratitis, some strains produce biofilms oncontact lenses [4,5], and endophthalmitis caused by P.aeruginosa contracted from surgical equipment has beenreported as a devastating complication after ocular surgery[6-8]. With regard to bacterial conjunctivitis in adults, itis most often caused by pathogens derived from the* Correspondence: hiroegu@clin.med.tokushima-u.ac.jp1Department of Ophthalmology, Institute of Health Biosciences, TheUniversity of Tokushima Graduate School, 3-18-15, Kuramoto-cho,Tokushima-shi 770-8503, JapanFull list of author information is available at the end of the article© 2013 Eguchi et al.; licensee BioMed CentralCommons Attribution License (http://creativecreproduction in any medium, provided the orindigenous bacterial flora of the ocular surface. There-fore, P. aeruginosa, which is not a resident bacterium ofthe ocular surface, is rarely isolated from conjunctivitiscases except those of patients who have some sort ofartificial devices in the eye [9-11].Most bacterial conjunctivitis encountered in the clinicalsetting can be treated by an empiric choice of commer-cially available antimicrobial ophthalmic solutions withoutrigorous identification of the species of the pathogen, andthe sporadic cases may go unnoticed unless an outbreakoccurs. Most cases of exogenous conjunctivitis, such asthat caused by P. aeruginosa, could be prevented by deter-mination both of the origin and of the transmission routeof the causative pathogen. Such prevention would contrib-ute to the proper usage of antimicrobials in the field ofophthalmology. Moreover, it is important for the patientswho have undergone intraocular surgery to understandthe distribution and the route of transmission of P.aeruginosa in order to prevent devastating complications.Herein, we describe a case of suture-related conjunctivitiscaused by P. aeruginosa after glaucoma surgery in whichLtd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.L      1       2      3       4     YEguchi et al. BMC Research Notes 2013, 6:245 Page 2 of 3http://www.biomedcentral.com/1756-0500/6/245we elucidated the route of transmission using pulsed-fieldgel electrophoresis (PFGE).48.597.0145.5194.0242.5291.0339.5Figure 2 Pulsed-field gel electrophoresis typing of fourPseudomonas aeruginosa strains, one was isolated from thepatient’s eye and three, from different environments. Lane 1shows the fragment pattern of the P. aeruginosa strain obtainedfrom the suture. Lane 2 shows the fragment pattern of the P.aeruginosa strain obtained from the patient’s bathroom. Lanes 3 and4 show the fragment patterns of the strains obtained from thehumidifying device and kitchen in the patient’s workplace,respectively. The strain from the suture is identical to that from thepatient’s bathroom. ‘L’ represents the lambda ladder; ‘Y’ the yeastchromosome ladder.Case presentationA 38-year-old man, who had undergone a trabeculotomyfor secondary glaucoma due to uveitis presented with red-ness, discomfort, and yellowish white mucopurulent dis-charge in the right eye. Slit-lamp microscopy revealedconjunctival hyperaemia and mucopurulent yellowishwhite discharge around a 9–0 silk suture that had been lefton the lateral inferior side of the conjunctiva for over2 years (Figure 1). A Gram-stained smear of the dischargeshowed polymorphonuclear neutrophils and Gram-negative rods; no eosinophils were observed in a Giemsa-stained smear. The suture was removed from the patient’seye and cultured, and P. aeruginosa was isolated. Drugsusceptibility testing using Etest® (bioMérieux SA, Lyon,France) showed that the isolate was susceptible toaminoglycosides (minimum inhibitory concentration(MIC) of tobramycin: 1 μg/ml) and to quinolones (MICof levofloxacin: 0.25 μg/ml), but resistant to cephems(MIC of ceftriaxone: >256 μg/ml). The conjunctivitisresolved after the application of tobramycin ophthalmicsolution 4 times daily for 2 weeks and removal of thesuture.To elucidate the route of transmission of P. aeruginosain this case, we first obtained bacterial samples by sur-veying the patient’s indoor and outdoor environments(with approval from the ethics committee of TokushimaUniversity Hospital). Then, bacterial strains were col-lected from the environmental samples, and PFGE wasperformed as previously described [12]. Three strains ofP. aeruginosa were isolated: from the bathroom in thepatient’s home, and the kitchen and a humidifying deviceat his workplace. The isolate from the 9–0 silk suturewas identical that obtained from the patient’s bathroom(Figure 2). Although the other isolates from the work-place were identical to each other, they differed from theisolate obtained from the suture.Figure 1 Conjunctivitis associated with a 9–0 silk. a) Markedconjunctival hyperaemia and yellowish white discharge around thesuture can be seen. b) The yellowish white discharge is stainedyellow green by fluorescein.DiscussionHerein we reported for the first time that P. aeruginosaisolated from the ocular surface was acquired from thepatient’s home environment. This suggests that the bac-teria colonising in humid home environments such asthe bathroom can infect ocular surfaces in associationwith biomaterials. Biomaterials such as sutures, punctualplugs, intraocular lenses, and contact lenses can serve ashotbeds for bacterial infections. Therefore, all clinicalcases involving the use of biomaterials require regularfollow-up. Although we did not examine the biofilmproductivity of the strain isolated from this case, manyGram-negative rods, including P. aeruginosa, are knownto be able to produce biofilms on the surfaces of bioma-terials. Knowledge of the distribution and route of trans-mission of pathogenic microorganisms is important forinfection control in patients with biomaterials. Biomate-rials around an infectious focus should be removed im-mediately after detection of the infection if it is deemednecessary and feasible to do so.P. aeruginosa endophthalmitis with disastrous resultshas been reported following intraocular surgery [7,8],Eguchi et al. BMC Research Notes 2013, 6:245 Page 3 of 3http://www.biomedcentral.com/1756-0500/6/245and in these cases the P. aeruginosa was determined tohave been transmitted from some surgical equipmentswith which related to water-based supplies. However, theunderlying cause of the pollution of the water was notidentified. Infections of buckling devices caused by P.aeruginosa following retinal detachment surgery havealso been described, although the origin and transmis-sion route were not mentioned [9-11]. The showerenvironment has been described as a source of oppor-tunistic pathogens [13], and we presume that theseinfections were likely to have been caused by strains ofP. aeruginosa present in humid indoor areas in thehome or hospital to which the patient was exposed.Considering that contaminated rooms may lead tohospital- and community-acquired infections, and alsoconsidering that P. aeruginosa is strongly associatedwith environmental contamination [1], disinfection orcleaning of humid home environments may help de-crease the risk for infection by P. aeruginosa.ConclusionPrecautionary protections of the eye from bacterial in-fections promoted by humid indoor conditions may beimportant. Removal of ophthalmic biomaterials immedi-ately after their use and application of ophthalmic solu-tions that target Gram-negative rods derived from indoorhumid environment should be considered for cases ofconjunctivitis related with some artificial devices on theocular surface.ConsentWritten informed consent was obtained from the patientfor submission and publication of this case report andany accompanying images. A copy of the written consentis available for review by the Editor of this journal.Competing interestsThe authors have no conflicts of interest to declare.Authors’ contributionsHE diagnosed and treated the patient, isolated the pathogen, conducted thesurvey of the environment, prepared the plugs for PFGE, performed PFGEand wrote the draft of the manuscript. TM and SM monitor the patient. TKperformed the PFGE. YM manages the patient’s entire clinical course. Allauthors read and approved the final manuscript.Author details1Department of Ophthalmology, Institute of Health Biosciences, TheUniversity of Tokushima Graduate School, 3-18-15, Kuramoto-cho,Tokushima-shi 770-8503, Japan. 2Department of Microbiology, Faculty ofMedicine, Kagawa University, Kagawa, Japan.Received: 25 September 2012 Accepted: 25 June 2013Published: 1 July 2013References1. Hota B: Contamination, disinfection, and cross-colonization: are hospitalsurfaces reservoirs for nosocomial infections? Clin Infect Dis 2004,39:1182–1189.2. Corona-Nakamura AL, Miranda-Novales MG, Leanos-Miranda B, Portillo-Gomez L, Hernadez-Chavez A, Anthor-Rendon J, Aguilar-Benavides S:Epidemiologic study of Pseudomonas aeruginosa in critical patients andreservoirs. Arch Med Res 2001, 32:238–242.3. Yetkin G, Otlu B, Cicek A, Kuzucu C, Durmaz R: Clinical, microbiologic, andepidemiologic characteristics of Pseudomonas aeruginosa infection in aUniversity Hospital, Malatya, Turkey. Am J Infect Control 2006, 34:188–192.4. Szczotka-Flynn LB, Imamura Y, Chandra J, Yu C, Mukherjee PK, Pearlman E,Ghannoum MA: Increased resistance of contact lens-related bacterialbiofilms to antimicrobial activity of soft contact lens care solutions.Cornea 2009, 28:18–26.5. McLaughin-Borlace L, Stapleton F, Matheson M, Dart JKG: Bacterial biofilmon contact lens and lens storage cases in wearers with microbialkeratitis. J Appl Microbiol 1998, 84:827–837.6. Ramappa M, Majji AB, Murthy SI, Balne PK, Nalamada S, Garudadri C, MathaiA, Gopinathan U, Garg P: An outbreak of acute post-cataract surgeryPseudomonas sp. endophthalmitis caused by contaminated hydrophilicintraocular lens solution. Ophthalmology 2012, 119:564–570.7. Mateos I, Valencia R, Torres MJ, Cantos A, Conde M, Aznar J: Nosocomialoutbreak of Pseudomonas aeruginosa endophthalmitis. Infect Control HospEpidemiol 2006, 27:1249–1251.8. Crucian M, Malena M, Amalfitano G, Monti P, Bonomi L: Molecularepidemiology in a cluster of cases of postoperative Pseudomonasaeruginosa endophthalmitis. Clin Infect Dis 1998, 26:330–333.9. Rich RM, Smiddy WE, Davis JL: Infectious scleritis after retinal surgery.Am J Ophthalmol 2008, 145:695–699.10. Chaudhry NA, Tabandeh H, Rosenfeld PJ, Miller D, Davis J: Scleral buckleinfection with ciprofloxacin-resistant Pseudomonas aeruginosa.Arch Ophthalmol 1998, 116:1251.11. Wirostko WJ, Covert DJ, Han DP, Connor TB Jr, Kim JE, Hammersley J,Lindgren K: Microbiological spectrum of organisms isolated fromexplanted scleral buckles. Ophthalmic Surg Laser Imaging 2003,40:201–202.12. Ogushi Y, Eguchi H, Kuwahara T, Hayabuchi N, Kawabata K: Moleculargenetic investigations of contaminated contact lens storage cases asreservoirs of Pseudomonas aeruginosa keratitis. Jpn J Ophthalmol 2010,54:550–554.13. Anaissie EJ, Penzak SR, Dignani MC: The hospital water supply as a sourceof nosocomial infection: a plea for action. Arch Intern 2002,162:1483–1492.doi:10.1186/1756-0500-6-245Cite this article as: Eguchi et al.: Infectious conjunctivitis caused byPseudomonas aeruginosa isolated from a bathroom. BMC Research Notes2013 6:245.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

Infectious conjunctivitis caused by Pseudomonas aeruginosa isolated from a bathroom

https://repo.lib.tokushima-u.ac.jp/files/public/11/114894/20200630112226619781/BMCRN_6_245.pdf

Infectious conjunctivitis caused by Pseudomonas aeruginosa isolated from a bathroom

Abstract

Similar works

Full text

Available Versions

Tokushima University Institutional Repository