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National emergency department trends for endogenous endophthalmitis: an increasing public health challenge

Abstract

Background/Objective

To characterize incidence rates and identify risk factors for admission and mortality in patients with endogenous endophthalmitis (EE) in the United States (US).

Subjects/Methods

Patients with EE were identified using the Nationwide Emergency Department (NEDS) Database from 2006 to 2017 in this cross-sectional study. Subjects were required to have diagnoses of both endophthalmitis and septicaemia using contemporary International Classification of Diseases diagnosis codes. Incidence rates, mortality rates and demographics were evaluated. Risk factors for admission and mortality were identified using weighted logistic regression analysis.

Results

A total of 6400 patients with EE were identified. Incidence increased from 0.10 (95% confidence interval [CI]: 0.07–0.12) per 100,000 in the US population in 2006 to 0.25 (95% CI: 0.21–0.30) in 2017 (p < 0.05). Most were female (55.4%), insured with Medicare (53.5%), were in the first income quartile earnings (29.3%) [bottom 25% income bracket], lived in the South (40.5%), and presented to metropolitan teaching hospitals (66.6%). Mortality increased from 8.6% (95% CI: 3.8–18.3%) in 2006 to 13.8% (95% CI: 9.7–19.2%) in 2017 (p = 0.94). Factors predicting admission included older age (odds ratio [OR] 32.59; [95% CI 2.95–359.78]) and intravenous drug use (OR 14.90 [95% CI: 1.67–133.16]). Factors associated with increased mortality included: human immunodeficiency virus infection/immune deficiencies (OR 2.58 [95% CI: 1.26–5.28]), heart failure (OR 2.12 [95% CI: 1.47–3.05]), and hepatic infections/cirrhosis (OR 1.89 [95% CI: 1.28–2.79]). Pneumonia and renal/urinary tract infections (UTI) were associated with both increased hospital admission [(pneumonia OR 9.64 (95% CI: 1.25–74.35, p = 0.030), renal/UTI OR 4.09 (95% CI: 1.77–9.48)] and mortality [(pneumonia OR 1.64 (95% CI: 1.17–2.29, p = 0.030), renal/UTI OR 1.87 (95% CI: 1.18–2.97)]. Patients with diabetes mellitus (DM) had decreased odds ratio for mortality (OR 0.49 [95% CI: 0.33–0.73]).

Conclusion

EE has increased in incidence throughout US. The two systemic factors that conferred both an increase in mortality and admission were pneumonia, and renal/UTI. Additional exploration of the potential protective association of DM with decreased mortality in this context is needed.

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Fig. 1: Incidence rates of emergency department visits for endogenous endophthalmitis.
Fig. 2: Median inflation-adjusted cost of ED visits.

Data availability

The data that support the findings of this study are available from the Nationwide Emergency Department Sample (NEDS) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of NEDS.

References

  1. Novosad BD, Callegan MC. Severe bacterial endophthalmitis: towards improving clinical outcomes. Expert Rev Ophthalmol. 2010;5:689–98.

    PubMed  PubMed Central  Article  Google Scholar 

  2. Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342 cases of endogenous bacterial endophthalmitis. Surv Ophthalmol. 2014;59:627–35.

    PubMed  Article  Google Scholar 

  3. Greenwald MJ, Wohl LG, Sell CH. Metastatic bacterial endophthalmitis: a contemporary reappraisal. Surv Ophthalmol. 1986;31:81–101.

    CAS  PubMed  Article  Google Scholar 

  4. Jackson TL, Eykyn SJ, Graham EM, Stanford MR. Endogenous bacterial endophthalmitis: A 17-year prospective series and review of 267 reported cases. Surv Ophthalmol. 2003;48:403–23.

    PubMed  Article  Google Scholar 

  5. Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, et al. Executive summary: clinical practice guideline for the management of candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62:409–17.

    PubMed  Article  Google Scholar 

  6. Breazzano MP, Day HR Jr, Bloch KC, Tanaka S, Cherney EF, Sternberg P Jr, et al. Utility of ophthalmologic screening for patients with Candida Bloodstream Infections: a systematic review. JAMA Ophthalmol. 2019;137:698–710.

    PubMed  Article  Google Scholar 

  7. Ratra D, Saurabh K, Das D, Nachiappan K, Nagpal A, Rishi E, et al. Endogenous endophthalmitis: A 10-Year Retrospective Study at a Tertiary Hospital in South India. Asia Pac. J Ophthalmol (Philos). 2015;4:286–92.

    Google Scholar 

  8. Hsieh M-C, Chen S-N, Cheng C-Y, Li K-H, Chuang C-C, Wu J-S, et al. Clinicomicrobiological profile, visual outcome and mortality of culture-proven endogenous endophthalmitis in Taiwan. Sci Rep. 2020;10:12481.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  9. Schiedler V, Scott IU, Flynn HW Jr, Davis JL, Benz MS, Miller D. Culture-proven endogenous endophthalmitis: clinical features and visual acuity outcomes. Am J Ophthalmol. 2004;137:725–31.

    PubMed  Google Scholar 

  10. Essman TF, Flynn HW Jr, Smiddy WE, Brod RD, Murray TG, Davis JL, et al. Treatment outcomes in a 10-year study of endogenous fungal endophthalmitis. Ophthalmic Surg lasers. 1997;28:185–94.

    CAS  PubMed  Article  Google Scholar 

  11. Sridhar J, Flynn HW Jr, Kuriyan AE, Miller D, Albini T. Endogenous fungal endophthalmitis: risk factors, clinical features, and treatment outcomes in mold and yeast infections. J Ophthalmic Inflamm Infect. 2013;3:60.

    PubMed  PubMed Central  Article  Google Scholar 

  12. Budoff G, Thangamathesvaran L, Zarbin MA, Bhagat N. Bacterial endogenous endophthalmitis in bacteremic inpatients. Ophthalmol Retin. 2019;3:971–8.

    Article  Google Scholar 

  13. Uppuluri A, Zarbin MA, Budoff G, Bhagat N. Risk factors for endogenous endophthalmitis in hospitalized patients with Candida Fungemia. Ophthalmol Retin. 2021;5:687–95.

    Article  Google Scholar 

  14. NEDS Database Documentation. Healthcare Cost and Utilization Project (HCUP) [Internet]. Agency for Healthcare Research and Quality. 2020. Available from: www.hcup-us.ahrq.gov/db/nation/neds/nedsdbdocumentation.jsp.

  15. Mir TA, Papudesu C, Fang W, Hinkle DM. Incidence of drug use–related endogenous endophthalmitis hospitalizations in the United States, 2003 to 2016. JAMA Ophthalmol. 2021;139:18–26.

    PubMed  Article  Google Scholar 

  16. Papudesu C, Mir T, Fang W, Thompson J, Hinkle DM. Trends in infantile endogenous endophthalmitis hospitalizations in the United States: an analysis from 2007 through 2014 using the national inpatient sample. Ophthalmol Retin. 2020;4:1109–17.

    Article  Google Scholar 

  17. Vaziri K, Pershing S, Albini TA, Moshfeghi DM, Moshfeghi AA. Risk factors predictive of endogenous endophthalmitis among hospitalized patients with hematogenous infections in the United States. Am J Ophthalmol. 2015;159:498–504.

    PubMed  Article  Google Scholar 

  18. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N. Engl J Med. 2003;348:1546–54.

    PubMed  Article  Google Scholar 

  19. Shiels MS, Almeida JS, García-Closas M, Albert PS, Freedman ND, Berrington, et al. Impact of population growth and aging on estimates of excess U.S. deaths during the COVID-19 pandemic, March to August 2020. Ann Intern Med. 2021;174:437–43.

    PubMed  Article  Google Scholar 

  20. Chee SP, Jap A. Endogenous endophthalmitis. Curr Opin Ophthalmol. 2001;12:464–70.

    CAS  PubMed  Article  Google Scholar 

  21. Pradipta IS, Sodik DC, Lestari K, Parwati I, Halimah E, Diantini A, et al. Antibiotic resistance in sepsis patients: evaluation and recommendation of antibiotic use. N. Am J Med Sci. 2013;5:344–52.

    PubMed  PubMed Central  Article  Google Scholar 

  22. Kalil AC, Opal SM. Sepsis in the severely immunocompromised patient. Curr Infect Dis Rep. 2015;17:487.

    PubMed  Article  Google Scholar 

  23. Breazzano MP, Bond JB 3rd, Bearelly S, Kim DH, Donahue SP, Lum F, et al. American Academy of Ophthalmology recommendations on screening for endogenous candida endophthalmitis. Ophthalmology. 2022;129:73–6.

    PubMed  Article  Google Scholar 

  24. Channa R, Zafar SN, Canner JK, Haring RS, Schneider EB, Friedman DS. Epidemiology of eye-related emergency department visits. JAMA Ophthalmol. 2016;134:312–9.

    PubMed  Article  Google Scholar 

  25. Breazzano MP, Tooley AA, Godfrey KJ, Iacob CE, Yannuzzi NA, Flynn HW. Candida auris and endogenous panophthalmitis: clinical and histopathological features. Am J Ophthalmol Case Rep. 2020;19:100738.

    PubMed  PubMed Central  Article  Google Scholar 

  26. Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of <em>Candida</em> bloodstream infection until positive blood culture results are obtained: a potential risk factor for Hospital Mortality. Antimicrobial Agents Chemother. 2005;49:3640–5.

    CAS  Article  Google Scholar 

  27. Arfaras-Melainis A, Polyzogopoulou E, Triposkiadis F, Xanthopoulos A, Ikonomidis I, Mebazaa A, et al. Heart failure and sepsis: practical recommendations for the optimal management. Heart Fail Rev. 2020;25:183–94.

    PubMed  Article  Google Scholar 

  28. Esper AM, Moss M, Lewis CA, Nisbet R, Mannino DM, Martin GS. The role of infection and comorbidity: factors that influence disparities in sepsis. Crit Care Med. 2006;34:2576–82.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Bhavsar MM, Devarajan TV, Nembi PS, Ramakrishnan N, Mani AK. Metastatic endogenous endophthalmitis: a rare presentation with methicillin-resistant staphylococcus aureus prostatic abscess. Indian J Crit Care Med: peer-reviewed, Off Publ Indian Soc Crit Care Med. 2017;21:172–5.

    Article  Google Scholar 

  30. Sadiq MA, Hassan M, Agarwal A, Sarwar S, Toufeeq S, Soliman MK, et al. Endogenous endophthalmitis: diagnosis, management, and prognosis. J Ophthalmic Inflamm Infect. 2015;5:32.

    PubMed  PubMed Central  Article  Google Scholar 

  31. Weng T-H, Chang H-C, Chung C-H, Lin F-H, Tai M-C, Tsao C-H, et al. Epidemiology and mortality-related prognostic factors in endophthalmitis. Investigative Ophthalmol Vis Sci. 2018;59:2487–94.

    Article  Google Scholar 

  32. Breazzano MP, Jonna G, Nathan NR, Nickols HH, Agarwal A. Endogenous Serratia marcescens panophthalmitis: a case series. Am J Ophthalmol Case Rep. 2019;16:100531.

    PubMed  PubMed Central  Article  Google Scholar 

  33. Kuo G, Lu Y-A, Sun W-C, Chen C-Y, Kao H-K, Lin Y, et al. Epidemiology and outcomes of Endophthalmitis in chronic dialysis patients: a 13-year experience in a tertiary referral center in Taiwan. BMC Nephrol. 2017;18:270.

    PubMed  PubMed Central  Article  Google Scholar 

  34. Stevenson KB, Hannah EL, Lowder CA, Adcox MJ, Davidson RL, Mallea MC, et al. Epidemiology of hemodialysis vascular access infections from longitudinal infection surveillance data: predicting the impact of NKF-DOQI clinical practice guidelines for vascular access. Am J Kidney Dis: Off J Natl Kidney Found. 2002;39:549–55.

    Article  Google Scholar 

  35. Rhee C, Jones TM, Hamad Y, Pande A, Varon J, O’Brien C, et al. Prevalence, underlying causes, and preventability of sepsis-associated mortality in US Acute Care Hospitals. JAMA Netw Open. 2019;2:e187571–e.

    PubMed  PubMed Central  Article  Google Scholar 

  36. Connell PP, O’Neill EC, Amirul Islam FM, Buttery R, McCombe M, Essex RH, et al. Endogenous endophthalmitis associated with intravenous drug abuse: seven-year experience at a tertiary referral center. Retin (Phila, Pa). 2010;30:1721–5.

    Article  Google Scholar 

  37. Tirpack AR, Duker JS, Baumal CR. An outbreak of endogenous fungal endophthalmitis among intravenous drug abusers in New England. JAMA Ophthalmol. 2017;135:534–40.

    PubMed  PubMed Central  Article  Google Scholar 

  38. Wang Z, Ren J, Wang G, Liu Q, Guo K, Li J. Association between diabetes mellitus and outcomes of patients with sepsis: a meta-analysis. Med Sci Monit: Int Med J Exp Clin Res. 2017;23:3546–55.

    Article  Google Scholar 

  39. Levi M, van der Poll T, Büller HR. Bidirectional relation between inflammation and coagulation. Circulation. 2004;109:2698–704.

    PubMed  Article  Google Scholar 

  40. Annane D, Bellissant E, Cavaillon J-M. Septic shock. Lancet. 2005;365:63–78.

    CAS  PubMed  Article  Google Scholar 

  41. Kinasewitz GT, Yan SB, Basson B, Russell JA, Cariou A, Um SL, et al. Universal changes in biomarkers of coagulation and inflammation occur in patients with severe sepsis, regardless of causative micro-organism [ISRCTN74215569]. Crit Care. 2004;8:R82.

    PubMed  PubMed Central  Article  Google Scholar 

  42. Stegenga ME, Vincent J-L, Vail GM, Xie J, Haney DJ, Williams MD, et al. Diabetes does not alter mortality or hemostatic and inflammatory responses in patients with severe sepsis. Crit Care Med. 2010;38:539–45.

    PubMed  Article  Google Scholar 

  43. Krinsley JS, editor Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clinic Proceedings; 2003: Elsevier.

  44. Leonidou L, Mouzaki A, Michalaki M, DeLastic AL, Kyriazopoulou V, Bassaris HP, et al. Cytokine production and hospital mortality in patients with sepsis-induced stress hyperglycemia. J Infect. 2007;55:340–6.

    PubMed  Article  Google Scholar 

  45. Jiménez-Ibáñez EO, Castillejos-López M, Hernández A, Gorocica P, Alvarado-Vásquez N. High mortality associated with hyperglycemia, neutrophilia, and lymphopenia in critically ill patients. Tohoku J Exp Med. 2012;226:213–20.

    PubMed  Article  CAS  Google Scholar 

  46. Yu W-K, Li W-Q, Li N, Li J-S. Influence of acute hyperglycemia in human sepsis on inflammatory cytokine and counterregulatory hormone concentrations. World J Gastroenterology: WJG. 2003;9:1824.

    CAS  Article  Google Scholar 

  47. Venot M, Weis L, Clec’h C, Darmon M, Allaouchiche B, Goldgran-Tolédano D, et al. Acute kidney injury in severe sepsis and septic shock in patients with and without diabetes mellitus: a multicenter study. PLoS ONE. 2015;10:e0127411.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  48. Valerius N, Eff C, Hansen N, Karle H, Nerup J, Søeberg B, et al. Neutrophil and lymphocyte function in patients with diabetes mellitus. Acta Med Scandinavica. 1982;211:463–7.

    CAS  Article  Google Scholar 

  49. Masuda M, Murakami T, Egawa H, Murata K. Decreased fluidity of polymorphonuclear leukocyte membrane in streptozocin-induced diabetic rats. Diabetes. 1990;39:466–70.

    CAS  PubMed  Article  Google Scholar 

  50. Cui Y, Chen W, Chi J, Wang L. Comparison of transcriptome between type 2 diabetes mellitus and impaired fasting glucose. Med Sci Monit: Int Med J Exp Clin Res. 2016;22:4699.

    CAS  Article  Google Scholar 

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Funding

This research was supported by unrestricted grants including Research to Prevent Blindness to the Wilmer Eye Institute (Baltimore, MD, USA) as well as from the VitreoRetinal Surgery Foundation in Edina, MN, USA (LT, MPB) and the Kogod Family (MPB).

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Each author contributed to the manuscript as follows: design and conduct of the study (LT, JC, AWS, FAW, MPB); collection, management, analysis, and interpretation of the data (LT, JC, MPB); preparation, review, or approval of the manuscript and decision to submit for publication (LT, JC, AWS, FAW, MPB).

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Correspondence to Mark P. Breazzano.

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Thangamathesvaran, L., Canner, J.K., Scott, A.W. et al. National emergency department trends for endogenous endophthalmitis: an increasing public health challenge. Eye (2022). https://doi.org/10.1038/s41433-022-02080-9

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