1. Multi-Drug Resistant Pseudomonas Keratitis Clinical Characteristics and Associated Features Jayesh Vazirani Merle Fernandes L V Prasad Eye Institute Visakhapatnam, India Jayesh Vazirani Merle Fernandes L V Prasad Eye Institute Visakhapatnam, India The authors have no financial interests to disclose

2. Purpose To study Clinical characteristics Risk factors For Multi-Drug Resistant (MDR) Pseudomonas aeruginosa keratitis

3. Methods Case – Control study design (2007-2014) Definitions Pseudomonas aeruginosa keratitis Clinical features of microbial keratitis Significant growth (two solid media / one solid and one liquid medium / correlation between smear and culture) of Pseudomonas aeruginosa on culture from corneal scrapings Multi-drug resistance Resistance to 3 or more classes of antimicrobial drugs, as tested by Kirby-Bauer disc diffusion method

4. Methods Inclusion criteria: Cases - MDR Pseudomonas keratitis Controls - Drug sensitive Pseudomonas keratitis Baseline characteristics studied – Age, gender, duration of symptoms, topical medication used prior to presentation, trauma, contact lens use, ocular surface disease, prior ocular surgery A multivariate logistic-regression model with stepwise elimination using Akaike information criteria (AIC) was used to assess the association of Cases and Controls with baseline characteristics Clinical course and outcomes also compared

5. Results MDR Pseudomonas keratitis Drug Sensitive Pseudomonas keratitis No of episodes 2367 No of eyes 2067 No of patients 1767 Bilateral cases 30 Median Age (years) 5449 % Male 52.9467.16 Graft infiltrates (%) 9 (39.13)21 (31.34) Median duration of symptoms (days) 74

6. Results MDR Pseudomonas keratitis Drug Sensitive Pseudomonas keratitis Topical Steroid use (%) 12 (52.17)23 (32.32) Lubricant ointment use (%) 18 (78.26)26 (38.80) Trauma (%) 2 (10)8 (11.94) Surgery (%) 11 (55)22 (32.83) Ocular surface disease (%) 18 (90)24 (35.82) Contact lens use (%) 5 (25)5 (7.46) Median Lesion size (mm) 85.4

7. Univariate Analysis p values

8. Multivariate Analysis p values

9. Association with Multi-Drug Resistance Multivariate Odds Ratio 95% Confidence Intervals p Value Contact lens use 11.14(1.31 – 94.43)0.027 Ocular surface disease 37.29(3.89 – 357.2)0.002 Lubricant ointment use 7.65(1.57 – 37.2)0.012 Univariate Odds Ratio 95% Confidence Intervals p Value Contact lens use3.44(0.9 - 13.23)0.072 Ocular surface disease 18.81(4.06 – 87.21)<0.001 Surgery2.98(1.12 – 7.91)0.029 Lubricant ointment use 5.68(1.88 – 17.16)0.002

10. Clinical Course & Outcomes MDR Pseudomonas keratitis Drug Sensitive Pseudomonas keratitis Perforation (%) 12 (52.17)8 (11.94) Median duration of medical therapy (days) 1830 Cyanoacrylate glue application (%) 11 (47.82)15 (22.38) Keratoplasty (%) 11 (47.82)14 (20.89) Evisceration (%) 2 (8.69)7 (10.44) Resolution (%) 8 (34.78)37 (55.22) Drug sensitivity (MDR group) – 60.86% isolates sensitive only to Imipenem/Colistin

11. Conclusions A compromised ocular surface, lubricant ointment use and contact lens use were the most common predisposing factors for MDR Pseudomonas aeruginosa keratitis Colistin and Imipenem were the most effective drugs for MDR Pseudomonas aeruginosa keratitis A majority of cases of MDR Pseudomonas aeruginosa keratitis needed surgical intervention Visual outcomes were extremely poor Lubricant eye ointment may act as a reservoir of infection

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