Supplementary issue:02 - 159 - Socio-Demographic Characteristics of Patients with Ocular Infection in Northern India Shariq Wadood Khan1, Adil Raza1, Shaik Mohammed Zakir2, *Mohd. Yasir Zubair3, Haris Manzoor Khan1, Mohammad Shahid4 1. Department of Microbiology J. N. Medical College, AMU, Aligarh, India 2. Institute of Ophthalmology J. N. Medical College, AMU, Aligarh, India 3. Department of Community Medicine J. N. Medical College, AMU, Aligarh, India 4. Department of Microbiology, Immunology & Infectious Diseases, College of Medicine & Medical Sciences, Kingdom of Bahrain * Correspondence: Dr. Mohd. Yasir Zubair Senior Resident, Department of Community Medicine J. N. Medical College, AMU, Aligarh, India Email Id: yasmuhsin@gmail.com ABSTRACT BACKGROUND: The microbiological and epidemiological patterns seem to vary with the patient population, site of infection, geographic location and it may also change over time. Hence, an understanding of the epidemiological features, risk factors and etiological agents that occur in a specific region are important in rapid recognition, timely institution of empirical therapy, optimal management and prevention of these infections. OBJECTIVE: To study association of various socio-demographic factors with ocular infections and microbiological positivity rates of collected samples at our tertiary care centre. METHODS: This study was conducted in the Department of Microbiology & Institute of Ophthalmology, Jawaharlal Nehru Medical College, Aligarh Muslim University (A.M.U.), Aligarh from July 2018 to February 2021. RESULTS: Out of 350 patients diagnosed with ocular infections in the study, 207(59.14%) were male patients, and 143 (40.8%) were female. Similar number of patients presented in each group. The clinical diagnosis of the infective conditions of the eye ranged from mostly innocuous Conjunctivitis to sight threatening Corneal ulcers and Endophthalmitis. The overall culture-positivity rate for bacterial isolation was 54.57% (191/350). CONCLUSION: There is slight gender preponderance towards males for infective ocular conditions. In this study, the most prevalent clinical condition was ocular adnexal bacterial infections, followed by corneal ulcers. From 350 patients with ocular infections, 54.57% Supplementary issue:02 - 160 - were culture-positive. Our study provides pattern of different ocular infections in OPD and IPD settings which may be may be of use to clinicians in their day to day practice. Keywords: Ocular infections, Culture, Sociodemographic Demographic Characteristics Introduction The eye is largely immune to external agents. The numerous mechanical, anatomical, immunologic, and microbiological elements work together to prevent ocular infections and prevent pathogenic micro-organisms from surviving in the eye.1-2 However, under certain conditions, micro-organisms manage to get past all the defenses and enter the eye, where they can then cause a variety of infections, from minor eye irritation to serious sight threatening infections like endophthalmitis. The bacteria that colonize the eye differ from those that do so in other areas of the body.3 There is a risk of bacterial, fungal, viral, and parasite infections in the outer layer of the eye. Additionally, bacteria can get inside the eye and harm its interior structures, which frequently causes varying degrees of vision loss. Both exogenous or endogenous factors may be the cause of an eye infection.4 External bacterial infections of the eye are usually localized but may frequently spread to adjacent tissue, from the conjunctiva to the cornea, the inner eye, the orbit and the brain. The conjunctival sac and lid margins of the eye harbor a variety of micro-organisms and the bacteria present in the conjunctival sac form a constant source of infection to other parts of the eye. Conjunctivitis, keratitis, blepharitis, canaliculitis, dacryocystitis, external hordeolum, and cellulitis are all clinical manifestations of external eye infections.5 Bacteria frequently produce the clinical signs and symptoms of ocular inflammation. Globally, Gram-positive bacteria are the predominant cause of these purulent infections. Organisms frequently isolated are Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus, and Staphylococcus epidermidis.6 However, the margins of the lids and conjunctival sacs of healthy individuals can also contain gram-negative pathogens. The microbiological and epidemiological patterns seem to vary with the patient population, site of infection, geographic location and it may also change over time. Hence, an understanding of the epidemiological features, risk factors and etiological agents that occur in a specific region are important in rapid recognition, timely institution of empirical therapy, optimal management and prevention of these infections. The present study was conducted with the objective of studying the Supplementary issue:02 - 161 - association of various socio-demographic factors with ocular infections and microbiological positivity rates of collected samples at our tertiary care centre. Materials & Methods This study was conducted in the Department of Microbiology & Institute of Ophthalmology, Jawaharlal Nehru Medical College, Aligarh Muslim University (A.M.U.), Aligarh from July 2018 to February 2021. A total of 350 patients presented during the study period to the outpatient and inpatient departments of the Institute of Ophthalmology, JNMCH, AMU. All the patients were examined under diffused torch light, followed by slit-lamp biomicroscopy by Ophthalmologists. Diagnosis was made clinically and appropriate specimen was collected for microbiological examination. The clinical specimens were processed in the laboratory. Direct microscopy of Gram-stained smear was performed for all the collected specimens, which were inoculated onto 5% sheep blood agar (SBA), chocolate agar (CA), MacConkey agar (MCA), Robertson cooked meat broth (RCM), thioglycolate medium, and brain-heart infusion broth (BHI). These were incubated at 37°C for 18-24 hours. The organism was identified based on morphology, culture characteristics, and biochemical tests. The clinical findings, microbiological profile and sociodemographic information was documented on a pre-designed semi-structured questionnaire. Data Management The data so collected was entered in IBM SPSS version 20.0 software for analysis. Ethics Ethical clearance was obtained from the Institutional Ethics Committee, Jawaharlal Nehru Medical College, AMU, Aligarh. Informed consent was obtained from patients/guardians for their participation. . Results Out of 350 patients diagnosed with ocular infections in the study, 207(59.14%) were male patients, and 143 (40.8%) were female. The male-to-female ratio was 1.4:1 (Table 1). The distribution of Supplementary issue:02 - 162 - patients with respect to different age groups is presented in Table 2. Similar number of patients presented in each group. Table 1. Distribution of patients according to sex (n=350) Gender Frequency (%) Percentage (95% CI) Male 207 59.2 (53.9-64.2) Female 143 40.8 (35.7-46.0) Table 2 Distribution of ocular infections according to age (n=350) Age group (years) Patients Percentage (95% CI) 0-10 53 15.14% (11.5-19.3) 11-20 32 9.14% (6.3-12.6) 21-30 48 13.71% (10.2-17.7) 31-40 58 16.57% (12.8-20.8) 41-50 40 11.42% (8.2-15.2) 51-60 66 18.86% (14.8-23.3) 61-70 38 10.85% (7.8-14.6) >70 15 4.28% (2.4-6.9) The clinical diagnosis of these infective conditions ranged from mostly innocuous Conjunctivitis to sight threatening Corneal ulcers and Endophthalmitis. Conjunctivitis, Dacryocystitis, Endophthalmitis and Corneal ulcers were found to be the most common Ocular infections in our study. Conjunctivitis was more commonly seen in patients less than 20 years of age, and endophthalmitis and corneal ulcer were more common in elderly patients. Dacryocystitis cases mostly belonged to the middle age group of 21-50 years accounting for 45.2% of cases. No age predominance was observed for pre-septal and orbital cellulitis. Around half of patients with Supplementary issue:02 - 163 - Endophthalmitis (51.9%) and Panophthalmitis (50%) belonged to older age group of >50 years (Table 3). Table 4 shows the bacterial culture positivity rate in different ocular infective conditions. The overall culture-positivity rate was 54.57% (191/350). The maximum culture positivity rate was found in Panophthalmitis, 04 (4/4; 100%) and post-surgical infection, 04(4/4; 100%), followed by Dacryocystitis, 50 (50/62; 80.64%) and internal hordeolum, 13 (13/21; 61.90%). More than half of Conjunctivitis (56.6%), Preseptal Cellulitis (60.0%) and External hordeolum (52.8%) were also culture positive. In Endophthalmitis, 23 of 81 patients (28.3%) were found to be culture positive. Table 3: Pattern of various bacterial ocular infections in relation to age Age Groups 0-20 years N, % (CI) 21-50 years N, % (CI) >50 years N, % (CI) Total N, % (CI) Conjunctivitis 27, 50.9% (36.8-64.9) 16, 30.2% (18.3-44.3) 10, 18.9% (9.4-32.0) 53 (15.1%) Corneal ulcer 04, 6.2% (1.7-15.2) 25, 39.1% (27.1-52.1) 35, 54.7% (41.7-67.2) 64 (18.3%) External hordeolum 02, 5.5% (0.6-18.7) 32, 88.9% (73.9-96.9) 02, 5.5% (0.6-18.7) 36 (10.3%) Internal hordeolum 03, 14.3% (3.1-36.3) 13, 61.9% (38.4-81.9) 05, 23.8% (8.2-47.2) 21 (6.0%) Dacryocystitis 17, 27.4% (16.9-40.2) 28, 45.2% (32.5-58.3) 17, 27.4% (16.9-40.2) 62 (17.7%) Preseptal cellulitis 05, 33.3% (11.8-61.6) 05, 33.3% (11.8-61.6) 05, 33.3% (11.8-61.6) 15 (4.2%) Orbital cellulitis 04, 40% (12.2-73.8) 02, 20% (2.5-55.6) 04, 40% (12.2-73.8) 10 (2.8%) Endophthalmitis 21, 25.9% (16.8-36.9) 18, 22.2% (13.7-32.8) 42, 51.9% (40.5-63.1) 81 (23.1%) Supplementary issue:02 - 164 - Panophthalmiitis 01, 25% (0.6-80.6) 01, 25% (0.6-80.6) 02, 50% (6.7-93.2) 04 (1.1%) Post-surgical infection 01, 25% (0.6-80.6) 01, 25% (0.6-80.6) 02, 50% (6.7-93.2) 04 (1.1%) Total (N) 85, 24.3% (19.9-29.1) 141, 40.3% (35.1-45.4) 124, 35.4% (30.4-40.7) 350 Table 4. Bacterial culture positivity rate of different ocular infections Ocular infections Patients Bacterial isolates Percentage (95% CI) Conjunctivitis 53 30 56.6 (43.2- 69.9) Corneal ulcer 64 31 48.4 (36.1-60.6) External hordeolum 36 19 52.8 (36.4-69.0) Internal hordeolum 21 13 61.9 (41.1-82.6) Dacryocystitis 62 50 80.6 (70.8-90.4) Preseptal cellulitis 15 09 60.0 (35.2-84.7) Orbital cellulitis 10 08 80.0 (44.3-97.4) Endophthalmitis 81 23 28.4 (18.33-37.7) Panophthalmiitis 04 04 100 Post-surgical infection 04 04 100 Total 350 191 54.57 (49.3-59.7) Supplementary issue:02 - 165 - Discussion: In the present study, a total of 350 patients with clinically diagnosed ocular infections were studiedf. In our study 59.2% patients were males and 40.8% were females. Tilahun Aweke et al7 (2014) in their study amongst 281 patients with external ocular infections reported that 59.4% patients were males and 40.6% were females. Amongst the various ocular infective conditions in our study, 34% (119/350) patients had ocular adnexal bacterial infections (External hordeolum, Internal hordeolum, Dacryocystitis), 15.14% (53/350) had Conjunctivitis, 18.28% (64/350) had corneal infections, 1.1% (4/350) had a post-surgical infection. The remaining 24.28% (85/350) had an infection of the intraocular tissues (Endophthalmiitis + Panophthalmitis). Belyhun Yeshambel et al8 (2018) in their study among 210 patients of external ocular infections reported conjunctivitis in 32.9% (69), blepharitis in 26.7% (56), dacryocystitis in 14.8% (51), blepharoconjunctivitis in 11.9% (25), and trauma in 10.0% (21) of their patients. Tilahun Aweke et al7 (2014) found 49.8% cases of Conjunctivitis, 19.6% Blepharitis, 11.03% cornral infections, 5.4% Dacryocystitis and 12.8% others. Most of the endophthalmitis cases in our study were subsequent to cataract surgery, and cataract is the disease of the elderly population; this provides an explanation for more endophthalmitis cases in elderly people. In our study, the overall culture-positive rate was 54.57 percent (191 out of 350). Bharathi JM et al.9(2010) and Tilahun Aweke et al.7 (2014) found a similar culture positivity rate of 58.8% and 48.8% respectively . Mohammed et al10 also reported a similar rate of 60% (198/332) in 2020. Hemavathi et al. (2014)11 conducted their study in Bangalore, India and it yielded 34.5% (81/235) of bacterial growth. The probability of isolating a causal organism is dependent on a number of variables, including the volume of inoculum12, the site from which it is collected, the types of media utilised for culture (enriched or basic media)13, and the empirical treatment received before the sample collection.14 This can partially explain culture-positivity rate across centres. The difference can also be attributed to geographic location, study period, study population, socioeconomic condition of the study population, and laboratory method used to isolate microorganisms. In our study, we found the highest culture positivity rate among the samples collected from panophthalmitis (100%; 4/4), post-surgical infections (100%; 4/4), and lacrimal apparatus Supplementary issue:02 - 166 - infections (Dacryocystis, 80.64%; 50/62). The possible reason might be that blockage of the nasolacrimal duct harbors a significant number of microorganisms resulting in significant recovery of bacteria in culture. We found positive culture in 56.6% cases of Conjunctivitis and 48.4% cases of Keratitis. Belyhun Yeshambel et al8 (2018) reported that 32.8% (43), 23.7% (31), and 16.0% (21) of the isolates could be detected in conjunctivitis, dacryocystitis, and blepharitis, respectively and 27.5% (36) of bacteria were detected in other infections of the eye. Conclusion: There is slight gender preponderance towards males for infective ocular conditions. In this study, the most prevalent clinical condition was ocular adnexal bacterial infections, followed by corneal ulcers. From 350 patients with ocular infections, 54.57% were culture- positive. Our study provides pattern of different ocular infections in OPD and IPD settings which may be may be of use to clinicians in their day to day practice. Limitations This was a hospital-based study at a tertiary care center and therefore it is subject to selection bias. The sample size of the study was small. Reference 1. McClellan KA. Mucosal defense of the outer eye. Surv Ophthalmol. 1997; 42:233–46. 2. Nassif KF. Ocular surface defense mechanisms. In: Tabbara KF, Hyndiuk RA, editors. Infections of the Eye. Boston: Little Brown and Company; 1996. 35–41 3. Hemavathi SP, Shenoy P. Profile of microbial isolates in ophthalmic infections and antibiotic susceptibility of the bacterial isolates: a study in an eye care hospital, Bangalore. J Clin Diagn Res. 2014; 8(1):23–5. 4. Muluye D, Wondimeneh Y, Moges F, Nega T, Ferede G. Types and drug susceptibility patterns of bacterial isolates from eye discharge samples at Gondar University Hospital, Northwest Ethiopia. BMC Res Notes. 2014;7(1): 292. 5. Schaefer F, Bruttin O, Zografos L, Guex-Crosier Y. Bacterial keratitis: a prospective clinical and microbiological study. Brit J Ophthalmol. 2001;85(7): 842–7. 6. Bremond-Gignac D, Chiambaretta F, Milazzo S. A European perspective on topical ophthalmic antibiotics: current and evolving options. Ophthalmol Eye Dis. 2011; 3:29. Supplementary issue:02 - 167 - 7. Tilahun Aweke, Gelila Dibaba, Kenenisa Ashenafi, Mengist, Kebede. Bacterial pathogens of exterior ocular Infections and their antibiotic vulnerability pattern in Southern Ethiopia. African Journal of Immunology Research Vol. 1 (2) pp. 019-025 8. Belyhun, Y., Moges, F., Endris, M. et al. Ocular bacterial infections and antibiotic resistance patterns in patients attending Gondar Teaching Hospital, Northwest Ethiopia. BMC Res Notes 11, 597 (2018) 9. Bharathi MJ, Ramakrishnan R, Meenakshi R, Mittal S, Shivakumar C, Srinivasan M. Microbial diagnosis of infective keratitis: Comparative evaluation of direct microscopy and culture results. Br J Ophthalmol. 2006; 90:1271–6. 10. Mohammed et al. Bacterial etiology of ocular and periocular infections, antimicrobial susceptibility profile and associated factors among patients attending eye unit of Shashemene comprehensive specialized hospital, Shashemene. Ethiopia BMC Ophthalmology (2020) 20:124 11. Hemavathi et al., Profile of Microbial Isolates in Ophthalmic Infections and Antibiotic Susceptibility of the Bacterial Isolates. Journal of Clinical and Diagnostic Research. 2014 Jan, 8(1): 23-25 12. Moeller CT, Branco BC, Yu MC, Farah ME, Santos MA, Hofling-Lima AL. Evaluation of normal ocular bacterial flora with two different culture media. Can J Ophthalmol. 2005; 40:448–53. 13. Gaynor BD, Chidambaram JD, Cevallos V, Miao Y, Miller K, Jha HC, et al. Topical ocular antibiotics induce bacterial resistance at extraocular sites. Br J Ophthalmol. 2005;89:1097– 9 14. Bharathi JM, Ramakrishnan R, Shivakumar C, Meenakshi R, Lionalraj D. Etiology and antibacterial susceptibility pattern of community-acquired bacterial .ocular infections in a tertiary eye care hospital in south India.Indian J Ophthalmol. 2010 Nov-Dec; 58(6): 497– 507.