Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : September | Volume : 16 | Issue : 9 | Page : NC01 - NC04 Full Version

Analysis of Conjunctival Bacterial Flora among Patients Undergoing Multiple Intravitreal Injections for Diabetic Macular Oedema: A Cohort Study


Published: September 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57099.16812
Roopashree Kamisetty, SM Rudresh

1. Assistant Professor, Department of Ophthalmology, ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India. 2. Associate Professor, Department of Microbiology, ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Roopashree Kamisetty,
Assistant Professor, Department of Ophthalmology, ESIC Medical College and PGIMSR, Rajajinagar, Bengaluru-560010, Karnataka, India.
E-mail: roopachee@gmail.com

Abstract

Introduction: Intravitreal Injections (IVI) are frequently used for the treatment of Diabetic Macular Oedema (DME). Serial IVI in these patients along with topical antibiotics as prophylaxis for infection has raised concern about the probable detrimental effect on conjunctival flora. However, the risk of postoperative endophthalmitis is higher in diabetics, especially with poor glycaemic control or in the presence of Chronic Kidney Disease (CKD) owing to poor immunity. Hence, preoperative conjunctival microbial growth has been studied in these patients to understand the need for antibiotic prophylaxis.

Aim: To evaluate the preoperative conjunctival microbiological profile in diabetic patients treated with serial IVI (minimum of three) for DME and its association to their glycated haemoglobin (HbA1c) levels and the presence of associated CKD.

Materials and Methods: This retrospective cohort study conducted in the Department of Ophthalmology at ESIC Medical College and Research Institute, Bengaluru, Karnataka, India, in May 2021. Total 92 eyes of 79 patients with type 2 diabetes mellitus who had received a minimum of three serial IVI of anti-Vascular Endothelial Growth Factor (anti-VEGF) injections for DME between May 2018 and January 2020 were included in the study. Conjunctival swabs for culture were taken from each eye before the injection and were evaluated for microbial growth. The association between microbial growth and HbA1c levels and/or CKD was analysed statistically using the Chi-square test.

Results: The conjunctival cultures taken before IVI, were positive in 29.3% (27 of 92 eyes). Among them, Coagulase Negative Staphylococcus (CONS) bacteria were isolated in 15 of 27 eyes (55.5%) followed by Micrococci in 10 eyes (37%) and Diphtheroids in two eyes (7.4%). The average HbA1c among the eyes with positive growth was 7.23±1.31 as compared to 6.64±1.08 in eyes with no growth (p-value=0.1). There was a statistically significant association of culture positivity in patients with CKD and having HbA1c ≥7% (p-value=0.01) with CONS being the most common organism.

Conclusion: A statistically significant association of conjunctival swab culture positivity in type 2 diabetics with DME requiring multiple IVI having uncontrolled diabetes HbA1c ≥7% and the presence of CKD was observed in the present study. Hence, the routine use of topical antibiotics as infection prophylaxis may be recommended in these patients as an additional precaution against endophthalmitis.

Keywords

Chronic renal failure, Diabetic retinopathy, Glycated haemoglobin, Vascular endothelial growth factor

Intravitreal Injection (IVI) of anti-Vascular Endothelial Growth Factor (anti-VEGF) has become the standard of care in the management of patients with Diabetic Macular Oedema (DME). Although IVI is considered to be an effective and safe method, endophthalmitis is the most feared complication. The incidence of post-IVI endophthalmitis has been reported to be 0.131% (1).

Treatment of DME in many patients requires repeated intravitreal anti-VEGF injections owing to the chronicity of the disease. The recurrent monthly usage of perioperative topical antibiotics as infection prophylaxis in DME patients requiring multiple IVI has been reported to cause detrimental effects on their conjunctival flora, questioning their routine use (2). However diabetic patients also have a higher risk of postoperative endophthalmitis than non-diabetic patients (3). Also, patients with chronic renal failure have innate and adaptive immunity defects, thus predisposing them to infection (4),(5). The main source of bacteria isolated in cases of postinjection endophthalmitis is the patient’s conjunctival bacterial flora. Therefore, evaluation of the conjunctival bacterial flora as a surrogate marker is of utmost importance to prevent postoperative endophthalmitisn (6).

There is an ongoing confusion regarding the use or avoidance of perioperative topical antibiotics in patients with DME requiring serial IVI, especially those with poor glycemic control and chronic renal disease. For this purpose, retrospective cohort study was done to analyse the preoperative conjunctival flora of type 2 diabetic patients who have undergone three or more consecutive IVI of anti-VEGF for DME. The association of conjunctival cultures to their systemic glycaemic control (glycated haemoglobin, HbA1c) and the presence of Chronic Kidney Disease (CKD) in the study group was also analysed.

Material and Methods

This retrospective cohort study conducted in the Department of Ophthalmology at ESIC Medical College and Research Institute, Bengaluru, Karnataka, India, in May 2021. Informed consent was obtained from the study subjects and ethical clearance for the study was obtained from the review board (Ref No. 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol.IV Dtd: 20/06/2021). The case records of all 79 patients over the age of 18 years and those who were treated with IVI of anti-VEGF for DME between May 2018 to Jan 2020 were collected.

Inclusion and Exclusion criteria: The patients who had received a minimum of three serial IVI of anti-VEGF (Ranibizumab or Aflibercept) were included in the study. The patients treated with triamcinolone acetonide injection, who had any prior ocular surgery within the past 6 months, chronic use of any topical antibiotics or topical steroids, or usage of contact lenses 6 months before the study were excluded from the study.

All patients had undergone IVI after routine investigations (including HbA1c) and physician clearance for the procedure. Among them, those with CKD underwent IVI after nephrologist clearance.

Procedure

Swab collection method: A thorough ocular examination was done to look for any abnormalities in the eyelids and conjunctiva. Two days before the planned injection, conjunctival swabs were taken from the eye to be treated. Samples were obtained after anesthetizing the conjunctival sac with sterile 0.5% proparacaine ophthalmic solution and gently rubbing the lower fornix with a sterile cotton swab (no antibiotics or antiseptics were used). Care was taken to minimize contact with the eyelids and eyelid margin. The swabs were transported to the microbiology laboratory within 30 minutes and were inoculated on culture plates with 5% sheep blood agar, chocolate agar and MacConkey’s agar; later incubated at 37°C in ambient air. Any growth was identified by various tests like Gram’s stain, catalase test, modified oxidase test, and coagulase test (7). After 48 hours, the culture plates were reviewed and listed the number of positive and negative cultures.

The patients with positive microbial growth were deferred IVI and started on topical moxifloxacin eye drops four times a day for five days. The conjunctival culture was repeated a week later and IVI was done after the swab showed no growth. The eyes with no culture growth were started on topical moxifloxacin eye drops, a day before IVI as prophylaxis. All the study patients had followed the same protocol in the previous injections done before the study period.

Intravitreal injection technique: All the intravitreal injections were done in the operating room by a single surgeon. Each patient received an injection from a new single-use vial of ranibizumab or aflibercept. Topical anaesthesia with proparacaine was applied in the conjunctival sac. The periorbital area was cleansed with 10% Povidone Iodine (PVI), and 5% povidone-iodine drops were applied in the conjunctival sac for two minutes. A self-adhesive sterile drape large enough to mask the patient’s face was placed. After applying the lid speculum, using a 30 gauge needle, 0.05 mL of anti-VEGF agent (ranibizumab or aflibercept) was injected through the pars plana route 3.5-4 mm from the limbus. Postinjection the culdesac was again flushed with PVI eyedrops. The eye was patched for two hours after injection and topical moxifloxacin (0.5%) eye drops were continued four times a day for five days for infection prophylaxis. Patients were reviewed on the next day, one week, and a 1 month postinjection to look for endophthalmitis or any complications.

In the present study, the association between the conjunctival swab bacterial growth with preoperative HbA1c level and the renal status (presence or absence of CKD) in the study patients was assessed. Patients with HbA1c ≥7% were considered as having poor glycemic control (American Diabetes Association) (8). Chronic kidney disease was defined as GFR <60 mL/min/1.73 m2 for ≥3 months, with or without kidney damage, and on regular treatment at our hospital nephrology clinic (National Kidney foundation KFDOQI guidelines) (9).

Statistical Analysis

The data collected was entered on Microsoft Excel and was analysed using IBM, Statistical Package for Social Sciences (SPSS) statistical software version 18.0. Descriptive statistics were analyzed as proportions for frequencies and mean with standard deviation for continuous measures. The Chi-square test was used to find the association between the categorical variables. A p-value <0.05 was considered as statistically significant.

Results

Among the 146 patient records collected during the study period, 92 eyes of 79 patients fulfilling the inclusion and exclusion criteria were included in the study. Out of total, 66 patients had IVI in one eye, while 13 patients had been treated in both eyes during the study period. Among the patients, 54 were males (68.35%) and 25 were females (31.64%). The mean age of participants was 58.21±9.13 years. The majority of the study participants were in the age group over 50 years. These patients had received an average of 4.3 (range 3-8) intravitreal injections in the past for DME. During the study period, 78 eyes (84.8%) received ranibizumab and 14 eyes (15.2%) received aflibercept. Conjunctival bacterial growth was seen in 27 of 92 eyes (29.34%) while 65 eyes (70.6%) had no growth. There was no significant association between age and positive conjunctival growth (p-value=0.185) nor association between sex and positive conjunctival growth (p-value=0.171). The bacteria isolated from the positive cultures were Coagulase Negative Staphylococcus (CONS) being the most common in 15 of 27 eyes (55.5%), Micrococci in 10 eyes (37%) and Diphtheroids in two eyes (7.4%) (Table/Fig 1).

The average HbA1c level at the time of injection among the study patients was 6.81±1.17% (range 5.1 to 9.3). The average HbA1c among the patients with positive bacterial growth was 7.23±1.31 as compared to 6.64±1.08 in patients with no growth (Table/Fig 2). There was no statistically significant difference between the HbA1c of patients with and without the presence of culture growth (p-value=0.1). Chronic kidney disease patients who had positive growth had significantly higher HbA1c (mean HbA1c=8.09%) compared to those with no growth (mean HbA1c was 6.30%) (p-value <0.001).

The CKD was present in 30 eyes (32.60%), among them four patients were on dialysis, and the remaining were on medical management. CKD was statistically associated with positive bacterial growth (p-value=0.01) (Table/Fig 3). Among the 30 eyes with CKD, 14 eyes (46.6%) had positive microbial growth with CONS being the most common bacteria isolated in nine eyes (30%). There was also a statistically significant association between positive growth found in CKD patients and their HbA1c levels (p-value=0.01).

No cases of endophthalmitis or worsening of nephropathy or other complications were reported in these patients at 1 month follow-up.

Discussion

The practice pattern of IVI of anti-VEGFs and infection prophylaxis varies from practice to practice and from country to country (10). The use of topical povidone-iodine on the ocular surface, eyelids, and eyelashes; the use of an eyelid speculum; and the avoidance of needle contact with surfaces other than the injection site have all been recommended by expert reviewers universally. In contrast, the application of topical antibiotics, either before or after the injection procedure, has remained a topic of debate (2),(11),(12). Recent survey noted the use of peri-IVI antibiotic practice among ophthalmologists across continents and reported antibiotic usage by 67% in Europe, 34% (pre-IVI), and 81% (post-IVI) in the USA, and 39% in the Asia-pacific region (13),(14),(15). In contrast, among the Indian retina specialists 60% used topical antibiotics in the pre-IVI period and 89.3% used them in the post IVI period (10).

In this study, the microbiological profile of conjunctival flora of diabetic patients who had received multiple IVI (minimum of three) was noted. The present study had a 29.3% conjunctival culture positivity rate and the most common bacterium isolated was Coagulase-negative Staphylococcus (55.5%). The results are consistent with published reports that showed that coagulase-negative Staphylococcus is the most common isolate from the conjunctiva (16),(17),(18). Hsu J et al., reported a 77% culture positivity rate in cultures taken from the conjunctiva in patients receiving annual IVI (17) Kaldirim H et al., found Coagulase-negative Staphylococcus (Staphylococcus Epidermidis) as the bacterium with the highest culture positivity done after six serial IVI for DME, 50% culture positives noted 1 month after 3rd IVI (p-value <0.001) and 65.5% culture positives 1 month after the 6th IVI (2). Yin VT et al., in a larger prospective study noted an increase in the percentage of isolates from 0% at baseline to 50% at 3 months after serial IVI, the most common isolate found being coagulase-negative Staphylococcus. Their study patients were treated with a 3 days course of topical moxifloxacin following each injection (19).

Studies have shown that the frequency of positive conjunctival cultures is found to be significantly higher in diabetics thereby increasing their risk of postoperative endophthalmitis compared to non diabetics (20),(21),(22). Isenberg SJ et al., noted a definite synergy between the use of the combination of preop topical antibiotics-PVI before cataract surgery or IVI ( 83% sterile cultures) against the use of either of them (31% in antibiotic prophylaxis alone, 40% in PVI alone) in terms of positive bacterial cultures (23). However, the Comparison of Age-related Macular Degeneration Treatments Trials (CATT) study group showed no statistically significant difference in endophthalmitis rates between groups with and without antibiotic use, although there was a trend towards lower rates in the antibiotic-treated groups (24).

The relationship between HbA1c values and culture positivity rates was also analysed. Patients with higher HbA1c (mean 7.23) had a slight, non statistically significant trend for positive cultures, but in eyes, with Coagulase-negative staphylococcus growth, the mean HbA1c was even higher (mean 7.62). Similar results of higher mean HbA1c (8.2±1.0%, p-value=0.14) were noted by Einan-Lifshitz A et al., after the third IVI and and Kaldirim H et al. (mean HbA1c 8.1%) in culture-positive patients (2),(25). Patients with chronic renal, failure have innate and adaptive have innate and adaptive immunity defects, thus predisposing them to infectious disease (4),(5). In the present study authors found a statistically significant association between the conjunctival growth of coagulase-negative Staphylococcus in CKD patients to higher HbA1c (mean 8.45). Kuo G et al., found seven dialysis patients having exogenous endophthalmitis after surgery. Of them, 57.1% had a positive vitreous culture with Coagulase-negative Staphylococcus, and Enterococcus Faecalis is the most common pathogen causing exogenous endophthalmitis in them (26).

The combination of periprocedural topical moxifloxacin 0.5% and antisepsis with 5% PVI has been proven to cause a greater decrease in positive cultures than the use of 5% PVI alone. It is known that after repeated exposure to PVI, there is no alteration in the conjunctival flora (27). But the concern is about repeated short-term exposure to topical antibiotics during intravitreal injections and thereby the significant increase in the antibiotic resistance of ocular surface flora. However, in a recent study, Zhu X et al., noted that the diversity and distribution of the conjunctival microbiome can be restored in 7 days after ceasing all postoperative medications regardless of T2DM presence, indicating that the influence of surgical procedures and perioperative topical antibiotics might be eliminated within a short period (28).

This study confirms a statistically significant increase in culture positivity in CKD patients with high HbA1c and a high positive growth rate in patients with HbA1c ≥7%. All culture positives responded to five days course of topical moxifloxacin eye drops where repeat conjunctival swab had no growth. No cases of endophthalmitis were reported in the study patients.

Pretreatment with topical antibiotics is based on the rationale that such application may have a synergistic effect with PVI in reducing the number of bacteria on the ocular surface and at the injection site, hence preventing their intraocular entry during or after the IVI, thereby resulting in a decrease in the risk of postinjection endophthalmitis. Since, the visual outcomes of endophthalmitis are poor in patients with poor glycaemic status (HBA1c ≥7%) and chronic renal disease or dialysis than in the general population, routine preop conjunctival growth evaluation, periprocedural topical antibiotic prophylaxis, and PVI use can be beneficial in these patients (29).

Limitation(s)

In the present study, the antibiotic sensitivity pattern of the isolated microorganism which would have helped in determining antibiotic resistance patterns in patients with repeated injections. There is a need for a prospective study in large number of subjects to look for conjunctival flora in the diabetics after having received serial IVI and the antibiotic susceptibility patterns in the Indian population. Randomised controlled studies are needed to suggest for or against the use of topical antibiotics in these patients.

Conclusion

A statistically significant association of conjunctival swab culture positivity in type 2 diabetics with DME requiring multiple IVI having uncontrolled diabetes (HbA1c ≥7%) and the presence of CKD was observed in the present study. Hence, routine use of topical antibiotics as infection prophylaxis may be recommended in these patients as an additional precaution against endophthalmitis.

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DOI and Others

DOI: 10.7860/JCDR/2022/57099.16812

Date of Submission: Apr 19, 2022
Date of Peer Review: May 14, 2022
Date of Acceptance: Aug 06, 2022
Date of Publishing: Sep 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 22, 2022
• Manual Googling: Aug 05, 2022
• iThenticate Software: Aug 09, 2022 (20%)

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