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2023 OMIG Abstract

Association of artificial tears with ocular and systemic infection: Carbapenem-resistant Pseudomonas aeruginosa (VIM-GES-CRPA) Outbreak

Frida Velcani¹, Irene C. Kuo², Robert M.Q. Shanks³, James Chodosh⁴, Prashant Garg⁵,
Guillermo Amescua⁶, and Michael E. Zegans<sup>1,7

1</sup>Geisel School of Medicine at Dartmouth, Hanover, NH; ²Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, MD; ³Charles T Campbell Laboratory of Ophthalmic Microbiology, Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA; ⁴Department of Ophthalmology and Visual Sciences, University of New Mexico School of Medicine, Albuquerque, NM; ⁵L V Prasad Eye Institute, Hyderabad, India; ⁶William Thode Ocular Microbiology Laboratory, Bascom Palmer Eye Institute University of Miami-Miller School of Medicine, Miami, FL; ⁷Department of Surgery, Section of Ophthalmology, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Purpose: To provide a current understanding of the carbapenem-resistant Pseudomonas aeruginosa (VIM-GES-CRPA) outbreak that has led to enucleation and been linked to several deaths in the United States. Additionally, to recommend strategies for public health surveillance and investigating treatment strategies such as novel antimicrobials, antiseptics, phage therapy, antimicrobial peptides, photodynamic therapy, and monoclonal antibodies.

Methods: A comprehensive review was conducted of FDA and CDC alerts/updates on contaminated EzriCare and Delsam Pharma's Artificial Tears, FDA manufacturing inspection processes, media reports, peer-reviewed articles, and anecdotal evidence highlighting P. aeruginosa infections progressing to keratitis and/or endophthalmitis.

Results: Specimens were collected between May 2022 to April 2023 and not all were ocular. As of May 15, 2023, CDC and local health departments have records of 81 patients in 18 states infected with extensively drug-resistant P. aeruginosa with VIM-80 and GES-9 markers. Data from March 14, 2023, showed that 37 out of 68 patients (54%) affected at the time were linked to four healthcare facility clusters. While details are still emerging, there have been 14 confirmed accounts of vision loss from infection and four cases of enucleation. Additionally, four patients have died within 30 days of culture collection, with at least one from hematogenous infection, although P. aeruginosa has not been implicated as the primary cause of death. Bacterial culture remains an important component of outbreak recognition and management.

Conclusions: Ophthalmologists are encouraged to report cases of unusual infections to public health officials who are in the best position to prevent and manage further outbreaks. Research to test novel antimicrobials such as Cefiderocol, an injectable cephalosporin (which, by binding iron, bypasses the bacterial porin system and thus many resistance mechanisms), and other antimicrobial strategies that circumvent the resistance mechanisms of this pathogen should also be urgently investigated. This outbreak also highlights the need for better oversight of manufacturing of over-the-counter products like artificial tears.

Disclosure: N (Velcani, Kuo); S (Shanks, National Eye Institute EY032517; Chodosh, National Eye Institute; Garg, UK Research Institute, Indian Council of Medical Research, Department of biotechnology, Government of India; Amescua, NIH SCUTII Trial Site, NIH ZEDS Trail (to University of Miami), Robson Foundation (philanthropic support)); Zegans, NIH/NEI R21 EY02877-01, Francis A. L'Esperance, Jr., MD, Visual Sciences Scholar Fund); C (Garg, Santen, International Joint Commission for Allied Health Personnel in Ophthalmology, Eye and Contact Lens Society, Operation Eye Sight Universal, India; Amescua, KALA Pharmaceuticals, PanAmerican Cornea Society Board Member, OMIG Past President (unpaid); Zegans, DETECT Study, NIH DSMC, NH Eye Society (Member), AAO, OMIG (Fellow, unpaid)); L (Amescua, Santen Laboratories, W. L. Gore & Associates, Inc.); P (Garg, WO 2019/220136 A1, WO 2019/220137 A1, WO 2019/193513; Amescua, Photodynamic Antimicrobial Therapy Device)

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