Vancomycin resistance among gram-positive bacterial endophthalmitis has become a major global health issue [
9]. Vancomycin - a glycopeptide - is the drug of choice for methicillin-resistant coagulase-negative
Staphylococcus and methicillin-resistant
Staphylococcus aureus (MRSA) infections [
10,
11]. Biofilm formation [
12] and alteration of binding sites of drug [
13] are the mechanisms of acquiring resistance to vancomycin. These resistant traits are then selected for in the presence of vancomycin. The Endophthalmitis Vitrectomy Study in 1996 reported the vancomycin sensitivity of gram-positive organisms to be 100%. A few reports of vancomycin resistance among
Bacillus,
Enterococcus, and
Staphylococcus species causing endophthalmitis have been published recently [
11,
13,
14]. In this patient, the organism was sensitive to piperacillin-tazobactam, cefotaxime, doxycycline, clarithromycin, cefixime, and gentamycin. Piperacillin-tazobactam is a combination of beta-lactam antibiotic with beta-lactamase inhibitor in a ratio of 8:1 (piperacillin/tazobactam) and has broad antibacterial activity against gram-positive and gram-negative pathogens [
9,
15]. Endogenous endophthalmitis is associated with poor anatomical and visual outcomes. In a study of 26 neonates [
6] with endogenous endophthalmitis, 22 out of 26 cases (84.61%) became phthisical. Khera et al. [
13] reported a single case of endogenous endophthalmitis, caused by vancomycin-resistant gram-positive cocci, in an adolescent resulting in enucleation. In our case, the child had a better outcome with complete resolution of endophthalmitis in both eyes and achieved fixing and following in the right eye. Maternal infections, sepsis during childbirth, low birth weight, etc. are the reported predisposing factors for neonatal endogenous endophthalmitis. In the present case, detailed history (both mother and child) did not reveal the predisposing factor. The fact that the child was born by a vaginal delivery in the rural India may raise the possibility of infection in perinatal or postnatal period.
In this case, no immunological workup to rule out impaired immunity was done. However, the child responded to the antibiotics well without any further recurrence or disease. Another limitation was that antibiotic resistance was assayed by disk diffusion only and not by minimum inhibitory concentration (MIC) because this assay was not available. Additionally, cultures were positive only from blood and not intraocular fluid; however, the subsequent response to treatment supports our clinical impression that the child’s bacteremia was the cause of endophthalmitis, implicating multidrug-resistant S. epidermidis as the target pathogen. To the best of our knowledge, this is the first reported case of vancomycin-resistant bilateral endogenous endophthalmitis in a neonate with good outcomes. This report emphasizes the need of early management including intravitreal antibiotics guided by culture sensitivities which can result in a favorable outcome.