Which patients with gram-negative (GN) bacteremia should be screened for endophthalmitis?

Screening for Endophthalmitis in Gram-Negative Bacteremia

Patients with Candida species bacteremia should undergo dilated retinal examination within the first week of therapy, but routine screening for endophthalmitis in gram-negative bacteremia is not recommended by current guidelines. 1, 2, 3

Guideline-Based Recommendations

Candida Bacteremia (Fungal, Not Gram-Negative)

• All patients with candidemia require dilated ophthalmological examination within the first week of therapy to detect endophthalmitis, particularly in non-neutropenic patients 1
• For neutropenic patients, optimal timing is the first week after recovery from neutropenia 1
• This recommendation is especially important for patients with visual complaints, altered mental status, or those receiving antifungals with limited intraocular penetration (such as echinocandins) 1

Gram-Negative Bacteremia

• Current guidelines do not recommend routine ophthalmologic screening for gram-negative bacteremia 1
• One investigation found that cardiovascular implantable electronic device (CIED) infection is unlikely in patients with gram-negative bacteremia, suggesting lower risk of hematogenous seeding complications 1

Clinical Context from Research Evidence

When to Consider Screening Despite Lack of Guidelines

While guidelines don't mandate screening, research reveals important patterns that should inform clinical judgment:

High-risk gram-negative organisms associated with endogenous endophthalmitis include: 4, 5

• Klebsiella pneumoniae (66.1% of gram-negative endogenous endophthalmitis cases) 4
• Pseudomonas aeruginosa (14.4% of cases) 4
• Escherichia coli (7.8% of cases) 4

Risk factors that should lower threshold for screening: 4, 5

• Diabetes mellitus (present in 55% of gram-negative endogenous endophthalmitis) 4
• Liver abscess as infection source (54.5% of cases) 4
• Asian ethnicity (81.7% of reported cases) 4
• Visual symptoms (decreased vision, eye pain, photophobia) 6

Clinical presentation warranting immediate ophthalmologic evaluation: 4, 5

• Vitreal opacity (49.6% of cases) 4
• Hypopyon (35.2% of cases) 4
• Any visual complaints in the setting of gram-negative bacteremia 6

Practical Algorithm

For patients with gram-negative bacteremia:

1. Immediate ophthalmologic consultation if:

   • Any visual symptoms present 6
   • Klebsiella pneumoniae bacteremia with liver abscess 4
   • Diabetes plus K. pneumoniae, Pseudomonas, or E. coli bacteremia 4

2. Consider screening (not guideline-mandated) for:

   • Persistent bacteremia >72 hours despite appropriate antibiotics 5
   • Asian patients with diabetes and gram-negative bacteremia 4
   • Immunocompromised hosts with gram-negative bacteremia 5

3. Routine screening not indicated for:

   • Uncomplicated gram-negative bacteremia without risk factors 1
   • Rapidly clearing bacteremia in immunocompetent hosts 1

Critical Pitfall

Do not confuse Candida (fungal) screening recommendations with gram-negative bacterial screening. The strong guideline recommendation for dilated retinal examination applies specifically to candidemia, not gram-negative bacteremia 1, 2, 3. However, maintain high clinical suspicion for endophthalmitis in gram-negative bacteremia when risk factors or symptoms are present, as outcomes are poor (55.2% with no light perception at discharge) 4.