الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Administration of eye medications is a fundamental aspect of caring for patients with associated eye or systemic disorders. Most ocular diseases are treated with a topical application of solutions administered as eye drops. Contaminated eye drops and other ophthalmic solutions are a potential cause of serious ocular infections. They can be associated with keratitis and corneal ulcers and carry the risk of transmitting opportunistic microorganisms, as well as pathogenic organisms, especially in cases of compromised corneal epithelium. Apart from the risk of infection bacterial contamination of eye drops may alter the pH of the solution and therefore reduce the effectiveness of the drug. Contaminated eye drops must be postulated as a serious public health problem. In human terms, the cost of an eye infection can be blindness. In financial terms, the cost of treating or litigating even a single eye infection could easily eliminate the savings achieved over several years. The current study aimed to investigate bacterial contamination of in-use ophthalmic drops in a health care setting in Alexandria, Egypt.
This cross sectional study was conducted during a 6 - month period from July to December 2015 at the Ophthalmology Department (outpatient clinics and inpatient wards) of the Alexandria Main University Hospital and the Microbiology Department at the HIPH and was approved by the Ethics Committee of the HIPH. It included two hundred and twenty five randomly selected eye DROP bottles of different multi- used ophthalmic solutionsthat were collected on either the first, second or fourth day of usage. from each examined ophthalmic bottle, three samples were taken from tip, cap and residual solution. Swabs from tips and caps together with 0.25 ml from residual solutions were streaked over the surface of blood and MacConkey‟s agar plates and were incubated aerobically at 37°C for 24 hours.Bacterial isolates were identified using standard microbiological methods. Enumeration of bacterial isolates from ophthalmic residual solution samples inoculated on blood agar plates was done using Quebec colony counter. Identified bacterial isolates were tested for their antimicrobial susceptibility patterns using disc diffusion method according to the CLSI recommendations.
The study revealed the following results:
1. Mydriatics were the most prevalent medication type representing 125/ 225 (55.6%), while the least encountered were antihistaminics 17(7.6%).
2. Most of the examined eye drops contained BAK as a preservative 89.3%.
3. Equal number of examined eye DROP bottles were collected on the first, second and fourth day of usage75 (33.33%) each.
4. Of the 225 examined ophthalmic bottles 140 (62.2%) were contaminated and 85(37.8%) were uncontaminated.
5. The most contaminated samples of the examined ophthalmic drops were those of the residual solutions (59.6%), while the least contamination rate was obtained from cap samples (13.1%). The difference between these figures was found to be statistically significant (p<0.001)
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6. Half of the 140 contaminated ophthalmic bottles were from outpatient clinics (50.0%) and the other half was from inpatient wards.
7. Of the 140 contaminated ophthalmic bottles, 70 (50%) were mydriatics, 30 (21.4%) were anti-inflammatory drops, 21 (15.0%) were anesthetics and 17 (12.1%) were antihistaminics. Only 2 antibiotic containing ophthalmic drops (1.4%) were contaminated. The difference between these figures was found to be statistically significant (p<0.001).
8. Of the 140 contaminated ophthalmic bottles, the highest contamination rate was found in bottles examined on the fourth day of usage 55 (39.3%). This was statistically significant (p=0.026)
9. The highest contamination percentage was detected among shared ophthalmic bottles (66.4%). This was statistically significant (p<0.001).
10. Ninety percent of the contaminated eye drops had BAK as a preservative.
11. Of the 168 contaminated samples, 161 (77.8%) yielded single bacterial isolates and 46 (27.3%) revealed mixed isolates.
12. The highest percentage of single isolates was recovered from the residual solutions of examined ophthalmic bottles (59.7%), while mixed bacterial isolates were recovered mostly from the tips and residual solutions of tested eye DROP bottles (43.5%) and (41.3%), respectively. This was statistically significant (P =0.013).
13. Two hundred and seven different bacterial agents were isolated from contaminated ophthalmic bottles. They were distributed as 117(56.5%) gram positive cocci and 90 (43.5%) gram negative bacilli.
14. As regards the recovered gram positive cocci, CoNS had the highest percentage of isolation 51(24.6%), while S. pyogenes was the least encountered bacterial agent 11 (5.3%). Whereas for gram negative bacilli, P. aeruginosa was the most frequently isolated bacterial agent 59(28.5%), followed by K. pneumoniae 31 (15.0%).
15. Highest percentage of gram positive cocci were isolated from tip samples (51.3%). While, the highest percentage of gram negative isolates were recovered from residual solution samples (82.2%).
16. Highest percentages of CoNS, S. aureus, and micrococci isolates were recovered from tip samples (51%, 60% and 60%, respectively). While the majority of S. pyogenes isolates were yielded from residual solution samples 81.8%.
17. The highest percentages of isolated gram negative bacilli (P. aeruginosa and K. pneumoniae) were recovered from residual solution samples (86.4% and 74.2%, respectively).
18. Of the 207 isolated bacterial agents, 114(55.1%) were from ophthalmic bottles in outpatient clinics and 93(44.9%) from inpatient ward eye drops.
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19. Highest percentages of yielded CoNS, S.aureus, and micrococci were from outpatient clinics (60.8%, 45.7%, and 65%, respectively). All eleven S. pyogenes isolates (100%) were recovered from ophthalmic bottles in outpatient clinics. This was found to be statistically significant (P =0.001).
20. About half (50.8%) of the P. aeruginosa isolates were recovered from outpatient clinics samples, while 58.1% of K. pneumoniae isolates were from inpatient ward samples.
21. Of the 112 examined mydriatics, CoNS showed the highest percentage of isolation(27.7%), whereas S. aureus was the most frequently encountered bacterial agent (28.3%) in anti-inflammatory eye drops. The two contaminated antibiotic containing ophthalmic drops revealed CoNS and S. aureus 50.0% each.
22. All isolated gram positive cocci were susceptible to oxacillin, cefoxitin, penicillin, teicoplanin and vancomycin (100.0%). While, all P. aeruginosa isolates were susceptible to levofloxacin, piperacillin- tazobactam, and imipenem (100%) each and no MBL P. aeruginosa were detected. All K. pneumoniae isolates were resistant to piperacillin, cefoperazone and cefotaxime. Nine (29%) K. pneumoniae isolates were ESBL producers.
23. The mean value of HPC of residual solution samples collected from outpatient clinics bottles was lower than those from inpatient wards (27.53 and 62.89 CFU/ mL, respectively). This was found to be statistically significant (P =0.001).
24. The highest HPC mean value of residual solution was found in antihistaminics (69.27 CFU/ mL, while mydriatics had the lowest HPC mean value (27.53 CFU/ mL). This was found to be statistically significant (P =0.001).
25. Eye drops with BAK preservative had the highest mean and median HPC values of the residual solution (47.21 and 44.0 CFU/ mL, respectively).
26. The mean value of HPC on the first day was 17.64 CFU/mL, and on the second day was 40.63 CFU/mL while it reached its highest value from ophthalmic bottles on their fourth day of usage (70.63 CFU/mL). The difference between these figures was found to be statistically significant (p< 0.001).
27. Of the 140 contaminated ophthalmic bottles, 124 (88.6%) were instilled by nurses, 100 (71.4%) didn‟t wash their hands, and 115 (82.1%) didn‟t wear their PPE. Ninety (64.3%) contaminated bottles touched the eyes with the bottle tips, 102 (72.9%) were not recapped after use, and 122 (87.1%) were handled in a non clean place.
28. Among the 51 ophthalmic bottles with CoNS contamination, 82.3% were instilled by nurses, 92.2% were handled without hand wash practice, 1.9% without alcohol hand rub, 43.1% touched the eyes with the bottle tips, 35.3% were recapped after use, and 92.2% were handled in a clean place.
29. Of the 58 P. aeruginosa contaminated eye drops 84.7% were instilled by nurses, 1.7% were without alcohol hand rub practice, 91.5% were handled without hand wash practice, 33.9% touched the eyes with the bottle tips and 32.2% were recapped after use.
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from the results of the present study, the following could be concluded:
- High contamination rate was detected among examined multi-used ophthalmic bottles in both outpatient clinics and inpatient wards.
- Mydriatics showed the highest contamination rate, while antibiotic containing eye drops had the lowest percentage of contamination.
- Among examined samples, residual solutions were the most contaminated samples, while cap samples were the least contaminated ones.
- Ophthalmic bottles contamination percentages increased significantly with the increase in the duration of usage.
- Most of the contaminated ophthalmic bottles had BAK as a preservative.
- The majority of the contaminated ophthalmic bottles were shared between patients.
- The highest percentage of contaminated samples yielded single bacterial isolates and they were mostly recovered from residual solutions.
- P. aeruginosa was the most frequently isolated bacterial agent, followed by CoNS, while S. pyogenes was the least encountered isolate.
- The highest percentages of isolated gram positive cocci were recovered from tip samples, while the highest percentages of detected gram negative bacilli were isolated from residual solutions.
- Mean and median values of HPC of residual solutions significantly increased with the increase in the duration of usage.
- Lower HPC values of the residual solutions were associated with instillation by nurses, practicing hand hygiene (hand wash and alcohol hand rub), avoiding touching the eyes with bottle tips and handling bottles in clean places.