Medical History, Clinical Features, Treatment Outcome and Its Predictors Among Infectious Keratitis Patients in Jimma University Medical Center, Southwest Ethiopia: Prospective Observational Study

Figures & data

Table 1 Grade of Severity for Infectious Keratitis

Factor	Grade I	Grade II	Grade III	Grade IV
Conjunctiva congestion	One quadrant congested	Two quadrant congested	Three quadrant congested	All quadrant congested
Corneal ulcer	0.5–1 mm	>1–2 mm	> 2–5 mm	> 5 mm
Hypopyon	Up to 1 mm	>1–2 mm	>2–3 mm	> 3 mm
Visual acuity	6/6–6/18	6/24–6/60	< 6/60–3/60	<3/60
Corneal infiltrates	Only up to epithelial surface	Infiltrates may be dense but superficial and limited to ulcer base	Dense infiltrates extending to mid stroma	Dense infiltrates extending deeper than mid stroma or up to sclera
Area	2 mm^2	2–6 mm^2	6–14 mm^2	>14 mm^2
Depth	Superficial one third	Superficial two thirds	Extending to inner one third	Involving full cornea

Figure 1 Participants enrollment at Jimma University Medical Center Ophthalmology Department from April 1 to September 30, 2019.

Table 2 Sociodemographic Characteristics of Study Participants Among at JUMCOD from April to September 2019 (n=131)

Sociodemographic Characteristics		n (%)
Age (years)	39.38±18.901 (mean ±SD)
	15–24	34 (26)
	25–44	41 (31.3)
	44–60	36 (0.5)
	>60	20 (15.3)
Sex (gender)	Male	87 (66.4)
	Female	44 (33.6)
Marital status	Married	91 (69.5)
	Single	30 (22.9)
	Widowed/divorced	10 (7.6)
Address of participants	Rural	89 (67.9)
	Urban	42 (32.1)
Occupational status	Indoor	67 (51.1)
	Farm workers	64 (48.9)
Educational status	No formal education	35 (26.7)
	Read and write	17 (13)
	1–8	52 (39.7)
	9–12	17 (13)
	College and above	10 (7.6)
Distance from hospital by car (h or km)	0–0.5 h (5 km)	21 (16)
	>0.5 h (5 km)	110 (84)

Abbreviation: JUMCOD, Jimma University Medical Center Ophthalmology Department.

Table 3 Historical Characteristics of Study Participants at JUMCOD During April to September 2019

Historical Characteristics		Frequency	%
Other health-care visit before admission	Government hospital	48	36.6
	Health center	39	29.8
	Private hospital	5	3.8
	Private clinic	9	6.9
	Private pharmacy	18	13.7
Ocular trauma	Wooden stick	25	19.1
	Vegetative material	24	18.3
	Finger nail, ash powder, object or stone	21	16.0
	Others	9	6.9
Previous ocular disease	Previous surgical procedure^a	13	9.9
	Previous epithelial defect secondary to VK	19	14.5
	Glaucoma	6	4.6
	Dry eye	7	5.3
	Blepharitis and allergic conjunctivitis	5	3.8
	Others	3	2.3
Systemic condition	Steroid use	88	67.2
	Cancer	2	1.5
	HIV	2	1.5
	DM	1	0.8
	Renal failure	2	1.5
	Leprosy	1	0.8
	Adrenal insufficiency	1	0.8
Traditional medicine use	Herbal medicine	45	34.4
Topical antibiotic use	Ciprofloxacilline 0.3% eye drops	26	19.8
	Tetracycline 1% eye ointment	49	37.4
	Ciprofloxacilline and TTC	22	16.8
	Ciprofloxacilline and gentamicin	5	3.8
	Gentamicin 0.3% eye drops	7	5.3
	Chloramphenicol eye drops	8	6.1
	Others	3	2.3
Use of eye glass		12	9.2
Time of presentation to JUMC (mean ±SD)=27.5±21.9 days (4–99)

Note: ^aLens changed, for one patient, cataract surgery, for two patients, repairing of trauma for eight patients, trabeculotomy one patient, repaired keratoplasty one patient.

Abbreviations: VK, viral keratitis; DM, diabetes mellitus; TTC, tetracycline.

Table 4 Characteristics of Ulcer at Admission and Other Objectively Measured Clinical Feature During April to September 2019 (n=131)

Clinical Features (Obtained on Physical Exam)		Frequency	%
Location of epithelial defect (ulcer)	Central	57	43.5
	Paracentral	27	20.6
	Periphery	29	22.1
	Nearly total and total	18	13.7
Ulcer depth	1/3	37	28.2
	>1/3	94	71.8
Infiltrate occurred	No infiltrate	13	9.9
	Grade IV	81	61.8
	Grade III	9	6.9
	Grade II	23	17.6
	Grade I	5	3.8
Thinning or perforation of the cornea at admission	Yes	45	34.4
Is hypopyon present at admission?	Yes	40	30.5
Ulcer size along larger axis	Mean ±SD	5.2±2.7 mm
Ulcer size along minor axis	Mean ±SD	3.9±2.5 mm
Ulcer area	Mean ±SD	25.7±31.0 mm^2

Table 5 Key Laboratory and Instrumental Diagnostic Used Among Study Participants at JUMCOD During April to September 2019

Types of Laboratory and Instrumental Investigations	Result	n
Ophthalmic ultrasound and CT scan*	Normal study	5
	Abnormal (perforation, endophthalmitis, and corneal opacity)	15
KOH mount and gram stain	Gram-positive cocci and fungal hyphae	2
	Only gram-positive cocci	3
	Only fungal hyphae seen	5
	No organism seen	14
Culture	Positive culture and pure bacterial growth	3
	Mixed bacterial and fungal growth	1
	Positive culture and fungal growth	2
	Negative	20
CBC count	Increased WBC and neutrophil	5
	Normal WBC and increased leukocyte/normal	2
RF	One positive and one negative	2
PICT	Positive	2
RBS	For diabetes test one suggestive other not	2

Note: *CT scan was only done for one patient and the result was central neuronal necrosis with vitreous floating echo.

Abbreviations: CBC, complete blood count; CT, computed tomography; RF, rheumatoid factor; PICT, provided initiative counseling test; RBS, random blood sugar; KOH, potassium hydro-oxide.

Table 6 Drug Susceptibility Test for Isolated Organism Among Study Participants at JUMCOD from April to September 2019

Species	Ampicillin	Ampicillin-sulbactam	Amoxicillin-clavulanic Acid	Tetracycline	Cefepime	Ceftriaxone	Ceftazidime	Chloramphenicol	Ciprofloxacilline	Erythromycin	Gentamicin	Meropenem	Tobramycin	Imipenem	Piperacillin-tazobactum	Cotrimoxazole
Klebsiella ozone	R				S	R		S	S		S			S	S
Klebsiella oxytoca	R	S			R			R	I		R	I
2 Haemophilus influenzae species			R	R	S	I and S	S	I and R	S	S and R	S	S	S			R

Abbreviations: R, resistant; I, intermediate; S, susceptible.

Figure 2 Ocular coorbid disease that were occurred on infectious keratitis patients at JUMCOD from April to September 2019.

Abbreviations: MGD, meibomian gland disease; ARMC, age-related mature cataract; ARIC, age-related immature cataract; PSC, posterior sub-capsular cataract and uveitis cataract.

Table 7 Treatment for Infectious Keratitis Patients at JUMCOD from April to September 2019

Treatment	Frequency	%
Fortified vancomycin eye drops 50 mg/mL (5%) and fortified gentamicin eye drops: 14 mg/mL (1.4%)	110	84.0
Vancomycin fortified eye drops 50 mg/mL (5%) and fortified ceftazidime eye drops 50 mg/mL	21	16.0
Fluconazole 0.3% eye drops	23	100
Fluconazole 200 mg po	16	69.6
Acyclovir 3% eye ointment	61	100
Acyclovir 200 mg or 400 mg po	53	86.9
TTC 1% eye ointment	131	100
Ciprofloxacin eye drops 0.3%	97	74.0
Chloramphenicol 0.3% eye drops	13	9.9
Others	2	1.5
Ceftazidime and vancomycin 0.1% intravitreal injection	14	10.7
Cloxacillin, ceftriaxone, and metronidazole injection	5	3.8
Tropic amide 0.3%	123	93.9
Acetazolamide 250 mg po	47	35.9
Ibuprofen 400 mg po	45	34.4
Diclofenac injection	7	5.3
Diclofenac eye drops	4	3.1
Tramadol 50 mg po	9	6.9
Natural tear eye drops	21	16.0
Glycerol	1	0.8

Table 8 Treatment Outcome of Patients Among Study Participants from April to September 2019 at JUMCOD (n=131)

Types of Outcome	Descriptions of Treatment Outcome		n	%
Primary outcome	Ulcer completely healed within 21 days (good outcome)		48	36.6
	Ulcer not healed within 21 days (poor outcome)		83	63.4
Secondary outcomes	Visual outcome	Visual acuity improved from baseline (good outcome)	42	32.1
		Visual acuity remained on baseline	18	13.7
		Visual acuity worsened from baseline (poor outcome)	71	54.2
	Complications	Perforation	19	14.5
		Endophthalmitis	10	8
		Corneal opacity	9	7
		Uveitis	7	5
		Corneal central scar within 21 days	8	6
		Panophtalmitis	5	4
		Descemetocele	3	2
		Anterior staphyloma	3	2
		Band keratopathy	1	1
	Length of hospital stay mean ±SD		17.38±12.6 days and nine patients were readmitted

Figure 3 Surgical treatments for infectious keratitis attending JUMCOD from April to September 2019.

Figure 4 Visual outcome at different time among study participants at JUMCOD from April to September 2019.

Abbreviations: CF, count finger, HM, hand movement; LP, light perception; NLP, no light perception.

Table 9 Predictors of Poor Treatment Outcome from April to September 2019

Variables in Multi-logistic Regression		Outcomes		COR (95%CI)	p-value	AOR (95%CI)
		Good (%)	Poor (%)
Occupation	Indoor	31 (23.7)	36 (27.5)
	Farm worker	17 (13.0)	47 (35.9)	2.4 (1.1–5)	0.035*	3.6 (1.1–11.8)
Systemic condition	Yes	29 (22.1)	67 (51.1)	2.7 (1.2–6.1)	0.078	3.2 (0.9–12)
	No	19 (14.5)	16 (12.2)
Ulcer depth	≤1/3	27 (20.6)	10 (7.6)
	>1/3	21 (16.03)	73 (55.7)	9.4 (3.9–22.5)	<0.001*	7.6 (2.5–23.5)
Traditional medicine use	Yes	7 (5.3)	38 (29.0)	4.9 (2–12.3)	0.005*	6.7 (1.8–25.4)
	No	41 (31.3)	45 (34.4)
Adherence	Poor	3 (2.3)	32 (24.4)	9.4 (2.7–32.8)	0.042*	5.254 (1.066–25.9)
	Good	45 (34.4)	51 (38.9)
Comorbid occurred	Yes	10 (7.6)	40 (30.5)	3.5 (1.6–8)	0.002*	7.7 (2.2–27.3)
	No	38 (29.0)	43 (32.8)
Thinning or perforation at admission	Yes	5 (3.8)	40 (30.5)	8 (2.9–22)	0.012*	6.125 (1.5–25.1)
	No	43 (32.8)	43 (32.8)

Notes: *Significant predictor. p-value, independent predictor that has statistically significant association with poor treatment outcome was p<0.05.

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio.