AUTHOR=Oliveira dos Santos Claudy , Kolwijck Eva , van Rooij Jeroen , Stoutenbeek Remco , Visser Nienke , Cheng Yanny Y. , Santana Nathalie T. Y. , Verweij Paul E. , Eggink Cathrien A. 

TITLE=Epidemiology and Clinical Management of Fusarium keratitis in the Netherlands, 2005–2016

JOURNAL=Frontiers in Cellular and Infection Microbiology

VOLUME=Volume 10 - 2020

YEAR=2020

URL=https://www.frontiersin.org/journals/cellular-and-infection-microbiology/articles/10.3389/fcimb.2020.00133

DOI=10.3389/fcimb.2020.00133

ISSN=2235-2988

ABSTRACT=Introduction. Recognizing fungal keratitis is challenging. Topical therapy may be initiated with antibacterial agents and corticosteroids, thus delaying the fungal diagnosis. We noticed an increase of fungal keratitis cases in the Netherlands, especially caused by Fusarium species, which prompted us to conduct a retrospective cohort study, aiming to describe the epidemiology, clinical management and outcome. 
Materials and methods. As fungi are commonly sent to the Dutch mycology reference laboratory for identification and in vitro susceptibility testing, the fungal culture collection was searched for Fusarium isolates from corneal scrapings, corneal swabs and from contact lens (CL) fluid. All Fusarium isolates had been identified with conventional and moleculair methods. Antifungal susceptibility testing was also performed. Four antifungal agents and an antisepticum were tested. Ophthalmologists provided demographic and clinical data of patients.
Results. Between 2005 and 2016, 89 cases of Fusarium keratitis. The number of cases showed a significant increase over time. The male to female ratio was 1:3 (p=0.014). Voriconazole was the most frequently used antifungal agent, but treatment strategies differed greatly between cases. Keratitis management was not successful in 27 (30%) patients, with 20 (22%) patients requiring corneal transplantation and seven (8%) requiring enucleation or evisceration. The mean visual acuity (VA) was moderately impaired at the time of Fusarium culture. Final average VA was within the range of normal vision. CL wear was reported in 92.9% of patients with Fusarium keratitis. The time between start of symptoms and diagnosis of fungal keratitis was significantly longer in patients with poor outcome as opposed to those with (partially) restored vision. Enucleation/evisceration occurred in patients with delayed fungal diagnosis. The most frequently isolated species was F. oxysporum (24.7%). The lowest MICs were obtained with amphotericin B followed by natamycin, voriconazole, chlorhexidine and posaconazole.
Conclusion. We found a significant increase of cases in the Netherlands. The course of infection may be severe and fungal diagnosis was often delayed. Antifungal treatment strategies varied widely and the treatment failure rate was high, requiring transplantation or even enucleation. Our study underscores the need for systematic surveillance of fungal keratitis and a consensus management protocol.