Clostridial Endophthalmitis after Cornea Transplantation: Identifying the Unexpected through Sentinel Event Procedures

Clostridial Endophthalmitis after Cornea Transplantation: Identifying the Unexpected through Sentinel Event Procedures Page E2 L. L. Fauerbach*, J. Janelle Close Close preview | Purchase PDF (62 K) | Related articles | Related reference work articles AbstractAbstract Abstract ISSUE: Clostridium perfringens endophthalmitis (CPE) has been associated with injury from soil-contaminated objects but not following corneal transplant. Two cases of endophthalmitis were reported 24 hours after transplantation. Commonalties were surgeon and donor. A sentinel event investigation was initiated. PROJECT: Infection Control (IC) investigation included: eye bank procedures; donor condition; recipient health status; surgical practices; and culture results of pre-transplant rim and pharmaceutical solutions. Investigation team included surgical team, microbiology, regional eye bank, infectious diseases, IC, pharmacy, and patient safety. External agencies (Eye Bank Association of America, AHCA, FDA, and CDC) were also involved. Procedures, practices, and cultures from clinical specimens and pharmaceutical products were analyzed. RESULTS: Eye bank and surgical procedures followed existing standards of care: body refrigerated within 3 hours, corneas recovered within 8 hours, normal donor tissue by slit lamp examination, tissue maintained in recommended antimicrobial solution, and implanted within 48 hours of recovery. Surgeon routinely cultured donor rims prior to transplantation. Cultures of pharmaceuticals were negative. Both pre-operative rim cultures and cultures after development of symptoms grew CP. Donor died of metastatic colon cancer. Donor blood cultures were negative. Recipients had no recognized underlying infections. LESSONS LEARNED: While not required by current guidelines, the surgeonʹs practice of culturing the rim prior to transplantation helped identify the source of infection in these cases and also identified current problems with decontamination of transplantation tissue. Routine culturing prior to transplantation might prevent future infections. Development of improved decontamination methods that include spores should be undertaken.