Even under the most expert care, a properly constructed intestinal anastomosis can fail to heal resulting in leakage of its contents, peritonitis and sepsis. The cause of anastomotic leak remains unknown and its incidence has not changed in decades. Here, we demonstrate that the commensal bacterium Enterococcus faecalis contributes to the pathogenesis of anastomotic leak through its capacity to degrade collagen and to activate tissue matrix metalloprotease-9 (MMP9) in host intestinal tissues. We demonstrate in rats that leaking anastomotic tissues were colonized by E. faecalis strains that showed an increased collagen-degrading activity and also an increased ability to activate host MMP9, both of which contributed to anastomotic leakage. We demonstrate that the E. faecalis genes gelE and sprE were required for E. faecalis-mediated MMP9 activation. Either elimination of E. faecalis strains through direct topical antibiotics applied to rat intestinal tissues or pharmacological suppression of intestinal MMP9 activation prevented anastomotic leak in rats. In contrast, the standard recommended intravenous antibiotics used in patients undergoing colorectal surgery did not eliminate E. faecalis at anastomotic tissues nor did they prevent leak in our rat model. Finally, we show in humans undergoing colon surgery and treated with the standard recommended intravenous antibiotics, that their anastomotic tissues still contained E. faecalis and other bacterial strains with collagen-degrading/MMP9 activity. We suggest that intestinal microbes with the capacity to produce collagenases and to activate host metalloproteinase MMP9 may break down collagen in the gut tissue contributing to anastomotic leak.

We recently demonstrated that Pseudomonas aeruginosa PAO1 undergoes a pronounced phenotypic change when introduced into the intestines of rats during surgical injury. Recovered strains displayed a specific phenotype (termed the P2 phenotype) characterized by altered pyocyanin production, high collagenase activity, high swarming motility, low resistance to chloramphenicol, and increased killing of Caenorhabditis elegans compared to the inoculating strain (termed the P1 phenotype). The aims of this study were to characterize the differences between the P. aeruginosa P1 and P2 phenotypes in quorum sensing and competitiveness. We then determined the presence of the P2 phenotype among PAO1 strains from various laboratories. Results demonstrated that P2 cells display accelerated growth during early exponential phase and early activation of quorum-sensing systems and overcome the growth of P1 cells in a mixed population. Among eight PAO1 strains obtained from different laboratories, four exhibited the P2 phenotype. Of 27 mutants analyzed from the P. aeruginosa MPAO1 transposon library, 25 displayed P2 phenotypes. The P2 phenotype in both cases correlated with a lack of expression of mexE or mexF due to mutations in mexT and mexF genes. In summary, strains possessing the P2 phenotype are distributed among PAO1 strains commonly used across a variety of research laboratories. Genetically, they are characterized by various mutations in mexT or mexF. Stable genetic mutations that change phenotypes can arise as microbes adapt to their environment to maximize propagation. This ecologically dependent shift in phenotype has been documented in many bacterial species and in diverse contexts (1, 2). Recently, we demonstrated that the MPAO1 strain of Pseudomonas aeruginosa became transformed to (or selected for) a more virulent phenotype when present in the colon of rats subjected to preoperative radiation followed by colon resection and anastomosis (3). The strain recovered from the anastomotic tissue (termed MPAO1-P2, i.e., having the P2 phenotype) exhibited high collagenase activity, swarming ability, increased pyocyanin production in liquid medium, and increased tissue-destroying capacity compared to the initial strain (termed MPAO1-P1, having the P1 phenotype). Comparative genomic sequencing analysis revealed that MPAO1-P2 harbored a single-nucleotide polymorphism (SNP) in the mexT gene that results in a truncated and nonfunctional MexT protein. Transformation of mexT-P1 into MPAO1-P2 reverted the strain back to the P1 phenotype. The phenotypes of P. aeruginosa that are similar to P1 and P2 have been previously described (4-7). In the cited studies, the wild-type PAO1 strain harbored an 8-bp insertion in mexT that results in a nonfunctional MexT protein and a phenotype similar to P2. Its derivative mutant that was selected by norfloxacin (referred to as a nfxC-type mutant) had a functional MexT protein and was characterized by attenuated pyocyanin production (5), high resistance to chloramphenicol (6), and absence of swarming ...

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Endogenous endophthalmitis is a rare but feared infectious ocular complication of injection drug use (IDU). The recent opioid epidemic in the United States threatens to increase the incidence of this disease. We report the first case of endogenous endophthalmitis in the United States caused by the emerging fungal pathogen Rhodotorula in an injection drug user which led to no light perception vision (NLP). Worldwide experience with Rhodotorula endogenous endophthalmitis is limited, but existing cases suggest infection by this particular fungal genus has a grim prognosis.

most commonly selected preferred treatment, many respondents indicated that more evidence was needed to guide treatment choices. 4 The MUTT I result was driven primarily by ulcers caused by Fusarium, which had the worst response to voriconazole. 1 After the results of MUTT I and 2 subsequent trials, 2,3 only a few experts indicated that they would prefer to treat Fusarium keratitis with voriconazole. Limitations of this study include that respondents self-reported practice patterns and it was not possible to validate the survey against actual practice patterns. Respondents may have underreported voriconazole use because of social desirability bias. The decrease in preference for voriconazole over time may indicate that randomized clinical trials led to changes in practice patterns and integration of evidence-based practices into the treatment of fungal keratitis.

Given the increasing rates of postkeratoplasty fungal infections, the identification of positive fungal cultures from donor rims and storage media warrants further evaluation of adding antifungals to storage media.

Objective Uveitis is an inflammatory process of the eye that can lead to severe vision loss. Non-infectious forms of uveitis constitute the majority of cases and chronic disease is typically treated with immunosuppressive drugs. A minority of uveitis cases are of an infectious cause, and in these cases, the use of immunosuppressive agents may aggravate the underlying infection. Design: Retrospective case series. Result. Five patients who initially presented with ocular findings suspicious for non-infectious uveitis and who were treated with corticosteroids. After failing to respond to corticosteroid therapy, and with a history of injection drug use (IDU) eventually reported by all five patients, there was a high degree of clinical suspicion for an underlying infectious process. All five were later classified as having endogenous endophthalmitis related to IDU, and experienced clinical improvement after antibiotic therapy and pars plana vitrectomy. Conclusions and Importance. Given the ongoing opioid crisis, this study demonstrates the importance of considering IDU-associated endogenous endophthalmitis in any individual with intraocular inflammation and history of IDU presenting with new-onset vision loss, irrespective of time since last reported use.