Faculty Bibliography

Purpose: To evaluate the cornea ulcer microbiology of patients at an urban city hospital. Methods: Corneal ulcer patients examined and cultured were identified retrospectively. The media and stains submitted were assessed, and the microbiology was analyzed. Gram stains were analyzed and correlated with positive cultures. The use of topical antibiotic and/or topical steroid at time of culture was analyzed to correlate with positive results. Results: 114 corneal ulcers were treated over 10 years (1/2004 to 12/2013). 71/114 (62.3%) ulcers were cultured. 68/71 (95.8%) of the cultures submitted were corneal scrapings plated on blood, chocolate, thioglycolate, sabaround's, and slides for gram stains. 3 included KOH stains for fungus. 3/71 submissions were corneal swab with gram stain.17/68 (25%) culture submissions from scrapings were incomplete, missing one of the media plates. 9/71(12.7%) submissions did not include a gram stain. 0/3 corneal swabs yielded a positive result. 24/68 (35.3%) of corneal scraping cultures yielded a positive result, including 1 mixed bacterial and 1 fungal. The most common was pseudomonas aeruginosa 8/68 (11.8%), followed by serratia 4/68, coag negative staph 3/68, and stenotrophomonas maltophilia 2/68. There was one positive result each for Bacillus, strep pneumoniae, MRSA, and beta strep group G. One culture grew both bacillus and coag negative staph. One culture grew Aspergillus. At time of culture, 21 patients were on a topical antibiotic (including the patient whose culture grew Aspergillus), 3 were on a topical steroid, and 2 were on both. Compared to positive cultures in patients not on any medications (14/41 or 24%), positive cultures were found in 6/23 (26%) of patients on topical antibiotic with or without steroids (P=0.849), and 2/3 (66%) of patients on steroid alone (P=0.267). 12/62 (19%) gram stains were positive. 5/5 gram stains that showed an organism had corresponding growth in culture. 8/12 (66.7%) of positive gram stains eventually yielded growth of a microorganism compared to 14/50 (28%) of negative gram stains (P=0.012). 0/3 of KOH stains submitted yielded fungal elements. Conclusions: The majority of ulcers cultured yielded bacteria, with pseudomonas the most common. The use of topical antibiotic or steroid did not statistically affect culture yield. A positive gram stain does correlate with a positive culture yield. However, there is a high frequency of incomplete cultures

OBJECTIVE: To further define the spectrum of clinical disease and treatment among patients with herpes zoster ophthalmicus (HZO) and ocular herpes simplex viral (HSV) infection presenting at a large city hospital for the underserved in the United States. METHODS: Retrospective review of medical records of 64 patients (40 HZO and 24 ocular HSV infection) presenting to the Bellevue Hospital Emergency Department for the management of herpetic eye disease for which an ophthalmologic consultation was obtained from January 1, 2006, to December 31, 2011. RESULTS: The mean age of patients with HZO was 51 +/- 15 years (n=40) versus 33 +/- 16 years for patients with ocular HSV infection (n=24; P<0.0001). Overall, 73% of patients with HZO were aged <60 years (n=29 of 40), of whom, 90% (26 of 29) were immunocompetent. The most common decade of onset of HZO was 50 to 59 years (11 of 40, 28%). Four patients with HZO were immunocompromised (n=4 of 40; 10%), with 3 aged <60 years attributable to human immunodeficiency virus (n=3 of 29, 10%). The study included 12 patients eligible to receive the herpes zoster vaccine. None of these patients had a history of vaccination. Of the 24 patients with ocular HSV infection, corneal stromal disease was present in 7 patients and infectious epithelial keratitis in 10 patients. No patients were treated with long-term oral antiviral prophylaxis. CONCLUSIONS: Acute HZO was seen more commonly than ocular HSV infection. Patients with HZO were significantly older than those with ocular HSV infection. Available prevention modalities, such as the vaccine against herpes zoster and long-term oral antiviral therapy to reduce ocular HSV infection recurrence, were underused.

PURPOSE:: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. METHODS:: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. RESULTS:: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). CONCLUSIONS:: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.

PURPOSE: To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. DESIGN: Prospective interventional cohort study. METHODS: setting: Academic City Hospital, Bellevue Hospital. participants: A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. interventions: The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. main outcome measures: Barriers to administration of the vaccine were evaluated. RESULTS: A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P