834

SCIENTIFIC REPORT

Bacterial keratitis: predisposing factors, clinical and

microbiological review of 300 cases
T Bourcier, F Thomas, V Borderie, C Chaumeil, L Laroche
.............................................................................................................................

Br J Ophthalmol 2003;87:834838

Aim: To identify predisposing factors and to define clinical

and microbiological characteristics of bacterial keratitis in
current practice.
Methods: A retrospective analysis of the hospital records
of patients presenting with bacterial keratitis and treated at
the Quinze-Vingts National Center of Ophthalmology,
Paris, France, was performed during a 20 month period. A
bacterial keratitis was defined as a suppurative corneal
infiltrate and overlying epithelial defect associated with
presence of bacteria on corneal scraping and/or that was
cured with antibiotic therapy. Risk factors, clinical and
microbiological data were collected.
Results: 300 cases (291 patients) of presumed bacterial
keratitis were included. Potential predisposing factors, usually multiple, were identified in 90.6% of cases. Contact
lens wear was the main risk factor (50.3%). Trauma or a
history of keratopathy was found in 15% and 21% of
cases, respectively. An organism was identified in 201
eyes (68%). 83% of the infections involved Gram positive
bacteria, 17% involved Gram negative bacteria, and 2%
were polymicrobial. Gram negative bacteria were associated with severe anterior chamber inflammation
(p=0.004), as well as greater surface of infiltrates
(p=0.01). 99% of ulcers resolved with treatment, but only
60% of patients had visual acuity better than the level at
admission, and 5% had very poor visual outcome.
Conclusions: Contact lens wear is the most important risk
factor. Most community acquired bacterial ulcers resolve
with appropriate treatment.

acterial keratitis is a serious ocular infectious disease that

can lead to severe visual disability.1 The severity of the
corneal infection usually depends on the underlying
condition of the cornea and the pathogenicity of the infecting
bacteria. Many patients have a poor clinical outcome if
aggressive and appropriate therapy is not promptly
initiated.24
Bacterial keratitis is rare in the absence of predisposing
factors.5 6 Until recently, most cases of bacterial keratitis were
associated with ocular trauma or ocular surface diseases.
However, the widespread use of contact lenses has dramatically increased the incidence of contact lens related
keratitis.79 The spectrum of bacterial keratitis can also be
influenced by geographic and climatic factors. Many differences in keratitis profile have been noted between populations
living in rural or in city areas, in western, or in developing
countries.4 912
In recent years the literature extensively addressed this
issue but only a few publications reviewed large series of
patients with bacterial keratitis.6 13 14 Very little information is
available on the frequency of factors predisposing to bacterial
keratitis and on the demographic characteristics of those
patients. The aim of the study was to identify predisposing

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factors and to define clinical and microbiological characteristics of bacterial keratitis in our current practice. We report a
retrospective study to evaluate a large population of patients
with bacterial keratitis. The influence of demographic,
medical, and ocular factors noted at presentation were
reviewed.

PATIENTS AND METHODS

We reviewed the charts of all patients with bacterial keratitis

who were treated in our hospital during the period January
1998 to September 1999. A bacterial keratitis was defined as a
suppurative corneal infiltrate and overlying epithelial defect
associated with presence of bacteria on corneal scraping
and/or that was cured with antibiotics. Patients suspected of
having or with a positive culture for fungal, viral, or
acanthamoeba infection were excluded.
The following data were collected from each chart: patient
age and sex, and duration of the symptoms at the time of the
presentation. History and examination were focused on the
following risk factors: corneal trauma, contact lens wear, ocular surface diseases (that is, previous herpetic infection,
bullous keratopathy, dry eye syndrome, blepharitis, or other
eyelid abnormalities), corneal surgery (refractive surgery,
penetrating keratoplasty). There were eight cases in which
contact lens wear was associated to ocular surface disease.
Those cases were classified as ocular surface diseases. The size
of the infiltrate was measured in square millimetres and its
location was determined according to five zones: central, nasal
superior, nasal inferior, temporal superior, and temporal inferior. The ulceration depth was evaluated as <%, %&, and >&
of the total corneal thickness. Anterior chamber inflammation, when present, was scored from 1 to 4 + for Tyndall effect
and cells. We recorded the antibiotics and other treatments
that were administered before examination.
All suspected infectious corneal infiltrates and ulcers were
scraped for microbial culture and sensitivity studies before
treatment was initiated or changed. A corneal smear was
taken after topical anaesthesia. Two slides were done for the
direct microscopic examination with spatula. The stainings
that we used were May Grnwald Giemsa (MGG) on one
slide, Gram, periodic acid Schiff (PAS) or acridine orange for
the second slide (depending on the MGG results or if
acanthamoeba infection was suspected). The results of the
stainings were transmitted to the clinician if they provided an
aetiological diagnosis or if specific appropriate therapy had to
be initiated before the culture results were available. Inoculation of agar culture plates (chocolate polyvitex agar, Schaedler
broth with globular extract, Portagerm-Amies agar swab
(Biomrieux, France) and Sabouraud-chloramphenicolgentamicin medium) was performed with cotton swab applicators. The chocolate polyvitex agar was incubated in an
atmosphere containing 3% carbon dioxide, and all media were
incubated at 37C, excepted Sabouraud medium, which was
incubated the first night at 37C and then at 30C. The media
were examined every day, during 1 week for the chocolate

Bacterial keratitis

polyvitex agar, 2 weeks for Sabouraud-chloramphenicolgentamicin agar, and 1 month for the Schaedler broth. The
bacteria were identified using standard methods: Gram staining, BBL crystal (Becton Dickinson), and/or Api (Biomerieux)
strips, biochemical tests. A single colony of a virulent
organism or at least three colonies of an organism that usually
is not considered to be highly pathogenic on the ocular surface
(such as coagulase negative staphylococcus) were considered
to be positive cultures. The resistance to antibiotics was evaluated with the standard disc diffusion method and interpreted
according to the guidelines established by the National Committee on Clinical Laboratory Standards (Villanova, PA, USA).
Contact lenses and storage cases were also analysed.
The decision to admit patients and the use of fortified antibiotics were influenced by the severity of the keratitis, based
on an overall clinical impression and the ability of the patient
to instill antibiotic eye drops. The standard fortified antibiotherapy consisted of topical ticarcillin (6 mg/ml), gentamicin
(20 mg/ml), and vancomycin (50 mg/ml), whereas commercially available antibiotics used were topical fluoroquinolone
(ofloxacin or ciprofloxacin) either alone or in combination
with aminoglycosides. Eye drops were administered alternatively every 15 minutes during the first 2 hours, then every
hour for the following 48 hours. The treatment was
progressively tapered and/or modified according to the clinical
response and the bacteria susceptibility.
Outpatient charts were consulted to determine visual acuity
in the affected eye at last visit and to identify patients who
subsequently underwent penetrating keratoplasty. Patients
were considered to have a good clinical outcome when corneal healing was not associated with a visual loss (visual acuity better than the level of initial examination), poor
outcome if they had one to three lines loss of visual acuity,
very poor outcome if visual loss was superior to four lines or
if a major complication occurred, or if they underwent
penetrating keratoplasty.
Univariate analysis was used to evaluate the possible associations between bacterial types, clinical characteristics, risk
factors, and clinical outcomes. 2 Test and Wilcoxon rank sum
test were used for univariate study. The variable lists were
reduced to those with p value less than 0.1 in the regression
analysis. Multivariate study was performed with logistic
regression model in order to predict the occurrence of very
poor visual outcome. SPSS software (V11.0) for Windows was
used for statistical analysis.

RESULTS

Clinical characteristics
A total of 291 patients (300 eyes) were seen with a corneal
infiltrate that was compatible with a diagnosis of bacterial
keratitis during the study period of 20 months; 228 eyes (76%)
were examined for the first time in the emergency department
of our hospital whereas 72 (24%) were referred by general
practitioners or ophthalmologists, most of whom practise in
Paris area, and were already being treated with topical antibiotics: fluoroquinolones (27 cases), aminoglycosides (18 cases),
rifamycin (11 cases). Nine patients were treated with corticosteroid eye drops. Self medication with topical anaesthetics
were noted in three cases.
The age of the patients ranged from 6 months to 94 years
(mean age 39 years). Sex distribution was close to 1:1 (152
men and 139 women). Most of patients were living in urban
areas. No significant difference in risk factors was noted
between patients living in rural or urban areas.
Predisposing factors of bacterial keratitis are summarised in
Table 1.
Contact lens (CL) wear was the most common risk factor.
This was encountered in 151 eyes (50.3%). Soft CL were noted
in 89.4% of cases, rigid gas permeable CL in 8.6%, and hard
PMMA CL in 2% of cases. Mean age of the patients with CL

835

Table 1 Frequency of predisposing ocular conditions

in bacterial keratitis
Factor

Number of cases
(n=300)

Percentage

Contact lens wear

Ocular surface disease
Corneal trauma
Corneal surgery
None

151
64
45
12
28

50.3
21.3
15
4
9.4

related microbial keratitis was 32 years and the mean delay

between the onset of the symptoms and the first examination
was 48 hours in this group.
Ocular surface diseases were present in 21% of cases and
acute corneal trauma (abrasion, laceration, penetration) in
15% of cases. Among keratopathies, herpes was present in 12
cases, bullous keratopathy in 10 cases, and exposure
keratopathy in six cases. Mean age of the patients with ocular
surface diseases was 56 years. In this group, the delay between
the onset of the symptoms and the first examination was 7
days. No risk factors were identified in 9.4% of cases. Systemic
risk factors were diabetes mellitus (seven cases), immunosuppressive treatment (six cases), psychiatric disorders (two
cases), and allergy (two cases). There was no significant
correlation between systemic risk factors and severity of clinical presentation.
Keratitis involved the right eye in 45.7% (137) of cases, and
the left eye in 54.3% (163) of cases. Infection was bilateral in
nine patients (3%).
Visual acuity on presentation ranged from 20/20 to no light
perception. Mean visual acuity was 0.51 (SD 0.4).
The location of the infiltrates was distributed as shown in
Figure 1. There was a predominance of inferior localisations
(46%). Corneal infiltrates were unique in 251 eyes (82%) and
multiple in 49 (18%).
The infiltrate surface was less than 5 mm2 in 123 eyes
(41%), 515 mm2 in 115 (38.3%), and greater than 15 mm2 in
62 (20.7%).
The infiltrate depth was less than one third in 232 eyes
(77.2%), between one third and two thirds in 39 (13.1%), and
over two thirds in 29 (9.7%).
Anterior chamber inflammation was absent in 75.6% of
cases. A 1+ to 2+ Tyndall effect was present in 16.6% of cases,
whereas severe anterior chamber inflammation (3+ to 4+)
and hypopyon were present in 1.7 and 6.1% of cases,
respectively. Corneal neovascularisation was observed in 35
eyes (11.7%).
Two patients had corneal perforation.
Microbiological characteristics
In 207 eyes (68.2%), bacteria were identified from the corneal
cultures. In patients in whom antibiotic therapy had been initiated before examination (73 eyes), our hospital culture grew

Figure 1 Location of the principal corneal infiltrate. Inferior, nasal,

and temporal locations were the most frequently observed; 4% of the
infiltrates were diffuse.

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836

Bourcier, Thomas, Borderie, et al

Table 2

Organisms isolated in bacterial corneal ulcers. Polybacterial infection was noted in 6 cases
Contact lens
wearer

Bacteria
Gram positive cocci
Staphylococcus aureus
Coagulase negative staphylococcus
Streptococcus pneumoniae
Other streptococcus spp
Subtotal
Gram negative cocci
Moraxella spp
Gram positive bacilli
Corynebacterium spp
Propionibacterium acnes
Actinomyces
Subtotal
Gram negative bacilli
Pseudomonas aeruginosa
Proteus spp
Klebsiella spp
Serratia spp
Subtotal
Positive corneal scraping

2
47
1
0
50 (52.6%)
0 (0%)
1
14
1
16 (16.8%)
18
0
0
11
29 (30.5%)
150

Ocular surface
disease

Traumas

6
21
1
6
34 (73.9%)

4
16
4
3
27 (84.3%)

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22
18
11
3
8
7
5
3
2
11
3
11
104

Total

3
11
1
1
16 (64%)

16
100
7
12
135 (65.2%)

0 (0%)

0 (0%)

0 (0%)

2
6
0
8 (17.4%)

1
4
0
5 (15.6%)

0
1
0
1 (11.1%)

1
6
0
7 (28%)

2
1
0
0
3 (6.5%)
62

Treatment and clinical outcome

Outpatient treatment had been initiated in 227 of the 300
cases (75.7%). Initial therapy consisted of antibiotics without

Gram negative bacteria

Pseudomonas aeruginosa
Serratia marcescens
Serratia liquefasciens
Klebsiella pneumoniae
Klebsiella oxytoca
Stenotrophomonas maltophilia
Alcaligenes xylosidans
Enterobacter cloacae
Shewanella putrefasciens
Others
Gram positive bacteria
Staphylococcus epidermidis
Negative
Total

1
5
0
2
8 (88.9%)

No risk factor

1 (0.3%)

an identifiable organism in 58% of cases. The bacterial

spectrum is shown in Table 2. Gram positive bacteria were
predominant (83% of all positive cultures), mainly coagulase
negative Staphylococcus species; Gram negative bacteria (17%)
were mostly Pseudomonas and Serratia species. Polybacterial
infection was noted in six cases (2%). Twenty eight per cent of
culture positive isolates were detected on smears.
In CL wearers group, 63.3% of the corneal scrapings were
positive. Thirty per cent of isolated bacteria were Gram negative, mostly Pseudomonas aeruginosa. Contact lens and/or
storage cases cultures were performed in 67 cases (Table 3). An
organism was identified in 83.6% (56) of cases. Ninety seven
per cent of the organisms were Gram negative bacteria. The
bacteria isolated were similar to the organism recovered by
corneal scraping in 14 cases.
The percentage of Gram positive bacteria was 91% in the
ocular surface disease group and 100% in the corneal trauma
group.
Gram negative bacteria were associated with severe anterior
chamber inflammation (p=0.004), as well as greater surface
of infiltrates (p=0.01). No other correlations were found
between the type of bacteria and other clinical characteristics
recorded at the time of presentation.

Table 3 Contact lenses

bacteriological study

Surgery

0
0
0
0
0 (0%)
47

0
0
0
0
0 (0%)
10

1
1
0
0
2 (8%)
37

1 (0.3%)
5
31
1
37 (17.9%)
21
2
0
11
34 (16.4%)
306

corticosteroids in all the cases. It was based on patient history,

clinical features, bacteria identification. Fortified antibiotics
(combination of ticarcillin, gentamicin, and vancomycin) were
used in 213 cases (71%) whereas commercially available antibiotics (fluoroquinolone monotherapy or combination with
tobramycin and/or rifamycin) were administered in 29% of
cases. The mean duration of hospital stay was 9 days (range
360 days). Complications of bacterial keratitis were noted in
18 eyes (6%). Among them, there were nine endothelitis, two
endophthalmitis, five posterior synechias, one hyphaema, one
severe ocular hypertony. Complications were mostly associated with previous history of keratopathy (eight eyes),
corticosteroid initial treatment (five eyes), self medication
with anaesthetics (three cases). Two eyes went on to penetrating keratoplasty and two eyes were enucleated.
Mean follow up was 2.5 months but 17% of the patients
were followed no more than a week. Sixty per cent of patients
had good visual outcome with visual acuity better than the
level at admission. Among the others the final clinical
outcome was poor in 35% and very poor in 5% as shown in
Table 4.
Statistical analysis revealed that very poor visual outcome
was significantly correlated with history of ocular surface disease (p<0.0001), history of systemic disease (p<0.001),
diffuse, central, or inferior localisations of the infiltrate
(p<0.001), severe anterior chamber inflammation (p<0.001),
and depth of the infiltrate (p<0.001). There was no
correlation between visual outcome and contact lens wear,
history of corneal trauma or surgery, number of localisations,
and type of bacteria.
The selection procedure of the logistic model retained
several variables (surface, stromal depth, presence of corneal
new vessels, presence of anterior chamber inflammation)
associated with unfavourable outcome. Among them, surface
of the infiltrate (p=0.0001) and depth of extension (p=0.003)
were the two most important factor to predict very poor
visual outcome.

DISCUSSION

The current study applied to the general population with bacterial keratitis that presents with a relative broad spectrum of
severity as seen in a large ophthalmic centre, including
primary, secondary, and tertiary patient care. However, caution
is necessary in the interpretation of this study. We did not see
those cases of bacterial keratitis that respond promptly to

837

CL = contact lenses wear, AC = anterior chamber, PBK = pseudophakic bullous keratopathy, BCVA = best corrected visual acuity, CF = counting fingers.

Central corneal scarring, BCVA 20/200

Permanent tarsorrhaphy
Corneal scarring, BCVA 20/200
Permanent tarsorrhaphy
Evisceration
Cyanoacrylate glue
PK
Conjunctival flap
Evisceration
Corneal scarring, BCVA 20/200
Corneal scarring, BCVA CF
Permanent tarsorrhaphy
Permanent tarsorrhaphy
Conjunctival flap
PK
10
12
11
8
20
13
11
4
7
15
14
3
10
60
19

Pseudomonas aeruginosa
Pseudomonas aeruginosa
Pseudomonas aeruginosa
Streptococcus spp
Streptococcus sanguis
Streptococcus pneumoniae
Streptococcus vestibularis
None
Staphylococcus aureus
Staphylococcus aureus
None
None
Staphylococcus epidermidis
Staphylococcus epidermidis
None
27
89
25
35
71
7
36
50
86
83
50
27
45
49
69
F
F
M
M
M
F
M
M
M
F
F
F
F
M
M

CL
Exposure keratopathy
CL
Exposure keratopathy
Removal of corneal suture
Corneal trauma
PBK
Chronic ulcer of unknown aetiology
PBK
Removal of corneal suture
Blepharoplasty
Exposure keratopathy
Exposure keratopathy
Chronic ulcer of unknown aetiology
Chronic ulcer of unknown aetiology

Oxybuprocane, fusidic acid

None
None
Tobramycin
None
None
Rifamycin, chloramphenicol
Dexamethasone, neomycin
None
None
Oxybuprocane, norfloxacine
Norfloxacine, rifamycin
None
Tobramycin
None

64
16
16
9
100
16
4
6
9
6
9
4
3
24
9

>2/3
>2/3
>2/3
>2/3
>2/3
perforation
1/3
perforation
>2/3
>2/3
>2/3
1/32/3
1/32/3
>2/3
>2/3

Hypopyon 1 mm
Hypopyon 1 mm
+
+
Phtysis bulbi
+++
+
+++
Phtysis bulbi
Hypopyon 3 mm
++
+
+
++
+

Duration of
hospitalisation
Bacteria identified
AC inflammation
(Tyndall effect)
Depth of
stromal
extension
Surface of
infiltrate
(mm2)
Previous topical treatment
Local risk factor
Age
Sex

Table 4

Demographic, risk factors, clinical, and microbiological characteristics of 15 cases of bacterial keratitis with very poor outcome

Outcome

Bacterial keratitis

treatment and therefore have no need for referral. We should

also acknowledge that the epidemiology of bacterial keratitis
reported in this study is specific to the city and the area of
Paris, France.
The age profile in our patients is comparable with previous
reports.6 14 15 Bimodality in the patients age distribution can be
attributed to CL related keratitis, corneal traumas in the
younger group, and predisposing ocular surface diseases, eyelid diseases in the older group. Bacterial keratitis is rare in the
absence of a predisposing factor.
Our series showed that more than 50% of the bacterial
keratitis were CL related keratitis. Nevertheless, some cases
might include sterile infiltrates such as contact lens related
inflammatory infiltrate that improves with discontinuation of
contact lens wear. This proportion of CL related infections is
more important than the percentages observed in other large
series in which about 2030% of infectious keratitis were
associated with contact lens use.13 14
There has been in the past several years a steady increase in
CL wearers.8 Subsequently, CL wear is now the major
predisposing factor for corneal infection in the United States
and Western Europe9 16 17 and a matter of public health
concern. Soft CL have greatly increased the risk of bacterial
keratitis, which is estimated to be 1020 times higher with the
use of extended wear disposable CL.8 Many physiopathological
effects of CL wear have been reported, the most important of
which is an induced hypoxia and hypercapnia of the cornea.18
History of ocular surface diseases represents the second
most common cause of bacterial keratitis, accounting for 21%
of cases. The association of bacterial keratitis with compromised corneas is common, but it also introduces the possibility
of eye drop contamination during long term use and microbial
resistance resulting from antibiotic use.19 Moreover, we
observed that these patients suffering chronic symptoms had
delayed referral. This situation is very often associated with
very poor visual outcome. This issue was raised previously by
Musch et al,6 who demonstrated that infectious ulcer patients
with a history of previous ocular surgery, and pre-existing
ocular pathology may be in a higher risk group for poor visual
outcome.
Acute corneal trauma was present in 15% of cases. Ocular
trauma was the most prevalent predisposing factor in young
patients in the 1980s.6 However, recent studies showed a
decrease of corneal ulcers following traumas,13 14 which is a far
more common predisposing factor in rural areas or low
income countries4 were it accounts for up to 77.5% of cases.
Our culture positive rate was 68% and is comparable with
previous reports. However, we should point out that this rate
might have been decreased by the application of topical
anaesthetic before corneal scraping. The spectrum of microorganisms that produce bacterial keratitis is usually most
influenced by contact lens wear or pre-existing disease or
injury of the cornea. The most common organisms cultured
from bacterial ulcers were Staphylococcus, Streptococcus, Pseudomonas, and Serratia species. Coagulase negative staphylococcus was the most common organism isolated on corneal
scrapings (21.8%). Currently, indigenous bacteria such as
coagulase negative staphylococcus are increasingly being isolated in bacterial keratitis and have become the bacterial
pathogen most responsible for infectious keratitis in our hospital. The same finding has been recently observed by Vajpayee
in India,4 in Europe,9 and in the United States.2 3 2022
Multiple organisms have been reported from the microbial
keratitis seen in association with CL wear. We found a moderate shift towards higher prevalence of Gram negative rods
compared with that prevalence in the absence of CL wear and
we confirmed the results of previous studies.7 23 These results
confirm that Gram negative bacteria are more often associated
with soft CL wear.8 However, conversely to what might be
expected, the percentage of Gram negative organisms is lower
than those of Gram positive organisms. Approximately two

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838

thirds of CL related bacterial keratitis are associated with

Gram positive cocci, such as staphylococci and streptococci
and one third is associated with Gram negative rods, especially
Pseudomonas aeruginosa, Serratia marcescens, and Serratia liquefaciens.
CL and/or storage cases cultures were positive in 83.6% of
cases while corneal scraping was positive in 64.7% of CL wearers. However, the interpretation of these CL and case cultures
is difficult since a recent survey showed that 81% of CL cases
were contaminated77% with bacteria, 24% with fungi, and
20% with protozoa.24 Furthermore, the bacteria isolated were
similar to the organism recovered by corneal scraping in only
14 cases (25%). Cultures obtained from the contact lenses and
the cases (rather than corneal scraping themselves) overwhelmingly yield Gram negative organisms, whereas corneal
cultures do in fact produce a high proportion of Gram positive
organisms. This result suggests that contact lenses and cases
may tend to preferentially harbour Gram negative organisms,
but that the causative organism may well not match that
organism, and indeed Gram positive organisms are important
in contact lens related keratitis.
Interestingly, we found that anterior chamber reaction
associated Gram negative rods were more important compared to inflammation associated with Gram positive bacteria.
This can be due to the higher pathogenicity of the Gram negative compared to Gram positive bacteria.
Not surprisingly, the severity of the presenting signs
(surface and depth of the infiltrate, presence of corneal new
vessels, presence of anterior chamber inflammation) were significantly related to bacterial keratitis outcome as already
shown.3 11 25 On the other hand, the systemic risk factors (that
is, diabetes mellitus, rheumatoid arthritis, immunodeficiency
states) and history of ocular surface disease, which were
reported as potential risk factors by some authors,6 26 were also
found to be prognostic factors in our study. Conversely, CL
wear was not associated with very poor clinical outcome.
More than three quarters of cases were treated initially on
an outpatient basis. Because our hospital is an academic centre, all the patients have been managed traditionally using
universal standards: pretreatment cultures and broad spectrum fortified antibiotics. Thus most patients (71%) have
received combination therapy with fortified antibiotics,
whereas broad spectrum antibiotic therapy with the fluoroquinolones was prescribed in the remaining cases. However,
the proportion of severe ulcers, associated with complications
and/or with very poor visual outcome, is relatively low (5%)
and similar to other large series in which monotherapy with a
fluoroquinolone antibiotic was compared to fortified
antibiotics.5 11 22 27 These data should probably lead us to widen
the use of fluoroquinolones5 11 22 27 even if the present study
suggests that Gram positive organisms predominate in the
setting of CL related keratitis. However, we believe that the
emerging resistance of Gram positive organisms to second
generation fluoroquinolones12 19 indicates the necessity to perform pretreatment cultures of corneal ulcers in all patients or
to use third or fourth generation quinolones characterised by
a superior Gram positive profile.
We reported the first substantive series of French patients
with bacterial corneal ulcers. Although not a completely true
representation of the population, our study does provide an
insight into the spectrum of bacterial keratitis. Our results
emphasise the importance of staphylococci as the major cause
of corneal infection, and the need to increase public education
about proper contact lens use.

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Bourcier, Thomas, Borderie, et al

.....................

Authors affiliations

T Bourcier, F Thomas, V Borderie, C Chaumeil, L Laroche,

Quinze-Vingts National Center of Ophthalmology, Paris, France
Correspondence to: Tristan Bourcier, MD, PhD, Service du Professeur
Laroche, CHNO des Quinze-Vingts, 28 rue de Charenton 75012 Paris,
France; bourcier@quinze-vingts.fr
Accepted for publication 10 January 2003

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