Determination and Prevalence of Bacterial and Fungal Keratitis among Patients in Baghdad City

The study included 234 patients attended to Iben AL-Haithem hospital of ophthalmology in Baghdad city having microbial keratitis , at age of (18-81) years for the period from September 2017April 2018 . there were 147 ( 63% ) patients with bacterial keratitis and 87 (37%) with fungal keratitis . Men with bacterial keratitis represented 60% (88) and women 40% (59) ,while men with fungal keratitis were 61% (53) and women 39% (34), the number of the patients with bacterial keratitis were 82(56%) and 51(59%) with fungal keratitis from Baghdad while the internally displaced were 62(44%) with bacterial and 36(41%) with fungal keratitis , the percentage of patients with bacterial keratitis and fungal keratitis were both (34%) at mean age of 73 ± 2.3 y . Most patients with bacterial keratitis recorded having diabetes mellitus(39%) while the diabetic with fungal keratitis represented (41%) , The results revealed that gram positive bacteria was 102 (69%) and gram negative 45 ( 31%) , S.aureus was the most common cause of bacterial keratitis42(29%), followed by S.epidermidis 36(24%) then Streptococcus spp. 24(16%) , Pseudomonas spp. 17 (12%) , Proteus, spp. 13 (9%) , Escherichia coli 9(6%) and Enterobacter spp 6(4%) while Aspergillus fumigates represented 26(30%) as the most common cause of fungal keratitis , Aspergillus flavus 19(22%) , Aspergillus niger 16(18%) , Pencillium spp 11(13%) , Fusarium oxysporium. 8(9%) , Fusarium solani 5(6%) and Candida spp 2(2%) . S. aureus isolates were susceptible to Cloramphenicol and Ciprofloxacin (83%) while they were resistant to Clindamycin (57%) . S.epidermidis isolates were susceptible to Cloramphenicol and Amikacin (86%) ,Streptococcus spp were susceptible to Tetracycline and Clindamycin (88% ,83%) , Pseudomonas spp showed their high susceptibility to Tetracycline(96%) followed by Cloramphenicol and Ciprofloxacin (88%) both each, Enterobacter spp were susceptible to Tetracycline and Gentamicin (100%) while E.coli were susceptible to Cloramphenicol (100%) followed by Ciprofloxacin and Gentamicin (89%) both, fungal isolates were susceptible to all types of antibiotics used in the study as (98%) of Aspergillus spp isolates were sensitive to Itraconazole (98%) Voriconazole, Amphotericin B and Natamycin (95%,93% ,92%) respectively, Pencillium spp. were sensitive to Amphotericin B (100%) then Natamycin and Itraconazole (91%) both, Fusarium spp were sensitive to Natamycin and Itraconazole (100%) , Candida isolates were sensitive (100%) to Amphotericin B, Natamycin and Voriconazole.

Microbial keratitis is defined as a corneal infection which caused by a range of non-viral pathogens, including bacteria, protists and fungi 1 . It characterized by pain and corneal ulceration with tissue infiltration,the vision will be affected according to the size and location of the ulcer 2 .
The climate and socio-economic factors play an important role in the prevalence of each causative organisms, fungal infection is the main cause of corneal blindness ,associated with agricultural injury 3 . Saprophytic fungi reported as a causative agents and Candida albicans was considered pathogenic in 45.8% of keratitis 4 . Hosted bacteria might infect the cornea, while the others can be found as normal flora on the lid margin 5 .
The more virulent bacteria cause corneal destruction and it may be complete in 24-48 hours which will lead to ulceration, abscess, surrounding corneal edema and anterior segment inflammation 6 .
Ocular surface disease such as trauma, surgery, topical steroid also increased wearing of contact lens and refractive surgery are additional risk factors 7 . In Iraq, the common risky factors for microbial keratitis are corneal abrasions, and ocular surface disorders such as dry eye, trichiasis, old scars and most of them are sequels of cicatricial trachoma 8 .
The study s aimed to determine the prevalence of microbial keratitis infection causatives and determination the susceptibility of the isolates to the most common antibiotics used .

Patients and Methods
This study was conducted in Ibn Al-Haitham hospital of ophthalmology in Baghdad, A total of 234 patients attended the hospital from September 2017-Apri 2018, the patient´s agreement was taken and information documented directly including the socio-demographic characters, age, and history of any disease.
The slit Lamp method was used to record the size and depth of the ulcer and the stromal suppuration. Height of hypopyon if present was also recorded 9 .
The scraping was divided into two ports bacterial and fungal detection, blood agar (Himedia, India), chocolate agar, brain heartinfusion agar (Salucea/Germany), MacConkey agar (BDH/England), Sabaroud agar (Biolife / Italy) and Gram reaction. After incubation, positive microbial cultures were further biochemical reaction were done to identified the species as most Staphylococcus spp. and Pseudomonas spp. were identified by API system (bio Merieux) 10 .
lacto phenol-cotton blue stain was used for examination of hyphae and spore morphological identification under the microscope 11 .

Antibiotic susceptibility
Antibiotic susceptibility was monitored with the disk diffusion assay (Kirby-Bauer), the zone of inhibition was interpreted according to NCCLS guidelines 12 .

Statistical Analysis Statistical Analysis
Chi-square test for statistical analysis. A P value <0.05 was used for finding the significance difference between the groups and correlated t-test was used to find the relation between the variables within the same group by using spss program 14 .

ReSultS
Out of 234 patients having microbial keratitis , there were 147 ( 63% ) patients with bacterial keratitis and 87 (37%) with fungal keratitis as shown in figure 1. Men with bacterial keratitis represented 60% (88) and women 40% (59) ,while men with fungal keratitis were 61% (53) and women 39% (34) as shown in figure 2. The results reveled that the number of the patients with bacterial keratitis were 82(56%) and 51(59%) with fungal keratitis from Baghdad while the internally displaced were 62(44%) and 36(41%) with bacterial and fungal keratitis, there was a significant differences between the two group as shown in table 1.
The results showed that the highest percentage of patients with bacterial keratitis and fungal keratitis were both (34%) at mean age of 73 ± 2.3 y while the lowest percentage of patients with bacterial keratitis was (18%) and with fungal keratitis (15%) at mean age of 25.5± 1.4 y as showed in table 2.Most patients with bacterial keratitis recorded having diabetes mellitus(39%) and the rest of them having arthritis and hypertension (31% ,30%) while the diabetic with fungal keratitis represented (41%) followed by arthritis and hypertension (35%,24%) as showed in table 3. The results of antibiotic susceptibility showed that S. aureus isolates were susceptible to Cloramphenicol and Ciprofloxacin (83%) followed by Doxycycline (81%) and Amikacin (74%) then Gentamycin , Erythromycin and Tetracycline (69%,64% ,62%) , while they were resistant to Clindamycin (57%) .S.epidermidis isolates were susceptible to Cloramphenicol and Amikacin (86%) then Erythromycin and Doxycycline (83%) followed by Clindamycin , Khalil   Pseudomonas spp isolates showed their high susceptibility to Tetracycline(96%) followed by Cloramphenicol and Ciprofloxacin (88%) both and Amikacin ,Doxycycline and Gentamycin(82%) each of them as shown in table 7.
The results showed that Enterobacter spp isolates were susceptible to Tetracycline and Gentamicin (100%) followed by Ciprofloxacin (83%) while E.coli isolates were susceptible to Cloramphenicol (100%) followed by Ciprofloxacin and Gentamicin (89%) both and they were resistant to Amikacin and Tetracycline (56%) both as shown in table 8.
Fusarium spp isolates were sensitive to Natamycin and Itraconazole (100%) then Amphotericin B and Voriconazole (92%) both as shown in table 11 .
The results reveled that Candida isolates were sensitive mostly to all types of the antibiotics were used in the study as showed in table 12.

DiScuSSion
Our study revealed that patients with bacterial keratitis were represented (63%) from the total patients with microbial keratitis ,men represented the highest levels (60%) while fungal keratitis patients were (37%) and men represented (61%) of them The relatively highest percentage of males with microbial keratitis as a compression with females seen almost closely to some other studies 15, 16 . According to the socio-demographic characters , the number of patients with microbial keratitis from Baghdad represented (57%) while the internally displaced were (43%) and this might be related to unsuitable health conditions or inappropriate life issues .
There was high percentage of patients with microbial keratitis at mean age of 73.5±0.3 and gradually decreases and these fining are different in other study in Baghdad , as the patients group (41-59) years were the most microbial keratitis infected with a percentage of (30.20 %), while the lowest infected (e" 60) year with a percentage of (17.80 %) and another study in south India they found that the age range of 41-60 years was more affected , this may be due to choosing of the common causes of infection 17 , 18 . The patients with bacterial keratitis recorded with diabetes mellitus were (39%) and the rest were having arthritis and hypertension (31% ,30%) while the diabetic with fungal keratitis were (41%) followed by arthritis and hypertension (35%,24%) and these results disagree with other findings depending on the age and other chronic disease due to health style (food and environment) 19,20 . The results revealed that gram positive bacteria was 102 (69%) and gram negative 45 ( 31%) , S.aureus was the most common cause of bacterial keratitis42(29%), followed by S.epidermidis 36(24%) then Streptococcus spp. 24(16%) , Pseudomonas spp. 17 (12%) , Proteus, spp. 13 (9%) , Escherichia coli 9(6%) and Enterobacter spp 6(4%) while the most common causes of fungal keratitis were Aspergillus fumigates 26(30%), Aspergillus flavus 19(22%) , Aspergillus niger 16(18%) , Pencillium spp 11(13%) , Fusarium  24 . other investigation found that the prevalence of fungal keratitis in Iraq the most common fungus isolated  26 ,27 . Enterobacter spp isolates were susceptible to Tetracycline and Gentamicin (100%) while E.coli isolates were susceptible to Cloramphenicol (100%) but they were resistant to Amikacin and Tetracycline (56%) both, however, Proteus spp isolates were susceptible to Cloramphenicol and Tetracycline (92%) and theses findings were recorded in many other studies 28,29 . fungal isolates showed high susceptibility as Aspergillus spp isolates were sensitive to Itraconazole (98%) , Voriconazole then Amphotericin B and Natamycin (95%,93% ,92%) respectively , Pencillium spp. isolates were sensitive to Amphotericin B (100%) then Natamycin and Itraconazole (91%) both while Fusarium spp isolates were sensitive to Natamycin and Itraconazole (100%) then Amphotericin B and Voriconazole (92%) both and Candida isolates were sensitive to the most antibiotics that used in the study ,these results were matching to many other results in the same field 30,31 .

concluSionS
Keratitis was very clear among the patients with ocular bacterial infections. S. aureus was the highest gram positive bacterial isolates followed by S.epidermids while gram negative dominant isolates were Pseudomonas spp . Aspergillus spp recorded high prevalence followed by Pencillium spp. Gram positive and negative isolates as well fungal isolates were susceptible to the most common tested antibiotics which will support the treatment strategies and control the common practice of self medication.