To report the clinical and microbiological characteristics of 5 cases of postsurgical endophthalmitis caused by Ralstonia mannitolilytica and to review the relevant literature.
Methods:
Medical records of patients diagnosed with endophthalmitis due to Ralstonia mannitolilytica were retrospectively reviewed. The organism was identified using an automated VITEK system, while antibiotic susceptibility testing was conducted using standard microbiologic protocols. Primary outcome measures included infection control, visual improvement at 4 to 6 weeks of follow-up, and the antibiotic sensitivity profile of Ralstonia.
Results:
Infection control was achieved in all cases. Visual outcomes were excellent in 3 out of 5 cases. All isolates demonstrated in vitro susceptibility to ciprofloxacin but differential sensitivity to ceftazidime.
Conclusions:
To our knowledge, this is the first reported case series of culture-proven R. mannitolilytica endophthalmitis. This series highlights the importance of accurate identification and antibiotic susceptibility-tailored management in infections caused by rare organisms such as Ralstonia.
LeopoldI.Incidence of endophthalmitis after cataract surgery. Trans Ophthalmol Soc UK. 1971;191:575-609.
2.
WykoffCCParrottMBFlynn HWJrShiWMillerDAlfonsoEC.Nosocomial acute-onset postoperative endophthalmitis at a university teaching hospital (2002–2009). Am J Ophthalmol. 2010;150(3):392-398.
3.
GentileRCShuklaSShahM, et al. Microbiological spectrum and antibiotic sensitivity in endophthalmitis: a 25-year review. Ophthalmology. 2014;121(8):1634-1642.
4.
OrmeJRivera-BonillaTLoliABlattmanNN.Native valve endocarditis due to Ralstonia pickettii: a case report and literature review. Case Rep Infect Dis. 2015;2015:324675. doi:10.1155/2015/324675
AldhafeeriWFHabalrihFAl OmarAH, et al. Postoperative cerebrospinal fluid infection by Ralstonia mannitolilytica: two case reports and a literature review. Surg Neurol Int. 2022;13:602. doi:10.25259/SNI_952_2022
7.
ComanIBilodeauLLavoieA, et al. Ralstonia mannitolilytica in cystic fibrosis: a new predictor of worse outcomes. Respir Med Case Rep. 2016;20:48-50.
8.
PapagrigorakisEVavourakisMVlachosC, et al. Osteomyelitis caused by Ralstonia mannitolilytica, a rare opportunistic pathogen. Cureus. 2022;14(4):e24151. doi:10.7759/cureus.24151
9.
LimCTSLeeSE.A rare case of Ralstonia mannitolilytica infection in an end-stage renal disease patient on maintenance dialysis during municipal water contamination. Pak J Med Sci. 2017;33:1047-1049.
10.
BlockCErgaz-ShaltielZValinskyL, et al. Déjà vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011. Euro Surveill. 2013;18:20471.
11.
MukhopadhyayCBhargavaAAyyagariA.Ralstonia mannitolilytica infection in renal transplant recipient: first report. Indian J Med Microbiol. 2003;21:284-286. doi:10.1016/S0255-0857(21)03017-6
12.
BoattiniMBiancoGBianconeLCavalloRCostaC.Ralstonia mannitolilytica bacteraemia: a case report and literature review. Infez Med. 2018;26(4):374-378.
13.
ShankarMRampureSSiddiniVBallalHS.Outbreak of Ralstonia mannitolilytica in hemodialysis unit: a case series. Indian J Nephrol. 2018;28(4):323-326. doi:10.4103/ijn.IJN_77_17
14.
LampropoulosPGkentziDTzifasS, et al. Ralstonia mannitolilytica, an unusual pathogen in the neonatal intensive care unit: a case of neonatal sepsis and literature review. Infect Disord Drug Targets. 2021;21:168-172. doi:10.2174/1871526520666200330163504
15.
SiddiquiTPatelSSSinhaRGhoshalUSahuC.Ralstonia mannitolilytica: an emerging multidrug-resistant opportunistic pathogen in a tertiary care hospital setting. Access Microbiol. 2022;4(5):acmi000367. doi:10.1099/acmi.0.000367
16.
LebeauxDGhigoJMBeloinC.Biofilm-related infections: bridging the gap between clinical management and fundamental aspects of recalcitrance toward antibiotics. Microbiol Mol Biol Rev. 2014;78:510-543. doi:10.1128/MMBR.00013-14
17.
ChoudhuryHJindalAPathengayAFlynnHWJr.An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection. Clin Ophthalmol. 2015;9:1117-1120. doi:10.2147/OPTH.S81218
18.
ChenYYHuangWTChenCP, et al. An outbreak of Ralstonia pickettii bloodstream infection associated with an intrinsically contaminated normal saline solution. Infect Control Hosp Epidemiol. 2017;38:444-448. doi:10.1017/ice.2016.327
19.
VincentiSQuarantaGDe MeoC, et al. Non-fermentative gram-negative bacteria in hospital tap water and water used for haemodialysis and bronchoscope flushing: prevalence and distribution of antibiotic-resistant strains. Sci Total Environ. 2014;499:47-54. doi:10.1016/j.scitotenv.2014.08.041
20.
AlshuhriSAlosaimiAAlnafeeK, et al. Ralstonia mannitolilytica infection in a tertiary care center: an outbreak report. Am J Infect Control. 2025;53(3):302-307. doi:10.1016/j.ajic.2024.09.019
21.
LucarelliCDi DomenicoEGTomaL, et al. Ralstonia mannitolilytica infections in an oncologic day ward: description of a cluster among high-risk patients. Antimicrob Resist Infect Control. 2017;6:20. doi:10.1186/s13756-017-0178-z
22.
JoyanesPdel Carmen ConejoMMartínez-MartínezLPereaEJ.Evaluation of the VITEK 2 system for the identification and susceptibility testing of three species of nonfermenting gram-negative rods frequently isolated from clinical samples. J Clin Microbiol. 2001;39(9):3247-3253. doi:10.1128/JCM.39.9.3247-3253.2001
23.
LingTKTamPCLiuZKChengAF.Evaluation of VITEK 2 rapid identification and susceptibility testing system against gram-negative clinical isolates. J Clin Microbiol. 2001;39:2964-2966. doi:10.1128/JCM.39.8.2964-2966.2001
24.
HuangTXuZXuA, et al. In-depth comparative pathogenome, virulome, and resistome analysis of an extensive drug-resistant Ralstonia mannitolilytica strain isolated from blood. Microb Pathog. 2024;196:106969. doi:10.1016/j.micpath.2024.106969
25.
GirlichDNaasTNordmannP.OXA-60, a chromosomal, inducible, and imipenem-hydrolyzing class D beta-lactamase from Ralstonia pickettii. Antimicrob Agents Chemother. 2004;48(11):4217-4225. doi:10.1128/AAC.48.11.4217-4225.2004
26.
BassoMVendittiCRaponiG, et al. A case of persistent bacteraemia by Ralstonia mannitolilytica and Ralstonia pickettii in an intensive care unit. Infect Drug Resist. 2019;12:2391-2395. doi:10.2147/IDR.S206492
27.
GeYChenXHuangYLyuHZhaoZZhouY.Drug resistance and protoporphyrin ferrochelatase of Ralstonia mannitolilytica. Zhejiang Da Xue Xue Bao Yi Xue Ban. 2017;46(4):413-420.
28.
NeelambaranKVelmuruganHVenkatesanSThangarajuP.Ralstonia mannitolilytica infections: a systematic review of case reports unveiling clinical patterns and therapeutic insights. Curr Drug Res Rev. 2025;17(2):293-300. doi:10.2174/0125899775287020240424071322
29.
MorletNGrahamGGGatusB, et al. Pharmacokinetics of ciprofloxacin in the human eye: a clinical study and population pharmacokinetic analysis. Antimicrob Agents Chemother. 2000;44:1674-1679. https://doi.org/10.1128/aac.44.6.1674-1679.2000
30.
LeskMRAmmannHMarcilGVinetBLamerLSebagM.The penetration of oral ciprofloxacin into the aqueous humor, vitreous, and subretinal fluid of humans. Am J Ophthalmol. 1993;115(5):623-628. doi:10.1016/s0002-9394(14)71460-6
31.
el BabaFZTrousdaleMDGaudermanWJWagnerDGLiggettPE.Intravitreal penetration of oral ciprofloxacin in humans. Ophthalmology. 1992;99(4):483-486. doi:10.1016/s0161-6420(92)31943-8
32.
AlfaroDVHudsonSJRafananMMMossSTLevySD.The effect of trauma on the ocular penetration of intravenous ciprofloxacin. Am J Ophthalmol. 1996;122(5):678-683. doi:10.1016/s0002-9394(14)70486-6
