title: Pan-antimicrobial failure of alexidine as a contact lens disinfectant when heated in Bausch & Lomb plastic containers: implications for the worldwide Fusarium keratitis epidemic of 2004 to 2006.
abstract: OBJECTIVE
  ReNu with MoistureLoc (ReNuML), containing the antimicrobial agent alexidine 0.00045%, was associated with the Fusarium keratitis epidemic of 2004 to 2006. Although a single-point source contamination was ruled out, only Fusarium organisms were reported during the outbreak. This study investigated whether the reported loss of antimicrobial effectiveness toward Fusarium of ReNuML after exposure to heat in high-density polyethylene (HDPE) plastic containers could also be demonstrated with other common fungal and bacterial agents of keratitis.
  
  
  METHODS
  A buffered solution of alexidine 0.00045% was incubated in glass and ReNu HDPE plastic containers at room temperature (RT) and 56°C for 4 weeks, serially diluted, and tested for its ability to inhibit the growth of 20 bacterial isolates, 12 non-Fusarium fungal isolates, and 7 Fusarium isolates originally involved in the keratitis epidemic.
  
  
  RESULTS
  A statistically significant loss of antimicrobial capability was seen with all fungi, all gram-positive bacteria, and all isolates of Klebsiella when alexidine 0.00045% was incubated at 56°C in ReNu HDPE containers compared with RT or glass incubation (P≤0.0001).
  
  
  CONCLUSIONS
  Heating of an alexidine solution in ReNu HDPE plastic (but not glass) containers results in the same loss of anti-Fusarium activity as reported when testing the original ReNuML solution. This loss of inhibitory activity is not specific to Fusarium and occurs with other fungi and bacteria that cause keratitis. The reasons for the lack of reports of bacterial and/or non-Fusarium fungal keratitis during the original Fusarium keratitis epidemic remain unclear at this time.
authors.affiliation: Departments of Pathology, Wright State University, Dayton, OH 45420-4006, USA.
authors.forename: B Laurel
authors.initials: BL
authors.lastname: Elder
authors.forename: John D
authors.initials: JD
authors.lastname: Bullock
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Warwar
authors.forename: Harry J
authors.initials: HJ
authors.lastname: Khamis
authors.forename: Shaden Z
authors.initials: SZ
authors.lastname: Khalaf
mesh_terms: D001645:Biguanides / Q000494:pharmacology*; D018639:Contact Lens Solutions / Q000494:pharmacology*; D003261:Contact Lenses / Q000382:microbiology*; D004203:Disinfection / Q000592:standards; D004349:Drug Packaging / Q000295:instrumentation; D004356:Drug Storage / Q000379:methods*; D015821:Eye Infections, Fungal / Q000453:epidemiology / Q000382:microbiology*; D005670:Fusarium / Q000187:drug effects*; D005898:Glass; D006358:Hot Temperature; D006801:Humans; D007634:Keratitis / Q000453:epidemiology / Q000382:microbiology*; D010969:Plastics
chemical_list: D001645:Biguanides; D018639:Contact Lens Solutions; D010969:Plastics; C001570:alexidine