What are the treatment options for dacryocystitis?

Treatment of Dacryocystitis

The treatment of dacryocystitis requires a combination of antibiotics targeting common pathogens (Staphylococcus aureus, Streptococcus species, and gram-negative bacteria) and surgical intervention to address the underlying nasolacrimal duct obstruction for definitive resolution. 1

Initial Medical Management

Antibiotic Therapy

• Empiric antibiotic selection:

  • First-line oral options for adults:
    • Amoxicillin-clavulanic acid 1
    • Levofloxacin (alternative with broader coverage) 2
  • For severe cases or surrounding cellulitis:
    • Dicloxacillin: 500 mg four times daily 3
    • Cephalexin: 500 mg four times daily 3
    • Clindamycin: 300-450 mg three times daily (for penicillin-allergic patients) 3
  • For suspected MRSA infections:
    • Trimethoprim-sulfamethoxazole
    • Clindamycin
    • Doxycycline (avoid in children under 8) 3

• Pediatric considerations:

  • Intravenous antibiotics are recommended for pediatric patients 1
  • Cephalexin: 25-50 mg/kg/day in 4 divided doses 3
  • Clindamycin: 10-20 mg/kg/day in 3 divided doses (for penicillin-allergic patients) 3

Adjunctive Measures

• Warm compresses applied to the affected area multiple times daily 3
• Gentle massage of the lacrimal sac area (when not acutely inflamed) 3

Surgical Management

Acute Dacryocystitis

• Incision and drainage of the infected lacrimal sac provides:
  • Immediate pain relief
  • Rapid control of infection
  • Optimal culture material for targeted antibiotic therapy 4
• This approach is particularly important given that 58.3% of infections may be caused by gram-negative rods, with 50% potentially resistant to most oral antibiotics 4

Definitive Treatment

• Dacryocystorhinostomy (DCR) is the definitive treatment to address the underlying nasolacrimal duct obstruction 1, 5
• DCR should be performed after the acute infection is controlled 5
• Benefits of DCR include:
  • Resolution of lacrimal fistula and nasolacrimal obstruction
  • Rapid control of dacryocystitis
  • Decreased period of infection 5

Special Considerations

MRSA Infections

• MRSA dacryocystitis is often resistant to conservative therapy
• Standard DCR with bicanalicular silicone tube insertion has shown success in treating MRSA dacryocystitis 5
• Culture results may become negative for MRSA as soon as 4 days after DCR 5

Atypical Pathogens

• Obtain cultures during surgical drainage to identify atypical pathogens (e.g., Mycobacterium abscessus) that may require extended antibiotic therapy 6
• The microbiologic profile of dacryocystitis is diverse, with S. aureus (30%), Pseudomonas species (12%), and Propionibacterium acnes (10%) being common isolates 2

Treatment Algorithm

1. Initial presentation:

   • Start empiric oral antibiotics (amoxicillin-clavulanic acid or levofloxacin)
   • Apply warm compresses
   • Consider incision and drainage for significant abscess

2. Obtain cultures during drainage procedure

3. Adjust antibiotics based on culture results and clinical response

4. Plan for DCR after acute infection resolves to prevent recurrence

5. Follow-up to ensure complete resolution and patency of the lacrimal system

Caution

Routine treatment with any single antibiotic may fail in up to one-third of patients due to the broad range of causative organisms, highlighting the importance of obtaining cultures 2.