Treatment of Dacryocystitis
Dacryocystitis requires systemic antibiotics targeting both Gram-positive cocci (particularly S. aureus, S. pneumoniae, S. epidermidis) and Gram-negative rods (H. influenzae, P. aeruginosa), with amoxicillin-clavulanic acid or levofloxacin as first-line empiric therapy, combined with definitive surgical management (dacryocystorhinostomy) to address the underlying nasolacrimal duct obstruction. 1
Empiric Antibiotic Selection
Adults - Oral Therapy
- Amoxicillin-clavulanic acid is effective against the bacteria commonly implicated in dacryocystitis and should be used as first-line oral therapy 1
- Levofloxacin is the most broadly effective oral fluoroquinolone, with resistance encountered in only 16% of cases based on contemporary microbiologic data 2
- Amoxicillin-clavulanic acid encounters resistance in approximately 32% of cases, making levofloxacin the preferred empiric choice when available 2
Pediatric Patients - Intravenous Therapy
- Intravenous antibiotics should be administered in pediatric patients, requiring hospital admission for both antibiotic delivery and monitoring for complications such as orbital cellulitis or abscess formation 1, 3
- Gentamicin combined with amoxicillin-clavulanic acid provides effective coverage against the typical bacterial spectrum in children 1
Acute Dacryocystitis Management Algorithm
Immediate Intervention
- Incision and drainage with direct antibiotic application into the infected lacrimal sac results in almost immediate pain resolution and rapid infection control 4
- This approach provides optimal culture material, which is critical given that 50% of isolates may be resistant to most oral antibiotics 4
- Gram-negative rods account for 58.3% of acute infections, necessitating broad-spectrum coverage 4
Culture-Guided Therapy
- Obtain cultures at the time empiric treatment is initiated, as routine treatment with any single antibiotic may fail in up to one-third of patients given the broad range of causative organisms 2
- S. aureus is the most common isolate (30%), followed by Pseudomonas species (12%) and Propionibacterium acnes (10%) 2
- Consider trimethoprim-sulfamethoxazole for atypical or treatment-resistant cases, particularly when Stenotrophomonas maltophilia is suspected 5
Surgical Management Timing
Definitive Treatment
- Dacryocystorhinostomy (DCR) should be performed after acute infection control to prevent clinical relapse, as the underlying distal nasolacrimal duct obstruction must be addressed 1
- Timing of surgery depends on clinical signs and symptoms, patient age, and general status 1
- In acute cases treated with incision/drainage and antibiotics, DCR can be performed once infection is controlled, with 100% cure rate in patients who underwent subsequent DCR 4
Pediatric-Specific Surgical Approaches
- Chronic low-grade dacryocystitis (67% of pediatric cases): Treat with outpatient nasolacrimal duct probing 3
- Acute dacryocystitis in neonates: Perform nasolacrimal duct probing with nasal endoscopy for intranasal duct cyst excision 3
- Acute dacryocystitis with periorbital cellulitis: Nasolacrimal duct probing after 1-2 days of IV antibiotics 3
- Acute dacryocystitis with orbital abscess: Inferior orbitotomy for abscess drainage, simultaneous nasolacrimal duct probing, and stent placement 3
Common Pitfalls and Caveats
Antibiotic Resistance Patterns
- β-lactam antibiotics alone may be ineffective in many cases, particularly when Gram-negative rods or resistant organisms are present 5
- Even the most effective oral antibiotics (levofloxacin, amoxicillin-clavulanic acid) will encounter resistance in 16-32% of cases, emphasizing the importance of culture data 2
Inadequate Source Control
- Antibiotic therapy without addressing the nasolacrimal duct obstruction leads to clinical relapse, as the underlying anatomic problem persists 1
- Acute dacryocystitis is frequently extremely painful and slow to resolve with systemic antibiotics alone 4