Can a healthcare provider prescribe Terracortil (hydrocortisone) and Tobrex (tobramycin) for Dacryocystitis?

Terracortil and Tobrex Are Not Appropriate for Dacryocystitis

Dacryocystitis requires systemic antibiotics, not topical ophthalmic preparations, because it is an infection of the lacrimal sac—a structure that cannot be adequately treated with eye drops or ointments applied to the ocular surface. 1, 2, 3

Why These Medications Are Inappropriate

Tobrex (Tobramycin) Limitations

• Tobramycin ophthalmic solution is FDA-approved only for "external infections of the eye and its adnexa caused by susceptible bacteria" 4
• The lacrimal sac is not accessible to topical ophthalmic antibiotics applied to the conjunctival surface 1, 2
• Topical antibiotics cannot achieve therapeutic concentrations within an infected, obstructed lacrimal sac 1

Terracortil (Hydrocortisone + Antibiotic) Contraindications

• Corticosteroids should never be used in active bacterial infections like dacryocystitis, as they suppress local immune response and can worsen the infection 5
• The combination of steroid with antibiotic does not overcome the fundamental problem that topical agents cannot reach the lacrimal sac 1, 2

Correct Treatment Approach for Dacryocystitis

Acute Dacryocystitis Management

• Systemic antibiotics are mandatory and should cover both Gram-positive organisms (Staphylococcus aureus, Streptococcus pneumoniae, Staphylococcus epidermidis) and Gram-negative bacteria (Haemophilus influenzae, Pseudomonas aeruginosa) 2
• Gentamicin and amoxicillin-clavulanic acid have proven effective against bacteria commonly causing dacryocystitis 2
• In adults, oral antibiotics are typically sufficient; in pediatric patients, intravenous antibiotics are preferred 2, 3

Surgical Intervention

• Incision and drainage with direct antibiotic application inside the infected sac provides almost immediate pain resolution and rapid infection control 1
• This approach also yields optimal culture material, which is critical since 58.3% of infections involve gram-negative rods, with 50% of isolates resistant to most oral antibiotics 1
• Definitive treatment requires dacryocystorhinostomy to address the underlying nasolacrimal duct obstruction and prevent clinical relapse 1, 2

Timing of Surgery

• For acute dacryocystitis with periorbital cellulitis, hospital admission for intravenous antibiotics is followed within 1-2 days by nasolacrimal duct probing 3
• For chronic low-grade dacryocystitis, outpatient nasolacrimal duct probing may be appropriate 3
• Acute cases complicated by orbital abscess require inferior orbitotomy for drainage, simultaneous nasolacrimal duct probing, and stent placement 3

Critical Pitfalls to Avoid

• Never rely on topical ophthalmic antibiotics alone for dacryocystitis—the infection is within the lacrimal sac, not on the ocular surface 1, 2
• Never use corticosteroids during active infection, as this worsens bacterial proliferation and delays resolution 5
• Always obtain cultures intraoperatively, as atypical organisms like Mycobacterium abscessus or Stenotrophomonas maltophilia may require extended antibiotic therapy with high resistance patterns 6, 7
• Monitor for progression to orbital cellulitis or abscess, which requires immediate escalation to intravenous antibiotics and possible surgical drainage 3

When Atypical Organisms Are Suspected

• Consider Mycobacterium abscessus in chronic cases not responding to standard therapy, requiring extended treatment with omadacycline and azithromycin 6
• Stenotrophomonas maltophilia should be considered when β-lactam antibiotics fail; trimethoprim-sulfamethoxazole is the appropriate choice 7
• Culture-directed therapy is essential for these antibiotic-resistant organisms 6, 7