What is the treatment for dacrocystitis?

Treatment of Dacryocystitis

Dacryocystitis requires systemic antibiotics targeting both gram-positive and gram-negative organisms, with levofloxacin or amoxicillin-clavulanate as first-line oral agents, combined with warm compresses and consideration for surgical drainage in acute cases or dacryocystorhinostomy (DCR) for definitive management of chronic or recurrent disease. 1, 2

Initial Management Approach

Antibiotic Selection

• Empiric oral antibiotics should target both gram-positive organisms (S. aureus, S. pneumoniae, S. epidermidis) and gram-negative bacteria (H. influenzae, P. aeruginosa) as these represent the most common pathogens 1
• Levofloxacin or amoxicillin-clavulanate are the most effective first-line oral antibiotics, though even these agents may encounter resistant organisms in 16-32% of cases 2
• Gentamicin combined with amoxicillin-clavulanic acid has demonstrated effectiveness against bacteria commonly implicated in dacryocystitis 1

Culture-Guided Therapy

• Obtain culture 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 commonly isolated organism (30%), followed by Pseudomonas species (12%) and Propionibacterium acnes (10%) 2
• Approximately 58% of infections involve gram-negative rods, with 50% of isolates resistant to most oral antibiotics 3

Acute Dacryocystitis Management

Surgical Intervention for Severe Cases

• Incision, drainage, and direct application of antibiotics inside the infected sac results in almost immediate resolution of pain and rapid control of infection 3
• This approach provides optimal culture material and should be considered when acute dacryocystitis is extremely painful or slow to resolve with systemic antibiotics alone 3
• Intravenous antibiotics should be administered in pediatric patients prior to any surgical intervention 1

Supportive Measures

• Warm compresses applied to the affected area can provide symptomatic relief 4
• Address any underlying nasolacrimal duct obstruction to prevent clinical relapse 1

Definitive Surgical Management

Dacryocystorhinostomy (DCR)

• External DCR is required to maintain patency of the nasolacrimal system and prevent recurrence in chronic or recurrent cases 5
• The timing of surgery depends primarily on clinical signs and symptoms, patient age, and general status 1
• All patients undergoing DCR after acute infection control have achieved full cure in reported series 3
• Distal nasolacrimal duct obstruction is the most common underlying cause and must be treated to prevent clinical relapse 1

Special Considerations and Pitfalls

Atypical Pathogens

• Consider atypical organisms like Proteus mirabilis in patients with long-term catheterization or Mycobacterium abscessus in cases with chronic, treatment-resistant infection 5, 6
• Proteus species can manifest as preseptal cellulitis if not recognized and treated promptly 5
• M. abscessus requires extended antibiotic therapy (omadacycline and azithromycin) and intraoperative culturing of lacrimal sac abscesses 6

Treatment Failure

• In nonresponsive cases, culturing of ocular discharge should be performed to identify the underlying pathogen and guide antibiotic selection 5
• Susceptibility testing can streamline the diagnostic and management sequence considerably in unclear or unresponsive cases 5
• Chronic recurrences and epiphora are potential sequelae even after appropriate antibiotic treatment 5

Patient Education

• Patients should be informed that DCR surgical procedure may be needed to prevent future recurrences, particularly in cases with persistent nasolacrimal duct obstruction 5
• Most patients return to normal after appropriate treatment, but surgical intervention is often necessary for definitive cure 5, 3