Dacryocystitis Treatment
Initiate empiric systemic antibiotics immediately while obtaining cultures, as routine treatment may fail in up to one-third of patients due to the broad range of causative organisms, and hospitalize pediatric patients for intravenous antibiotics given the significant risk of orbital complications. 1, 2
Initial Assessment and Culture
- Assess visual acuity immediately to evaluate for intraconal abscess formation, which can cause vision loss 1
- Obtain cultures at the time empiric antibiotics are started, as this proves extremely valuable when initial therapy fails 1, 2
- Culture specimens can be obtained from refluxing material after irrigating the lacrimal sac with sterile saline, or during surgical drainage if performed 3, 4
Empiric Antibiotic Selection
For adults with acute dacryocystitis:
- Oral levofloxacin or amoxicillin-clavulanate are the most effective empiric choices, though even these encounter resistant organisms in 16-32% of cases 2
- Alternative effective regimens include gentamicin combined with amoxicillin-clavulanic acid, which cover both Gram-positive (S. aureus, S. pneumoniae, S. epidermidis) and Gram-negative bacteria (H. influenzae, P. aeruginosa) commonly implicated 5
For pediatric patients:
- Hospital admission with intravenous antibiotics is mandatory due to significant risk of progression to orbital complications 1
Microbiology Considerations
The causative organisms are diverse 2:
- S. aureus is most common (30% of isolates), followed by Pseudomonas species (12%) and Propionibacterium acnes (10%) 2
- Gram-negative rods account for 58.3% of infections, with 50% of isolates resistant to most oral antibiotics 3
- For Gram-positive organisms, cefoxitin shows highest sensitivity, followed by vancomycin and clindamycin 4
- For Gram-negative organisms, imipenem is most sensitive, followed by gentamicin 4
Adjusting Therapy Based on Response
- If infection improves on empiric therapy, continue the current regimen even if isolated organisms show in vitro resistance, as clinical response supersedes laboratory susceptibility 1
- Modify antibiotics to cover all isolated organisms only if clinical response is inadequate 1
Surgical Management
For acute dacryocystitis with abscess formation:
- Incision, drainage, and direct application of antibiotics inside the infected sac results in almost immediate pain resolution and rapid infection control 3
- This approach also provides optimal culture material 3
For definitive treatment:
- Most patients require dacryocystorhinostomy (DCR) for underlying nasolacrimal duct obstruction and chronic dacryocystitis to prevent clinical relapse 1, 3
- Timing of surgery depends on clinical signs, symptoms, age, and general patient status 5
- All patients undergoing DCR after acute infection control achieve full cure 3
Critical Pitfalls
- Do not rely solely on empiric therapy without cultures, as atypical pathogens like Mycobacterium abscessus may require extended antibiotic courses with specific agents 6
- Do not delay surgical intervention in patients with chronic dacryocystitis, especially before planned intraocular surgery, due to grave risk of endophthalmitis 4
- Avoid outpatient oral therapy in pediatric patients, as they require intravenous administration 1, 5