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Acute Dacryocystitis Resistant to Oral Antibiotic Treatment Abstract Cases of acute dacryocystitis can fail to respond to oral antibiotics, requiring intravenous antibiotics and dacryostorhinotomy (DCR). This report reviews the frequency, likely causes, and management strategies for treating resistant dacryocystitis. I. Case History: 66 year old Caucasian male presented with eye pain OD o Onset = 3 days ago o Symptoms worsening with pain scaled as 5/10 o Accompanied by swelling of the nasolacrimal sac o No changes in vision, fever, itching, tearing, or discharge. Ocular History: o Unremarkable OU o Visited outpatient clinic 1 day prior to his appointment Treatment initiated but no improvement of symptoms after 2 days: 875 mg Augmentin BID x 10 days Warm compresses TID OD Medical History: (+)HTN, DM, TIA, Hypothyroidism Medications: Artificial Tears-PRN OU, Metformin, Insulin, Lisinopril, Levothryoxine, Warfarin Allergies: Lyrica, Gabapentin II. Pertinent Findings Clinical Examination: o VA(cc): OD: 20/20-2, OS: 20/20 o Extraocular Muscles: FROM OU; (+) dull pain/soreness in all gazes OD o Pupils, confrontation visual fields, and Ishihara color vision testing were unremarkable OD and OS o External Examination: (-)proptosis OU o Slit Lamp Examination: Lids/Lashes: 1.5mmx2mm tender nodule of nasolacrimal sac OD Erythema, pain/tender on palpation Unable to express contents with palpation. All other structures were unremarkable OU o IOP: 16/16 mmHg o Undilated 78D Slit Funduscopy: Unremarkable OU o Physical: Alert and Oriented x 3; Temperature: 99.9F Laboratory Studies: Culturing of lacrimal sac fluid o Staphylococcus Lugdunensis Gram-positive Coagulase-negative Has spherical cells that appear in clusters Radiology Studies: Unremarkable Orbital CT scan without deviation into post-septal region. III. Differential diagnosis Primary Diagnosis: Dacryocystitis Other Differentials: o Pre-septal cellulitis Focal swelling of one of the meibomian glands No pain on eye movement o Orbital cellulitis Fever, proptosis, APD, and/or changes in color vision Positive orbital CT o Canaliculitis Pouted/inflamed puncta Follicular conjunctivitis o Dacryostocele Congenital blockage of Rosenmuller valve and Hasner valve Grey-blue cystic swelling just below the medial canthus IV. Diagnosis and Discussion Dacryocystitis is inflammation of the lacrimal sac secondary to nasolacrimal obstruction and growth of bacteria due to stationary fluid within the lacrimal sac. Symptoms: o Epiphora, redness, and tenderness of the tissue over the lacrimal sac Pathogens: o Common Pathogens are Gram-positive bacteria5,6 Staphylococcus Aureus Staphylococcus Epidermidis Staphylococcus Virdians o Uncommon Pathogens are Gram-negative bacteria5,6 Pseudomonas aeruginosa V. Treatment and Management Treatment of the patient in this case report o Day 1 = Day of Consult Continue warm compresses & ocular massage Increase Augmentin to TID x 10days Add Naproxen 500mg BID o Day 3 No improvement noted Referral to Ophthalmology for incision, drainage, and culturing of lacrimal sac fluid. Patient admitted and IV Clindamycin initiated o Day 4 o Day 5 o Day 6 2.0cm reduction in infraorbital erythema Continue IV clindamycin Significant improvement surrounding incision site Continuing improvement in clinical appearance and symptoms o Day 7 Improvement with 4 day IV clindamycin. Patient discharged from hospital Start 14 day course of 150 mg oral clindamycin at home Discontinue 875mg augmentin o Day 15 Well healed incision No need to restart oral antibiotics Patient to complete EnDCR with oculoplastic clinic in 6 weeks. Common Dacryocystitis Treatments: o Warm compresses o Systemic antibiotics Augmentin Cephalosporins Clindamycin o Surgery = dacryostorhinotomy (DCR). Purpose: Drain lacrimal sac fluid to ward off acute infection Alleviate symptoms (epiphora) Complications: prolong healing, cutaneous scarring, and fistula formation7. Surgical Types: External DCR (ExDCR) Incision made over the skin & lacrimal bone is removed to extrapolate the contents of the sac 93.8% success rate in comparison to orals alone6 Endoscopic DCR (EnDCR) Parts of the nasal mucosa are removed to create an opening near the lacrimal bone, which creates a bridge between the sac and nasal mucosa Drills or lasers can be used to make the incisions Can reach the lacrimal sac through noninfected tissue Can prevent spread of infection that could be potentiated with external DCR or incision/drainage 96.2% success rate4 90% patency versus 60% seen in ExDCR4 Swelling & edema & epiphora symptoms resolve faster with EnDCR7 92.3% reduction in epiphora in 2-3 days Less chance of needing repeat drainage Possible sequelae if aggressive surgical treatment not enacted orbital cellulitis orbital abscess Bacterial Susceptibility o Cephalosporins and Augmentin combat 86.4% of acute dacryocystitis6 o Ceftriaxone, erythromycin, gentamycin are more effective than ampicillin, amoxicillin, penicillin, and tetracycline2 o Gram-positive bacteria such as S. Aureus showed good sensitivity to penicillin, cephalosporins, and vancomycin1 o Some common gram negative bacteria were sensitive to penicillin, quinolones, and aminoglycosides1 Bacterial Resistance: o 28.6% of acute dacryocystitis cases are resistant to initial antibiotic treatment6 o 33% of S. Aureus showed resistance to erythromycin, tetracycline, and penicillin2 o In the Mill’s study, 5/23 of the S. Aureus isolates were MRSA, which were mostly found in acute cases6 Bibliography 1. Ali, Mohammad Javed, The microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. Journal of Ophthalmic Inflammation and Infection. 2013; 3:57: 15. 2. Assefa, Yared, Bacteriological profile and drug susceptibility patterns in dacryocystitis patients attending Gondar University Teaching Hospital, Northwest Ethiopia. BioMed Central Ophthalmology. 2015;15:34:1-8. 3. Ben Simon, Guy J. External versus Endoscopic Dacryocystorhinostomy for Acquired Nasolacrimal Duct Obstruction in a Tertiary Referral Center. Ophthalmology. 2005. 112:8: 1463-1468. 4. Christy, Naja, Long-term Outcomes of Powered Endoscopic 5. 6. 7. Dacryocystorhinostomy in Acute Dacryocystitis. The Larynoscope. 2015;1-3. Eshraghi, Bahram, Microbiologic spectrum of acute and chronic dacryocystitis. Int J Ophthalmology. 2014;7 (5): 864-867. Mills, David M. The Microbiologic Spectrum of Dacryocystitis: A National Study of Acute Versus Chronic Infection. Ophthalmic Plastics and Reconstructive Surgery. 2007; 23:4: 302-306. Naik, Sudhir M. Endonasal DCR with Silicon Tube Stents: A Better Management for Acute Lacrimal Abscesses. Indian Journal Otolaryngology Head Neck Surgery. 2013; 65:2: S343-S349. VI. Conclusion o The most common etiology of dacryocystitis is gram positive bacteria. o The patient in this case report was infected with Gram-positive Staphylococcus Lugdunensis o 1st Line treatment with Augmentin did not resolve the patient’s condition o 2nd line treatment was then initiated with Clindamycin and Endoscopic DCR, due to worsening of his condition, unresolved symptoms, and suspicion for presence of a resistant bacteria, which have a high incidence in acute cases o Combined antibiotics with surgical approach in persistent & chronic cases resolve symptoms fast Endonasal DCR is the preferred surgery