Treatment of acute dacryocystitis

Advise patients with acute dacryocystitis to apply warm compresses and massage the lacrimal sac to encourage drainage of purulent materialThe Royal Victorian Eye and Ear Hospital (RVEEH), 2023.

For empirical therapy for acute dacryocystitis without systemic features, use:

1cefalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days; if clinical response if slow, consider a total duration of 10 days. For dosage adjustment in adults with kidney impairment, see cefalexin dosage adjustment cefalexin cefalexin cefalexin

OR if adherence to a 6-hourly regimen is unlikely in a child

1cefalexin 20 mg/kg up to 750 mg orally, 8-hourly for 5 days¹; if clinical response is slow, consider a total duration of 10 days. cefalexin

Cefalexin can be used for patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin².

For patients with acute dacryocystitis without systemic features who have had a severe (immediate or delayed)³ hypersensitivity reaction to a penicillin or those at increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA), use:

1trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly for 5 days; if clinical response is slow, consider a total duration of 10 days. For dosage adjustment in adults with kidney impairment, see trimethoprim+sulfamethoxazole dosage adjustment trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole

2clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 days; if clinical response is slow, consider a total duration of 10 days. clindamycin clindamycin clindamycin

Consider using a topical antibiotic if the patient also has bacterial conjunctivitis.

Modify antibiotic therapy for acute dacryocystitis based on results of microbiological testing, if available.

The usual duration of antibiotic therapy for acute dacryocystitis is 5 days for patients with substantial clinical improvement. Advise patients to return for review after 5 days of treatment if symptoms are not improving or earlier if symptoms worsen; a total duration of up to 10 days may be considered.

For patients with significant pain, refer to an ophthalmologist because surgical drainage may be indicated.

Patients with systemic features require intravenous antibiotic therapy and review by an ophthalmologist; seek expert advice.

¹ Unpublished pharmacokinetic and pharmacodynamic modelling data for cefalexin show similar levels of target attainment with the 6- and 8-hourly regimens above. It is the consensus view of the Antibiotic Expert Group that either regimen can be used for children.Return

² Cefalexin may be used in patients who have had a nonsevere (immediate or delayed) reaction to amoxicillin or ampicillin. However, because cross-reactivity between these drugs is possible, consideration should be given to the extent of the reaction, patient acceptability, and the suitability of non–beta-lactam options.Return

³ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return