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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 28
| Issue : 1 | Page : 24-29 |
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Bacteriology of Lacrimal Drainage System Following Obstruction of the Nasolacrimal Duct in a Reference Population
El-Said G Metmoah, Samar A Bukhatwa, Sabah S Eldressi
Ophthalmology Department, Faculty of medicine, University of Benghazi, Libya
| Date of Submission | 20-Oct-2019 |
| Date of Decision | 25-Feb-2020 |
| Date of Acceptance | 05-Mar-2020 |
| Date of Web Publication | 07-Sep-2020 |
Correspondence Address:
Prof. Samar A Bukhatwa
Ophthalmology Department, Faculty of medicine, University of Benghazi
Libya
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njo.njo_21_19
Context: Lacrimal drainage system obstruction gives discomfort to patients and threatens intraocular surgeries by infection, thus, knowledge of its bacteriology leads to the choice of effective therapy. Aim: To determine the bacteriology of nasolacrimal duct obstruction in an adult Libyan patient population and to analyze the appropriate antimicrobial therapy based on susceptibility testing. Settings and Design: A prospective study was conducted at the Great River Eye hospital, Benghazi/Libya in the period between September 2005 and February 2007. Methods: Lacrimal swab materials collected from patients aged 18–62 years who were diagnosed as having lacrimal passage obstruction and referred for lacrimal drainage surgery. The specimens were cultured and results analyzed. Results: Of 86 cases, 87.2% yielded a positive culture result. The majority of microorganisms were gram positive bacteria (73.3%) with Staphylococcus Aureus being the most frequently cultured species (36%) of the sample. Gram negative bacteria represented 26.7% of the isolates. The most common gram negative bacteria were Pseudomonas, Klebsiella, and E. coli which were isolated in 8% of the cases each. Staphylococcus aureus was isolated from 28.6% of cases having epiphora with no clinical signs of lacrimal drainage system infection. Ciprofloxacin (96%) and Gentamycin (94.7%) were found to be the most sensitive antibiotics against isolated organisms. Conclusions: Adult patients with lacrimal drainage system obstruction harbor microorganisms in their lacrimal sacs indicating the importance of investigating patients before planning for intraocular surgeries and considering prophylactic use of antibiotics before lacrimal drainage procedures.
Keywords: Lacrimal drainage obstruction, microbiology, susceptibility tests
How to cite this article:
Metmoah ESG, Bukhatwa SA, Eldressi SS. Bacteriology of Lacrimal Drainage System Following Obstruction of the Nasolacrimal Duct in a Reference Population. Niger J Ophthalmol 2020;28:24-9 |
Key Messages
Prophylactic use of antibiotics should be considered before lacrimal drainage procedures.
Gram-positive bacteria (Staphylococcus species predominance) are the most common isolates in the lacrimal drainage system.
Ciprofloxacin and Gentamycin are the most sensitive antibiotics against isolated organisms. Penicillin showed the highest resistance which should be taken in consideration when treating cases of dacryocystitis putting in mind that appropriate use of antibiotic can control the antibiotic resistance.
| Introduction | |  |
Chronic dacryocystitis is a chronic infection of the lacrimal sac that usually results from lacrimal duct obstruction.
Lacrimal sac and nasolacrimal duct obstruction cause considerable discomfort and sometimes, threatening ophthalmic problem especially when another intraocular procedure such as cataract surgery has to be done.
Nasolacrimal duct obstruction can affect any age group, it may be caused by idiopathic inflammatory stenosis secondary to trauma, infection, inflammation neoplasm or mechanical obstruction.[1],[2]
The obstruction of the lacrimal drainage system occurs most often at either the junction of the sac and nasolacrimal duct or within the bony nasolacrimal duct, distal obstruction with the stagnation of secretions within the Lacrimal sac creating an infection that leads to chronic dacryocystitis with epiphora and purulent discharge.[3]
Some patients tolerate nasolacrimal obstruction with epiphora for many years without clinical infection as simple stenosis of the nasolacrimal duct,[4] and during the past years, there have been a few studies on the bacteriology of adult nasolacrimal duct obstruction, which showed Staphylococcus epidermidis  staphylococcus aureus as the commonest isolated organisms.[5]
The treatment of adult nasolacrimal duct obstruction is surgery either external or endo nasal dacryocystorhinostomy (DCR) or occasionally silicon intubations. According to Walland and Rose[6], there is a five-fold risk of soft tissue infection after open lacrimal surgery without systemic antibiotic prophylaxis; therefore, post-operative soft tissue infection represents a major risk for lacrimal surgery failure.
Knowledge of the bacteriology of nasolacrimal duct obstruction contributes significantly to the choice of prophylactic antimicrobial agents.[7]
The purpose of this study was to identify the bacteriology of nasolacrimal duct obstruction in an adult Libyan patient population and to determine the appropriate antimicrobial therapy based on susceptibility testing.
| Subjects and Methods | | |
A prospective study was conducted according to the principles of the World Medical Association Declaration of Helsinki with the approval of Great River Eye hospital/Benghazi authorities in the period between September 2005 and February 2007.
Informed consent to participate was obtained from all of the patients enrolled in this study.
All patients had been referred for lacrimal drainage surgery.
All patients presented with obstruction of the nasolacrimal duct, which was confirmed by a positive regurgitation test, and by reflux of the irrigated fluid from the upper punctum after injecting saline into the lower punctum while the sac becoming distended with no saline passing to the nose or nasopharynx, also by probing up to the nasal wall of the Lacrimal sac fossa.
Patients who have done previous lacrimal drainage surgery were excluded from the study.
Patients were classified into three sub groups according to the severity of infection:
Group 1 (G1): Included cases of chronic dacryocystitis with copious purulent discharge or thick mucus discharge (and referred to as severe).
Group 2 (G2): Were cases of epiphora and minor mucopurulent discharge (referred to as moderate).
Group 3 (G3): Included cases complaining of epiphora only and no clinical signs of infection to the Lacrimal drainage system (referred to as mild).
Bacterial isolation
In all cases the collection of the samples was performed at the time of surgery by applying pressure over the Lacrimal sac and allowing the purulent material to reflux through the Lacrimal punctum or by using of sterile saline to irrigate the Lacrimal drainage system and the samples from the refluxing material were collected. Prior to the collection of the samples, povidone-iodine 5% was instilled into the conjunctiva along with cleaning of the surrounding area with it, and the samples were collected with sterile cotton swabs ensuring that the lid margin or the conjunctiva were not touched, local and systemic antibiotics were stopped at least two weeks before collecting the specimen.
Organisms grown were identified using standard biochemical reactions and antibiotic sensitivity test was done by the Kirby-Bauer disc diffusion method as per the Clinical and Laboratory Standards Institute guidelines.[8],[9]
Statistical analysis was performed using Statistical Package for the Social Science (Windows version 17.0; SPSS Inc., Chicago [IL], US). Data were presented as frequencies and mean ± standard deviation (SD). Chi-square χ2 was used with P-values of 0.05 or less were considered as statistically significant.
| Results | | |
Cultures from 86 adult Libyan patients with the diagnosis of obstruction of the nasolacrimal duct were submitted for microbiological studies.
There was a predominance of female subjects 80 (93%) compared to male subjects 6 (7%).
The mean age of patients was 34.3 ±10.25yrs (range,18-62 years) with the majority of cases (73.3%) in the age between 20 and 39 years old.
According to severity of infection the patients were distributed into the followings:
Severe (G1) with 38 (44.2%) cases; Moderate (G2) with 27 cases (31.4%) and Mild (G3) 21 cases (24.4%)
Our clinical diagnosis for these 21 cases was simple stenosis of naso-lacrimal duct [Table 1].
Bacteriology findings
Of the 86 samples; 75 (87.2%) yielded a positive culture.
All the cases of no growth 100% (11 cases) were in the mild group, while 50.7% (38cases) of the cases with growth were in the severe group and that was statistically significant P<.0001
Of the 75 samples with positive culture results no mixed cultures were isolated. The majority of microorganisms 55 cases (73.3%) were gram-positive bacteria with Staphylococcus Aureus being the most frequent cultured species which was isolated in 27(36%) of the sample.
Gram-negative bacteria were recovered from 20 samples (26.7%) of the isolates. The most common Gram-negative bacteria were Pseudomonas, Klebsiella, and E. coli which were isolated in 6 (8%) of the cases each. Neither anaerobic microorganisms nor fungi were cultured from the samples [Table 2]. | Table 2 Bacteriological findings of the contents of lacrimal sac in 75 adult patients with lacrimal duct obstruction
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Staphylococcus aureus was the major isolate 15 cases (39.5%) in group1 (severe) form followed by Streptococcus pyogenes, 8 cases (21.1%), Gram-negative organisms were 11 in number which account for 29% of the isolates in this group, and although proteus were isolated in only two cases; they constitute all the cases of proteus in all the three groups (100%) and that was statistically significant (P= 0.004) [Table 3].
In group2 (moderate), Staphylococcus aureus was the main bacteriological finding 6 cases (22.2%) followed by Staphylococcus epidermidis five cases (18.5%).
Gram-negative organisms were 33% of all isolates in this group (group 2).
And although Streptococcus pneumonia were 3 cases (11.1%) this account for all the cases (100%) within the bacteriological study, P= 0.006 [Table 4].
Although in group3 (mild) Staphylococcus aureus, six cases (28.6%), was also the main bacteriological finding; all the cases of no growth laid in this group, 11 cases (100%) [Table 5].
Microbiological sensitivity tests
Based on the sensitivity tests, Ciprofloxacin was found to be most effective antibiotic (96%) against all gram-positive isolates followed by Chloramphenicol (85%).
Regarding gram-negative isolates the most effective agent was Gentamycin (94.7%) followed by Tobramycin (90.7%).
The highest resistance was to penicillin (32%) which is a broad-spectrum antibiotic [Table 6].
These results of microbiological sensitivity tests were all statistically highly significant, P < 0.0001.
| Discussion | | |
The lacrimal excretory system draws tears into the lacrimal sac which then pass through the nasolacrimal duct into the inferior meatus of the nose by gravity and tissue elasticity. As a result of stenosis or obstruction of the nasolacrimal duct, tears will be retained in the cavity of the lacrimal sac, which facilitates the growth and propagation of microorganisms causing dacryocystitis.
In the 1930s, Streptococcus pneumonia was the most common species in chronic dacryocystitis in adults.[3] In 1980s Huber Spitzy et al.[10] reported Staphylococcus aureus (45%) and Streptococcus epidermis (20%) followed by gram-negative E. Coli as predominant isolates.
In the present study, gram-positive bacteria were found in 73.3% of the isolates. This is in close agreement with the observation of 65% of gram-positive organisms by Coden et al.[5] The most common organisms cultured in our study were Staphylococcus species counting for 53.3% of isolates. This percentage compares fairly well with the previous reports that ranged between (49%-73%).[5],[10],[11],[12] but is higher than what was reported by Negm et al.[13] (38.8%), the cause of disparity between Negm et al. results and the present study could be due to the difference in the number as well as the techniques of samples collection used in both studies. In Negm et al. study there were 25 samples obtained directly from the contents of lacrimal sac during the DCR surgery, whilst in the present study; the number was 86 sample collected before the surgery from the reflux of the purulent material through the lacrimal punctum after applying pressure over the lacrimal sac.
Streptococcus pneumonia represented 4% of the isolates in the present study, which was slightly higher than Huber Spitzy et al.[5] (2%) and Coden et al.[10] (2.3%) reports, but lower than Chaudhry et al (10.2 %)[12] and Negm, S et al (22%).[13] These dissimilarities could be due to the difference in the number and the type of dacryocystitis cases studied (Spitz et al.[10] included cases of acute dacryocystitis in their study).
Gram-negative organisms represented (26.7%) of the isolates of the total material in this study, the most frequently isolated species being pseudomonas, klebsiella and E. Coli (8% each). Previously Huber Spitzy et al. reported that gram-negative organisms accounted for 26% of the isolates in their study, the most frequent species being E. Coli (12%), while Coden et al. observed gram-negative organisms in 27% of all isolates including Pseudomonas aeruginosa in 9% and Haemophilus species in 6% of isolates.[5],[10] In the present study, the cases with chronic dacryocystitis with copious mucopurulent discharge (G1); the gram-negative organisms were isolated in 29% of the sample. But found in 33% in cases with mild mucopurulent discharge (G2). This goes with the practice that chronic dacryocystitis with mucous or purulent discharge is a contraindication for elective intraocular surgery; and on doing lacrimal drainage surgery for cases of nasolacrimal duct obstruction, the antimicrobial prophylaxis should cover both gram-positive and gram-negative organisms.
Treatment of infection of the lacrimal drainage system has no regimen in Libya; thus, knowledge of its bacteriology leads to the choice of effective therapy.
In the present study, according to susceptibility testing, Ciprofloxacin is the most effective therapeutic agent (96%) against gram-positive isolates followed by chloramphenicol (85%), while Gentamycin is the most effective isolate (94%) against Gram-negative isolates followed by Tobramycin (90%). These results are in accordance with Eslami et.al. and Pornpanich et al.[14] who showed that Ciprofloxacin (75%) was the most effective antibiotic to isolated bacteria,[14],[15] but in contradictory to Chaudhary et al.[7] and Usha et al.[16] who showed that chloramphenicol is the most effective agent in lacrimal duct obstruction. This discrepancy may be due to the unwise use of broad-spectrum antibiotics, in the treatment of non-infectious conditions or as a prophylactic for long periods, with the emergence of more virulent organisms that are drug-resistant.[17],[18]Most of the isolates in the present study showed the highest resistance to penicillin (32%), which are similar to previously reported results.[16],[19]
Bacterial resistance has increased over the last years due to the usage of antibiotics without microbiological testing; the appropriate use of antibiotics should be encouraged to avoid the emergence of resistant strains and to decrease the failure rate of lacrimal duct surgery due to soft tissue infection.[6],[16]
| Conclusion | | |
Adult patients with lacrimal drainage system obstruction harbor microorganisms in their lacrimal sacs indicating the importance of investigating patients before planning for intraocular surgeries and considering prophylaxis use of antibiotics before lacrimal drainage procedures.
Gram positive bacteria are the most common isolates in the lacrimal drainage system obstruction with a predominance of Staphylococcus species (53.3%), and gram-negative bacteria constitute a considerable amount (26.7%) of isolates.
Ciprofloxacin and Gentamycin are the most sensitive antibiotics against isolated organisms while penicillin showed the highest resistance which should be taken in consideration when treating cases of dacryocystitis putting in mind that appropriate use of antibiotic can reduce antibiotic resistance.
Limitation of the study
There were no previous studies that determine the bacteriology of nasolacrimal duct obstruction in the Libyan population to compare with the present study.
Another limitation is that, although an attempt to ensure minimal contamination with normal ocular surface flora was carried out by the prior installation of povidone-iodine 5% into the conjunctiva, this does not absolutely prevent this; so, we recommend to change the way of sample collection to be direct from the lacrimal sac contents while making sac flap during DCR surgery in the future studies.
Financial support and sponsorship
This research didn’t receive grants from any funding agency in the public, commercial or not-for-profit sectors.
Conflicts of interest
The authors declare no conflict of interest.
| References | | |
| 1. | Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology 1986;93:1055-63.  |
| 2. | Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1. Ophthal Plast Reconstr Surg 1992;8:237-42. |
| 3. | Traquair HM. Chronic dacryocystitis; its causation and treatment. Arch Ophthalmol 1941;26:165-80. |
| 4. | Linberg JV. Disorders of the lower excretory system. In Milder B, Weil BA, eds. The lacrimal system. New York: Appleton −Century-crofts, 1983; 1-134. |
| 5. | Coden DJ, Hornblass A, Haas BD. Clinical bacteriology of dacryocystitis in adults. Ophthalmic Plast Reconstr Surg 1993;9:125-31 |
| 6. | Walland MJ, Rose GE. Soft tissue infections after open lacrimal surgery. Ophthalmology 1994;101:608-11. |
| 7. | Chaudhary M, Bhattarai A, Adhikari SK. Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis. Nep J Oph 2010;2:105-13. |
| 8. | Forbes Betty A, Daniel FS, Alice S. Bailey and Scott’s Diagnostic Microbiology 11th ed. Philadelphia: Mosby publications; 2004 927-38. |
| 9. | Clinical Laboratory Standards Institute (CLSI) guidelines. Performance standards for antimicrobial susceptibility testing: twentieth informational supplement. Document M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010. |
| 10. | Huber-Spitzy V, Steinkogler FJ, Huber E, ArockerMettinger E, SchiVbänker M. Acquired dacryocystitis: microbiology and conservative therapy. Acta Ophthalmol 1992;70:745-9. |
| 11. | Blicker JA, Buffam FV. Lacrimal sac, conjunctival, and nasal culture results in dacryocystorhinostomy patients. Ophthal Plast Reconstr Surg 1993;9:43-6. |
| 12. | Chaudhry IA, Shamsi FA, Al-Rashed W. Bacteriology of chronic dacryocystitis in a tertiary eye care center. Ophthal Plast Reconstr Surg 2005;21:207-10. |
| 13. | Negm S, Aboelnour A, Saleh YM, Hassanin O. Clinicobacteriological study of chronic dacryocystitis in Egypt. Bull Natl Res Cent 2019;43:35. |
| 14. | Pornpanich K, Luemsamran P, Leelaporn A, Santisuk J, Tesavibul N, Lertsuwanroj B et al. Microbiology of primary acquired nasolacrimal duct obstruction: simple epiphora, acute dacryocystitis, and chronic dacryocystitis. Clin Ophthalmol 2016;10:337-42. |
| 15. | Eslami F, Basir HR, Moradi A, Farah S. Microbiological study of dacryocystitis in northwest of Iran. Clin Ophthalmol 2018;12:1859-64. |
| 16. | Usha K, Smitha S, Shah N, Shah N, Lalitha P, Kelkar R. Spectrum and the susceptibilities of microbial isolates in cases of congenital nasolacrimal duct obstruction. J AAPOS 2006;10:469-72. |
| 17. | Altan-Yaycioglu R, Canan H, Sizmaz S, Bal N, Pelit A, Akova YA. Nasolacrimal duct obstruction: clinicopathologic analysis of 205 cases. Orbit 2010;29:254-9. |
| 18. | Ghose S, Mahajan VM. Fungal flora in congenital dacryocystitis. Indian J Ophthalmol 1990;38:189-90. [ PUBMED] [Full text] |
| 19. | Pradeep AVP, Patil SS, Koti SV, Arunkumar JS, Garag SS, Hegde JS. Clinico-bacteriological study of chronic dacryocystitis cases in Northern Karnataka, India. J clin Diag Res 2013;7:2502-4. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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