Assessing the Microbiological Spectrum of Dacryocystitis Patients at a Tertiary Eye Hospital: A Retrospective Study

Assessing the Microbiological Spectrum of Dacryocystitis Patients at a Tertiary Eye Hospital: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the Microbiological Spectrum of Dacryocystitis Patients at a Tertiary Eye Hospital: A Retrospective Study Amjad Alshehri, Manal Alwazae, Ghaliah AlAbdulakadir, Faisal Altahan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4559567/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : The purpose of this study is to determine the microbiological spectrum and the demographics of dacryocystitis patients. Methods : A retrospective chart review on patients’ electronic medical records were utilized to collect data on patients who presented with dacryocystitis. A total of 97 patients were included and data were collected on the demographics, type of organisms, antibiotic sensitivity, response to antibiotics therapy, management, and complications. Results : Gram-positive cultures predominated in all genders in both adult and pediatric age groups and accounted for 61.3% of the sample. In adults, Staphylococcus aureus was the leading gram-positive organism (25.7%) while Pseudomonas aeruginosa (7.9%) and Haemophilus influenzae (6.9%) were the most common gram-negative organisms. In pediatric cases, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, and Streptococcus intermedius were equally prevalent and gram-negative infection was exclusively due to Haemophilus species (26%). Conclusions : Comprehending the microbiologic spectrum and its trend is crucial for managing an infection and recommending suitable antibiotic therapy. Initial Empirical therapy for dacryocystitis cases is targeted toward the Gram-positive organisms due to its prevalence. As a result, we heartily advise conducting a local study from time to time to assess the trend in the microbiological spectrum and shift in epidemiology, along with the antimicrobial sensitivity. dacryocystitis microbiological spectrum antimicrobial susceptibility Introduction Dacryocystitis is the most common disorder of the lacrimal drainage system. 1 Blockage of the lacrimal drainage system either congenital or acquired is usually the main cause. 2 It leads to the accumulation of tears and stasis thus creating a suitable environment for secondary infection. 3,4 Moreover, children and neonates in particular could be more prone to severe infection due to an immature immune system. 1,5 Therefore, treatment of dacryocystitis in a timely manner is crucial to prevent complications. 6–9 Most ophthalmologists treat acute dacryocystitis empirically and then tailor the treatment according to the sensitivity of the isolated organism if available or according to the clinical response. 10 Bacterial infection in dacryocystitis plays a major role in 60.8–94.9% of all dacryocystitis. 3 Historically, gram-positive organisms are predominant in the peer reviewed literature. 1,11,12 However, there are recent reports on the increasing incidence of gram-negative organisms, as well as the methicillin-resistant Staphylococcus aureus (MRSA). 1,12,13 Hence, this implies that the causative microbiological spectrum is changing and the broad-spectrum antibiotic approach could play a role in the corresponding change in ocular surface flora and susceptibility to antibiotics. 10 Thus, understanding the microbiologic spectrum and its trend with time is critical for controlling the infection and to provide accurate antimicrobial coverage. However, there are relatively few studies focusing on the microbiologic characteristics of dacryocystitis in the current literature, and no study has conducted a review of the spectrum in the Saudi population. Therefore, this study aims to identify the demographics and microbiologic spectrum of dacryocystitis patients presenting to a tertiary eye hospital. Methods This retrospective study reviewed the electronic medical records of patients presenting between 2018 to March 2022 at our tertiary eye hospital. Patients were included if they were diagnosed clinically with acute or chronic dacryocystitis irrespective of age, with positive culture results from the lacrimal sac secretions. Patients were excluded if they had undergone surgical management outside the institute and had nasolacrimal duct obstruction without previous episodes of dacryocystitis. Data were collected on patient demographics, clinical presentation, date of presentation, laterality, recurrence, causative organisms, complications at the time of diagnosis or during the course of management, use of empirical therapy, sensitivity to the antimicrobial agents, and management. The Institutional Review Board (IRB) approved this study. This study adhered to the ethical guidelines of the Declaration of Helsinki of 1975 as amended in 2003. The data were analyzed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Categorical data are reported as frequencies and percentages and compared using the Chi-squared or Fisher’s exact tests, as appropriate. To summarize the continuous variables, mean and standard deviation or median and interquartile range (IQR) are reported. The Student’s t -test was used to compare means. P < 0.05 is considered statistically significant. Results Subject Characteristics The study sample was comprised of 97 patients with dacryocystitis. Table 1 presents the demographic profile, surgical, and medical history. Thirty (30.9%) patients had a history of one previous episode of dacryocystitis, while 67 (69.1%) had a history of multiple episodes. Table 1 Demographics, medical and surgical profile of dacryocystitis patients. Characteristic n [%] Age at presentation in years, mean ± SD [Range], median 47.9 ± 26.5 [birth – 91.9], 53.9 Age-group Pediatrics < years 17 [17.5] Adults ≥ 18 years 80 [82.5] Gender Male 31 [32.0] Female 66 [68.0] Medical history Unremarkable 57 [58.8] Remarkable 39 [40.2] Unknown 1 [1.0] Specifying the remarkable medical history [n = 39] DM 31 HTN 5 CKD 2 Others 6 Remarkable ocular surgery [n = 17] Lacrimal 10 [58.8] Ocular 7 [41.2] Eye OD 39 [40.2] OS 55 [56.7] Bilateral 3 [3.1] The Microbiologic spectrum of Dacryocystitis by Age group and Gender In adults, there were 101 microbial isolates whereas in pediatric cases, 23 isolates were identified. Gram-positive isolates were predominant in both adult and pediatric cases. Staphylococcus aureus was present in most cultures: 25.7% of isolates from adult cases and 13% of isolates in pediatric cases. Another common gram-positive microorganism was Streptococcus pneumonia in 11.9% of isolates from adults and 13.0% of isolates in pediatric cases. The most common gram-negative isolate in pediatric cases (21.7%) was Haemophilus influenza. In adults, Pseudomonas aeruginosa was slightly more prevalent than H. influenza at 7.9% and 6.9%, respectively. Only 1 adult who was otherwise medically healthy was positive for a fungal culture ( Candida parapsilosis). Table 2 presents the microbiologic spectrum of dacryocystitis in the adult and pediatric groups. Gram-positive organisms were predominant in both genders. The microbiological spectrum was not significantly different between genders apart from Pseudomonas aeruginosa , which was observed in 7 females and only in 1 male patient. C. parapsilosis was only isolated from 1 (1.1%) female patient. Table 2 The microbiologic spectrum of dacryocystitis in adults and pediatric age groups. Pediatrics [n = 17] n [%] Adults [n = 80] n [%] Total n [%] Gram-positive isolates Streptococcus pneumoniae 3 [13.0] 12 [11.9] 15 [12.1] Streptococcus oralis 0 [0.0] 1 [1.0] 1 [0.8] Streptococcus Pyogenes 3 [13.0] 2 [2.0] 5 [4.0] Streptococcus Intermedios 3 [13.0] 0 [0.0] 3 [2.4] Streptococcus anginosus 0 [0.0] 2 [2.0] 2 [1.6] Streptococcus mitis 0 [0.0] 2 [2.0] 2 [1.6] Staphylococcus aureus 3 [13.0] 26 [25.7] 29 [23.4] staphylococcus aureus [MRSA] 1 [4.3] 5 [5.0] 6 [4.8] Staphylococcus epidermidis 0 [0.0] 4 [4.0] 4 [3.2] staphylococcus Constellatus 1 [4.3] 1 [1.0] 2 [1.6] Viridans Streptococci 1 [4.3] 0 [0.0] 1 [0.8] corynobactenum amycolatum 0 [0.0] 3 [3.0] 3 [2.4] Corynebacterium Pseudodiphtheriticum 0 [0.0] 2 [2.0] 2 [1.6] propionibacterium species 0 [0.0] 1 [1.0] 1 [0.8] Gram-negative isolates Pseudomonas aeruginosa 0 [0.0] 8 [7.9] 8 [6.5] Escherichia Coli 0 [0.0] 2 [2.0] 2 [1.6] Moraxella catarrhalis 2 [8.7] 0 [0.0] 2 [1.6] Haemophilus influenzae 5 [21.7] 7 [6.9] 12 [9.7] Haemophilus parainfluenzae 1 [4.3] 6 [5.9] 7 [5.6] Burkholderia cepacia 0 [0.0] 1 [1.0] 1 [0.8] sphingomonas paucimobilis 0 [0.0] 2 [2.0] 2 [1.6] Actinobacter baumannii complex 0 [0.0] 1 [1.0] 1 [0.8] Neisseria sica 0 [0.0] 1 [1.0] 1 [0.8] klebsiella Pneumonia 0 [0.0] 3 [3.0] 3 [2.4] Brevundimonas diminuta 0 [0.0] 1 [1.0] 1 [0.8] Citrobacter freondii 0 [0.0] 2 [2.0] 2 [1.6] Serratia marcescens 0 [0.0] 2 [2.0] 2 [1.6] Citrobacter koseri 0 [0.0] 1 [1.0] 1 [0.8] Achromobacter 0 [0.0] 1 [1.0] 1 [0.8] Enterobacter cloacae 0 [0.0] 1 [1.0] 1 [0.8] Fungus isolates Candida Parapsilosis 0 [0.0] 1 [1.0] 1 [0.8] microorganisms in total 23 [100] 101 [100] 124 [100] Previous swab results From the entire study sample, only 12 (12.4%) had swab results from previous episodes as follows: 9 were Gram-positive isolates and S. pneumoniae ( 2 ) and S. aureus ( 2 ) were the most common followed by Streptococcus constellatus ( Bhemolyti Strep), Viridans streptococci, Cornybacterium amycolatum, S. pyogenes, Achromobacter, Klebsiella pneumonia, and Streptococcus Gordonii and; there were only two cases of Gram-negative isolates including, P. aeruginosa and H. influenzae . Complications Among 97 patients, 38 (39.2%) had complications due to an episode of dacryocystitis. The most common complication was preseptal cellulitis which was present in 22 (57.9%) patients (Table 3 ). Most complications were associated with S. aureus (20 cases) and H. influenzae / parainfluenza e (13 cases). Only one case of Escherichia coli infection progressed to endophthalmitis. Table 4 presents a summary of the complications in relation to the causative microorganisms. Complications occurred in 20% of pediatrics cases and 80% of adult cases. Table 3 Complications in patients with dacryocystitis with a confirmed microbial infection. n [%] None 59 [60.8] Yes 38 [39.2] Preseptal cellulitis 22 [57.9] Worsening with Admission for IV antibiotics 14 [36.8] Orbital cellulitis 12 [31.6] Draining fistula 11 [28.9] Endophthalmitis 1 [2.6] Table 4 Complications in relation to the causative microorganisms of dacryocystitis. Preseptal cellulitis Admission for IV antibiotics Orbital cellulitis Draining fistula Endophthalmitis Total Gram-positive isolates Streptococcus pneumoniae 2 1 2 1 0 6 Streptococcus oralis 0 0 0 1 0 1 Streptococcus Pyogenes 2 2 1 1 0 6 Streptococcus Intermedios 1 1 0 0 0 2 Streptococcus mitis 0 0 0 1 0 1 Staphylococcus aureus 7 3 5 5 0 20 staphylococcus aureus [MRSA] 1 0 1 2 0 4 Staphylococcus epidermidis 2 0 2 0 0 4 staphylococcus Constellatus 2 2 0 0 0 4 Gram-negative isolates Pseudomonas aeruginosa 1 1 0 1 0 3 Escherichia Coli 0 0 0 0 1 1 Moraxella catarrhalis 0 0 0 1 0 1 Haemophilus influenzae 4 3 1 0 0 8 Haemophilus parainfluenzae 2 1 1 1 0 5 Burkholderia cepacia 1 0 1 0 0 2 sphingomonas paucimobilis 1 0 1 0 0 2 Actinobacter baumannii complex 1 1 0 0 0 2 klebsiella Pneumonia 1 0 1 0 0 2 Brevundimonas diminuta 0 0 0 1 0 1 Citrobacter freondii 1 0 1 0 0 2 Citrobacter koseri 0 1 0 0 0 1 Achromobacter 0 1 0 0 0 1 TOTAL 29 17 17 15 1 79 Management The initial antimicrobial agent used was amoxicillin/clavulanic acid as empiric therapy in 66 (68%) patients, however, we noted that 53 patients used an unknown type of antibiotic prior to presenting to our institute. Other, less commonly used antibiotics were oral cefuroxime, ciprofloxacin, and intravenous cefazolin combined with intravenous gentamycin. At initial presentation, the antibiotic therapy was started empirically in (95.9%). Among the patients receiving empiric therapy, 19 (19.6%) received antibiotics matching the sensitivity. Failed Lacrimal surgeries and microorganisms About 10 (58.8%) patients had a previous history of failed lacrimal surgeries. Four out of these cases had dacryocystitis due to multiple organisms. The surgical procedures performed on these patients were dacryocystorhinostomy (DCR), dacryocystectomy (DCT), and post-probing either with or without stent placement. S. aureus isolates was the most common isolated organism in failed lacrimal procedures. Other isolates were MRSA isolates, S. pyogenes, S. constellatus, Corynobactenum amycolatum, Corynebacterium pseudodiphtheriticum, Moraxella catarrhalis , and H. influenzae (Table 5 ). Table 5 Previous failed lacrimal surgeries and microorganisms isolates. DCR* DCT** Probing Total organism isolate Gram-positive isolates Streptococcus Pyogenes 1 0 0 1 Staphylococcus aureus 4 2 0 6 staphylococcus aureus [MRSA] 1 0 1 2 staphylococcus Constellatus 0 0 1 1 corynobactenum amycolatum 0 1 0 1 Corynebacterium Pseudodiphtheriticum 1 0 0 1 Gram-negative isolates Moraxella catarrhalis 1 0 0 1 Haemophilus parainfluenzae 0 0 1 1 TOTAL 8 3 3 14 *Dacryocystorhinostomy, **Dacryocystectomy Discussion Epidemiologically, dacryocystitis shows a bimodal distribution, as early as after birth or in middle aged individuals older than 40 years. 1 In our review, the mean age at presentation of the disease was 47.9 years, ranging from birth to 91.9 years. Our study sample was comprised of 80 adults and 17 pediatric patients with dacryocystitis. Previous studies have reported a greater prevalence of dacryocystitis among females of relatively low socioeconomic position. 10,14,16 Another study of 18 chronic dacryocystitis cases reported an 8:1 female-to-male ratio. 15 This observation can be attributed to the skeletal nasolacrimal system in females with a narrower lower and middle nasolacrimal fossa, which may account for the greater frequency of dacryocystitis in females. 17 Similarly, in our retrospective review, the prevalence of females was much larger, comprising up to 68% of cases. The microbiologic spectrum of dacryocystitis tends to be predominated by gram-positive isolates as documented in several studies. 11,12,18,19 The prevalence of Gram-positive organisms in dacryocystitis ranges from 78.3–88%. 11,22 However, in their recent article Luo et al found that the gram-positive and gram-negative isolates were equally prevalent in adults which may indicate that infection by gram-negative isolates is emerging, unlike the pediatric group where the gram-positive pathogens still predominate. 1 Among the gram-positive microbes, S. aureus is the most common pathogen in some studies. 11,22 In other studies S. pneumoniae is the predominant gram-positive organism in both adult and pediatric cases. 1 P. aeuroginosa was reported in multiple studies as the most common gram-negative organism. 19,22 But Luo et al , found that H. influenzae was the most common isolated gram-negative pathogen. 1 In our study, gram-positive organisms still predominated in all genders in both adult and pediatric cases (61.3%). In adults, we observed that S. aureus is the leading gram-positive organism [25.7%]. However, in pediatric cases, we did not observe a predominate gram-positive organism and S. aureus, S. pneumoniae, S. pyogenes , and S. intermedius were equally prevalent. However, there was a difference in gram-negative isolates between adult and pediatric cases. We found that P. aeruginosa was slightly more common than H. influenza (7.9% and 6.9%, respectively) in our adult patients. However, in pediatric patients, gram-negative infections were exclusively due to Haemophilus species. In our study, there was only one case of dacryocystitis due to a fungal infection ( C. parapsilosis) in a healthy adult female. Treating MRSA related dacryocystitis may present a treatment challenge. 12 The clinical suspicion for MRSA infection or multidrug resistant organisms should be considered in cases that do not respond to empiric antibiotic therapy. 22 As MRSA infection is emerging, this might significantly affect the choice of antibiotics in dacryocystitis cases. 11 The prevalence of community acquired MRSA ranges between 17.4% − 26.6% in patients with chronic dacryocystitis. 10,13 Our study sample included six isolates of MRSA, with four cases (66%) developing complications of pre-septal cellulitis, orbital cellulitis, and fistula. We observed that half of these cases were relatively immunocompromised (2 diabetic patients and 1 pregnant patient). Additionally, one of these patients had a history of failed endoscopic DCR with stent placement and another of these patients had failed probing with stent placement. The history of failed lacrimal procedures in these cases might be a sequelae of being infected with drug-resistant organisms, or the bacterial colonization of the lacrimal system was secondary to the presence of the foreign body (stent) with biofilm formation. In our study, 50% of MRSA isolates were resistant to more than one class of antibiotics (beta-lactamases including cephalosporins such as ceftazidime, macrolides, fusidic acid, and clindamycin). If left untreated, dacryocystitis can lead to serious complications including vision threatening sequelae. Alsalamah et al reported 7 cases of visual loss following orbital cellulitis secondary to acute dacryocystitis from gram-positive organisms. 24–30 The etiology of vision loss was attributed to optic nerve compression or intraocular pressure elevation by the mass effect of the abscess, which results in central retinal artery or ophthalmic artery obstruction. 25,26 In our study, 39% of dacryocystitis patients had complications as sequelae of their infection. The most common complication was pre-septal cellulitis (57.9%) and to a lesser extent orbital cellulitis (31.6%). Most of the complications occurred in adults (80%). The leading cause of complications were associated with infection by S. aureus [25.3% (20 cases)] and H. influenzae / parainfluenzae [16.4% (13 cases)]. One case progressed to a devastating complication of endophthalmitis secondary to E coli infection. Regular antibiotic therapy for dacryocystitis may fail in up to one-third of individuals due to the wide variety of pathogenic organisms. 12 When treating individuals with dacryocystitis, collecting cultures at the time of initiating empiric antibiotic therapy is very beneficial to provide a better treatment course. 12,30 Previous swabs are usually used to guide the management as well, here we found 69.1% had multiple episodes of dacryocystitis but the previous swabs were available only in only 12.4% of patients. An interesting observation noted in this group of patients was that only 25% of the new culture results matched the previous pathogenic organism but 40.6% of cases were due to a different pathogen and 25% were cases of multi-organism infection, which supports the advice of using a swab for culture and sensitivity at each episode as it will provide a more accurate guide for treatment. We found that most (95.5%) patients had initially received empiric coverage therapy. In these patients, the sensitivity matched the empiric therapy in 19.6% of cases. Amoxicillin/clavulanic acid was the most common antibiotic used as empirical therapy in 68% patients. The recurrence rate of dacryocystitis in patients who underwent DCR for dacryocystitis is relatively low (12%). 31 It can be attributed to multiple factors including, surgeon experience, size and site of the osteotomy, deviated septum, synechiae formation and intranasal adhesions. 32 There are some studies of the presurgical colonization and failure of the lacrimal surgery due to infectious causes. 31 Dhar et al, reported 7 eyes of 7 patients were diagnosed with recurrent dacryocystitis after DCR, the most common isolates were MRSA followed by P. aeruginosa , H. parainfluenzae , alpha-hemolytic Streptococcus viridians , and Citrobacter . 31 In our review, we had 10 (58.8%) patients with previous failed lacrimal procedures (dacryocystorhinostomy, dacryocystectomy, and post probing). In these patients, the infectious organisms were S. aureus in 60% of cases, MRSA in 20% of cases, and other isolated organisms including S. pyogenes, S. constellatus, C. amycolatum, C. pseudodiphtheriticum, M. catarrhalis , and H. influenza. The failure of the lacrimal procedure cannot be attributed directly to the bacterial infection/colonization, as other factors were not evaluated in these patients. Further studies evaluating the preoperative bacterial colonization and postoperative infection in relation to the failure rate of the lacrimal procedures might yield valuable results in guiding preventive measures. Conclusion We evaluated the microbiological spectrum of dacryocystitis at a tertiary eye institute, as the spectrum of this entity has not been studied in our area before. The trend of the microbiological spectrum and the sensitivity to antimicrobial therapy can change over time as well. Hence, understanding the current data will help in directing the first line therapy when encountering such patients. Further studies to investigate acute versus chronic cases to determine a colonization pattern, as well as evaluating the cases with nasolacrimal duct obstruction without episodes of infection are warranted, as this might reflect isolates with low virulence, in addition to evaluating the detailed pattern of infection in patients of all age groups and the clinical response to empiric therapy can yield more informative results as it was outside the scope of this study. Declarations Acknowledgments None Funding details The authors report no funding associated with the work featured in this article. Disclosure statement The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. 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Bacterial isolates and their antimicrobial susceptibility pattern among patients with external ocular infections at Borumeda hospital, Northeast Ethiopia. BMC Ophthalmol. 2015;15:103. doi: 10.1186/s12886-015-0078-z . Dhar S, Allard F, Lee I, Lee J, Freitag S. Incidence of recurrent dacryocystitis after dacryocystorhinostomy in patients with presurgical dacryocystitis, a retrospective case series review. Invest Ophthalmol Vis Sci. 2010;51(13):3522–3522. Lin GC, Brook CD, Hatton MP, Metson R. Causes of dacryocystorhinostomy failure: External versus endoscopic approach. Am J Rhinol Allergy. 2017;31(3):181–185. doi: 10.2500/ajra.2017.31.4425 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4559567","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317896436,"identity":"f7112a9e-fce7-4914-b1c8-da19141019e8","order_by":0,"name":"Amjad Alshehri","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amjad","middleName":"","lastName":"Alshehri","suffix":""},{"id":317896437,"identity":"48b32737-da93-4a75-aa92-663e0b70c894","order_by":1,"name":"Manal Alwazae","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Manal","middleName":"","lastName":"Alwazae","suffix":""},{"id":317896438,"identity":"72f755b4-8032-4ec2-b980-974122a80dc2","order_by":2,"name":"Ghaliah AlAbdulakadir","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ghaliah","middleName":"","lastName":"AlAbdulakadir","suffix":""},{"id":317896439,"identity":"3a6cfc72-cf5e-4af5-bd40-d9f3e5ee992c","order_by":3,"name":"Faisal Altahan","email":"","orcid":"","institution":"Dhahran Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Faisal","middleName":"","lastName":"Altahan","suffix":""},{"id":317896440,"identity":"6e9d5a64-99f2-4992-9c27-3c367e80d32c","order_by":4,"name":"Abdulrahman AlThaqib","email":"","orcid":"","institution":"King Khalid University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdulrahman","middleName":"","lastName":"AlThaqib","suffix":""},{"id":317896441,"identity":"460cb993-050c-4fbb-b756-e37c6fc24e28","order_by":5,"name":"Hamad Alsuliman","email":"","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hamad","middleName":"","lastName":"Alsuliman","suffix":""},{"id":317896442,"identity":"c4816148-8420-45cf-8394-cc5008deed51","order_by":6,"name":"Rawan AlThaqib","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFACHiA2OCAnAaSZwQIHCOlgg2gxJlULw4HEGURrMZ/fe/DDm4I76TN7Dh/+XMCwTY7vAPvDD/i0yBzjS5acY/AsdzZvW5r0DIbbxpIHeIwl8GmRYOMxkOYxOJw7j5/HjJmH4XbihgM8DIS0GP8GakmX4+f//BmopX7DAfbHPwhoMQPZkiDN28MgDdSSYHCAwYyALTlmlkC/GM7sOQbSe9tw5mEeMwu8WpjPGN948+eOvMSZ5MefeSpuy/Mdb398A58WMOCBswwYYLFDtJZRMApGwSgYBVgAAGzmRYBBXGC7AAAAAElFTkSuQmCC","orcid":"","institution":"King Khaled Eye Specialist Hospital","correspondingAuthor":true,"prefix":"","firstName":"Rawan","middleName":"","lastName":"AlThaqib","suffix":""}],"badges":[],"createdAt":"2024-06-10 17:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4559567/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4559567/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62432815,"identity":"dd6dc0ef-11d3-47ca-831a-15b78ab1cb3c","added_by":"auto","created_at":"2024-08-14 07:05:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":859483,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4559567/v1/372dab22-78ea-499e-ad69-9a7055cc8334.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Microbiological Spectrum of Dacryocystitis Patients at a Tertiary Eye Hospital: A Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDacryocystitis is the most common disorder of the lacrimal drainage system.\u003csup\u003e1\u003c/sup\u003e Blockage of the lacrimal drainage system either congenital or acquired is usually the main cause.\u003csup\u003e2\u003c/sup\u003e It leads to the accumulation of tears and stasis thus creating a suitable environment for secondary infection.\u003csup\u003e3,4\u003c/sup\u003e Moreover, children and neonates in particular could be more prone to severe infection due to an immature immune system.\u003csup\u003e1,5\u003c/sup\u003e Therefore, treatment of dacryocystitis in a timely manner is crucial to prevent complications.\u003csup\u003e6\u0026ndash;9\u003c/sup\u003e Most ophthalmologists treat acute dacryocystitis empirically and then tailor the treatment according to the sensitivity of the isolated organism if available or according to the clinical response.\u003csup\u003e10\u003c/sup\u003e Bacterial infection in dacryocystitis plays a major role in 60.8\u0026ndash;94.9% of all dacryocystitis.\u003csup\u003e3\u003c/sup\u003e Historically, gram-positive organisms are predominant in the peer reviewed literature.\u003csup\u003e1,11,12\u003c/sup\u003e However, there are recent reports on the increasing incidence of gram-negative organisms, as well as the methicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (MRSA).\u003csup\u003e1,12,13\u003c/sup\u003e Hence, this implies that the causative microbiological spectrum is changing and the broad-spectrum antibiotic approach could play a role in the corresponding change in ocular surface flora and susceptibility to antibiotics.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThus, understanding the microbiologic spectrum and its trend with time is critical for controlling the infection and to provide accurate antimicrobial coverage. However, there are relatively few studies focusing on the microbiologic characteristics of dacryocystitis in the current literature, and no study has conducted a review of the spectrum in the Saudi population. Therefore, this study aims to identify the demographics and microbiologic spectrum of dacryocystitis patients presenting to a tertiary eye hospital.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This retrospective study reviewed the electronic medical records of patients presenting between 2018 to March 2022 at our tertiary eye hospital. Patients were included if they were diagnosed clinically with acute or chronic dacryocystitis irrespective of age, with positive culture results from the lacrimal sac secretions. Patients were excluded if they had undergone surgical management outside the institute and had nasolacrimal duct obstruction without previous episodes of dacryocystitis. Data were collected on patient demographics, clinical presentation, date of presentation, laterality, recurrence, causative organisms, complications at the time of diagnosis or during the course of management, use of empirical therapy, sensitivity to the antimicrobial agents, and management. The Institutional Review Board (IRB) approved this study. This study adhered to the ethical guidelines of the Declaration of Helsinki of 1975 as amended in 2003. The data were analyzed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Categorical data are reported as frequencies and percentages and compared using the Chi-squared or Fisher\u0026rsquo;s exact tests, as appropriate. To summarize the continuous variables, mean and standard deviation or median and interquartile range (IQR) are reported. The Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test was used to compare means. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSubject Characteristics\u003c/h2\u003e\n \u003cp\u003eThe study sample was comprised of 97 patients with dacryocystitis. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic profile, surgical, and medical history. Thirty (30.9%) patients had a history of one previous episode of dacryocystitis, while 67 (69.1%) had a history of multiple episodes.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographics, medical and surgical profile of dacryocystitis patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en [%]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at presentation in years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD [Range], median\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 [birth \u0026ndash; 91.9], 53.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge-group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatrics\u0026thinsp;\u0026lt;\u0026thinsp;years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 [17.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdults\u0026thinsp;\u0026ge;\u0026thinsp;18 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80 [82.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 [32.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 [68.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnremarkable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 [58.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRemarkable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 [40.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecifying the remarkable medical history [n\u0026thinsp;=\u0026thinsp;39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRemarkable ocular surgery [n\u0026thinsp;=\u0026thinsp;17]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLacrimal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 [58.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOcular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 [41.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEye\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 [40.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 [56.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [3.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eThe Microbiologic spectrum of Dacryocystitis by Age group and Gender\u003c/h2\u003e\n \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n \u003cp\u003eIn adults, there were 101 microbial isolates whereas in pediatric cases, 23 isolates were identified. Gram-positive isolates were predominant in both adult and pediatric cases. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was present in most cultures: 25.7% of isolates from adult cases and 13% of isolates in pediatric cases. Another common gram-positive microorganism was \u003cem\u003eStreptococcus pneumonia\u003c/em\u003e in 11.9% of isolates from adults and 13.0% of isolates in pediatric cases. The most common gram-negative isolate in pediatric cases (21.7%) was \u003cem\u003eHaemophilus influenza. In\u003c/em\u003e adults, \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e was slightly more prevalent than \u003cem\u003eH. influenza\u003c/em\u003e at 7.9% and 6.9%, respectively. Only 1 adult who was otherwise medically healthy was positive for a fungal culture (\u003cem\u003eCandida parapsilosis).\u003c/em\u003e Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the microbiologic spectrum of dacryocystitis in the adult and pediatric groups. Gram-positive organisms were predominant in both genders. The microbiological spectrum was not significantly different between genders apart from \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e, which was observed in 7 females and only in 1 male patient. \u003cem\u003eC. parapsilosis\u003c/em\u003e was only isolated from 1 (1.1%) female patient.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe microbiologic spectrum of dacryocystitis in adults and pediatric age groups.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePediatrics [n\u0026thinsp;=\u0026thinsp;17]\u003c/p\u003e\n \u003cp\u003en [%]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdults [n\u0026thinsp;=\u0026thinsp;80]\u003c/p\u003e\n \u003cp\u003en [%]\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003en [%]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-positive isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [13.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 [11.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 [12.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus oralis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus Pyogenes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [13.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 [4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus Intermedios\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [13.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus anginosus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus mitis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaphylococcus aureus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3 [13.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e26 [25.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e29 [23.4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus aureus [MRSA]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [4.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 [5.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [4.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 [4.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 [3.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus Constellatus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [4.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eViridans Streptococci\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [4.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ecorynobactenum amycolatum\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCorynebacterium Pseudodiphtheriticum\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003epropionibacterium species\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-negative isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 [7.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 [6.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEscherichia Coli\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMoraxella catarrhalis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [8.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaemophilus influenzae\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 [21.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 [6.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e12 [9.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eHaemophilus parainfluenzae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [4.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 [5.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 [5.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eBurkholderia cepacia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003esphingomonas paucimobilis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eActinobacter baumannii complex\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNeisseria sica\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eklebsiella Pneumonia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [3.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 [2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eBrevundimonas diminuta\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCitrobacter freondii\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSerratia marcescens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [2.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 [1.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCitrobacter koseri\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAchromobacter\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFungus isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCandida Parapsilosis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 [0.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 [0.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003emicroorganisms in total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e23 [100]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e101 [100]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e124 [100]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevious swab results\u003c/h2\u003e\n \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n \u003cp\u003eFrom the entire study sample, only 12 (12.4%) had swab results from previous episodes as follows: 9 were Gram-positive isolates and \u003cem\u003eS. pneumoniae\u003c/em\u003e (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) and \u003cem\u003eS. aureus\u003c/em\u003e (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) were the most common followed by \u003cem\u003eStreptococcus constellatus\u003c/em\u003e (\u003cem\u003eBhemolyti Strep), Viridans streptococci, Cornybacterium amycolatum, S. pyogenes, Achromobacter, Klebsiella pneumonia, and Streptococcus Gordonii and;\u003c/em\u003e there were only two cases of Gram-negative isolates including, \u003cem\u003eP. aeruginosa\u003c/em\u003e and \u003cem\u003eH. influenzae\u003c/em\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eComplications\u003c/h2\u003e\n \u003cp\u003eAmong 97 patients, 38 (39.2%) had complications due to an episode of dacryocystitis. The most common complication was preseptal cellulitis which was present in 22 (57.9%) patients (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Most complications were associated with \u003cem\u003eS. aureus\u003c/em\u003e (20 cases) and \u003cem\u003eH. influenzae / parainfluenza\u003c/em\u003ee (13 cases). Only one case of \u003cem\u003eEscherichia coli\u003c/em\u003e infection progressed to endophthalmitis. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents a summary of the complications in relation to the causative microorganisms. Complications occurred in 20% of pediatrics cases and 80% of adult cases.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComplications in patients with dacryocystitis with a confirmed microbial infection.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en [%]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59 [60.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38 [39.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreseptal cellulitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 [57.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorsening with Admission for IV antibiotics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 [36.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrbital cellulitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 [31.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDraining fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 [28.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndophthalmitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 [2.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComplications in relation to the causative microorganisms of dacryocystitis.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePreseptal cellulitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission for IV antibiotics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOrbital cellulitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDraining fistula\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEndophthalmitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-positive isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus oralis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus Pyogenes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus Intermedios\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus mitis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus aureus [MRSA]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus Constellatus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"15\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-negative isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eEscherichia Coli\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMoraxella catarrhalis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHaemophilus influenzae\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHaemophilus parainfluenzae\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBurkholderia cepacia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003esphingomonas paucimobilis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eActinobacter baumannii complex\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eklebsiella Pneumonia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBrevundimonas diminuta\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCitrobacter freondii\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCitrobacter koseri\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eAchromobacter\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ch2\u003eManagement\u003c/h2\u003e\n \u003cp\u003eThe initial antimicrobial agent used was amoxicillin/clavulanic acid as empiric therapy in 66 (68%) patients, however, we noted that 53 patients used an unknown type of antibiotic prior to presenting to our institute. Other, less commonly used antibiotics were oral cefuroxime, ciprofloxacin, and intravenous cefazolin combined with intravenous gentamycin. At initial presentation, the antibiotic therapy was started empirically in (95.9%). Among the patients receiving empiric therapy, 19 (19.6%) received antibiotics matching the sensitivity.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eFailed Lacrimal surgeries and microorganisms\u003c/h2\u003e\n \u003cp\u003eAbout 10 (58.8%) patients had a previous history of failed lacrimal surgeries. Four out of these cases had dacryocystitis due to multiple organisms. The surgical procedures performed on these patients were dacryocystorhinostomy (DCR), dacryocystectomy (DCT), and post-probing either with or without stent placement. \u003cem\u003eS. aureus\u003c/em\u003e isolates was the most common isolated organism in failed lacrimal procedures. Other isolates were \u003cem\u003eMRSA\u003c/em\u003e isolates, \u003cem\u003eS. pyogenes, S. constellatus, Corynobactenum amycolatum, Corynebacterium pseudodiphtheriticum, Moraxella catarrhalis\u003c/em\u003e, and \u003cem\u003eH. influenzae\u003c/em\u003e (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrevious failed lacrimal surgeries and microorganisms isolates.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDCR*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDCT**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Probing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal organism isolate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-positive isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStreptococcus Pyogenes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus aureus [MRSA]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003estaphylococcus Constellatus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ecorynobactenum amycolatum\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCorynebacterium Pseudodiphtheriticum\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram-negative isolates\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMoraxella catarrhalis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHaemophilus parainfluenzae\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\n \u003cp\u003e*Dacryocystorhinostomy, **Dacryocystectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEpidemiologically, dacryocystitis shows a bimodal distribution, as early as after birth or in middle aged individuals older than 40 years.\u003csup\u003e1\u003c/sup\u003e In our review, the mean age at presentation of the disease was 47.9 years, ranging from birth to 91.9 years. Our study sample was comprised of 80 adults and 17 pediatric patients with dacryocystitis. Previous studies have reported a greater prevalence of dacryocystitis among females of relatively low socioeconomic position.\u003csup\u003e10,14,16\u003c/sup\u003e Another study of 18 chronic dacryocystitis cases reported an 8:1 female-to-male ratio.\u003csup\u003e15\u003c/sup\u003e This observation can be attributed to the skeletal nasolacrimal system in females with a narrower lower and middle nasolacrimal fossa, which may account for the greater frequency of dacryocystitis in females.\u003csup\u003e17\u003c/sup\u003e Similarly, in our retrospective review, the prevalence of females was much larger, comprising up to 68% of cases.\u003c/p\u003e \u003cp\u003eThe microbiologic spectrum of dacryocystitis tends to be predominated by gram-positive isolates as documented in several studies.\u003csup\u003e11,12,18,19\u003c/sup\u003e The prevalence of Gram-positive organisms in dacryocystitis ranges from 78.3\u0026ndash;88%.\u003csup\u003e11,22\u003c/sup\u003e However, in their recent article Luo et al found that the gram-positive and gram-negative isolates were equally prevalent in adults which may indicate that infection by gram-negative isolates is emerging, unlike the pediatric group where the gram-positive pathogens still predominate.\u003csup\u003e1\u003c/sup\u003e Among the gram-positive microbes, \u003cem\u003eS. aureus\u003c/em\u003e is the most common pathogen in some studies.\u003csup\u003e11,22\u003c/sup\u003e In other studies \u003cem\u003eS. pneumoniae\u003c/em\u003e is the predominant gram-positive organism in both adult and pediatric cases.\u003csup\u003e1\u003c/sup\u003e \u003cem\u003eP. aeuroginosa\u003c/em\u003e was reported in multiple studies as the most common gram-negative organism.\u003csup\u003e19,22\u003c/sup\u003e But Luo \u003cem\u003eet al\u003c/em\u003e, found that \u003cem\u003eH. influenzae\u003c/em\u003e was the most common isolated gram-negative pathogen.\u003csup\u003e1\u003c/sup\u003e In our study, gram-positive organisms still predominated in all genders in both adult and pediatric cases (61.3%). In adults, we observed that \u003cem\u003eS. aureus\u003c/em\u003e is the leading gram-positive organism [25.7%]. However, in pediatric cases, we did not observe a predominate gram-positive organism and \u003cem\u003eS. aureus, S. pneumoniae, S. pyogenes\u003c/em\u003e, and \u003cem\u003eS. intermedius\u003c/em\u003e were equally prevalent. However, there was a difference in gram-negative isolates between adult and pediatric cases. We found that \u003cem\u003eP. aeruginosa\u003c/em\u003e was slightly more common than \u003cem\u003eH. influenza\u003c/em\u003e (7.9% and 6.9%, respectively) in our adult patients. However, in pediatric patients, gram-negative infections were exclusively due to \u003cem\u003eHaemophilus\u003c/em\u003e species. In our study, there was only one case of dacryocystitis due to a fungal infection (\u003cem\u003eC. parapsilosis)\u003c/em\u003e in a healthy adult female.\u003c/p\u003e \u003cp\u003eTreating MRSA related dacryocystitis may present a treatment challenge.\u003csup\u003e12\u003c/sup\u003e The clinical suspicion for MRSA infection or multidrug resistant organisms should be considered in cases that do not respond to empiric antibiotic therapy.\u003csup\u003e22\u003c/sup\u003e As MRSA infection is emerging, this might significantly affect the choice of antibiotics in dacryocystitis cases.\u003csup\u003e11\u003c/sup\u003e The prevalence of community acquired MRSA ranges between 17.4% \u0026minus;\u0026thinsp;26.6% in patients with chronic dacryocystitis.\u003csup\u003e10,13\u003c/sup\u003e Our study sample included six isolates of MRSA, with four cases (66%) developing complications of pre-septal cellulitis, orbital cellulitis, and fistula. We observed that half of these cases were relatively immunocompromised (2 diabetic patients and 1 pregnant patient). Additionally, one of these patients had a history of failed endoscopic DCR with stent placement and another of these patients had failed probing with stent placement. The history of failed lacrimal procedures in these cases might be a sequelae of being infected with drug-resistant organisms, or the bacterial colonization of the lacrimal system was secondary to the presence of the foreign body (stent) with biofilm formation. In our study, 50% of MRSA isolates were resistant to more than one class of antibiotics (beta-lactamases including cephalosporins such as ceftazidime, macrolides, fusidic acid, and clindamycin).\u003c/p\u003e \u003cp\u003eIf left untreated, dacryocystitis can lead to serious complications including vision threatening sequelae. Alsalamah et al reported 7 cases of visual loss following orbital cellulitis secondary to acute dacryocystitis from gram-positive organisms.\u003csup\u003e24\u0026ndash;30\u003c/sup\u003e The etiology of vision loss was attributed to optic nerve compression or intraocular pressure elevation by the mass effect of the abscess, which results in central retinal artery or ophthalmic artery obstruction.\u003csup\u003e25,26\u003c/sup\u003e In our study, 39% of dacryocystitis patients had complications as sequelae of their infection. The most common complication was pre-septal cellulitis (57.9%) and to a lesser extent orbital cellulitis (31.6%). Most of the complications occurred in adults (80%). The leading cause of complications were associated with infection by \u003cem\u003eS. aureus\u003c/em\u003e [25.3% (20 cases)] and \u003cem\u003eH. influenzae / parainfluenzae\u003c/em\u003e [16.4% (13 cases)]. One case progressed to a devastating complication of endophthalmitis secondary to \u003cem\u003eE coli\u003c/em\u003e infection.\u003c/p\u003e \u003cp\u003eRegular antibiotic therapy for dacryocystitis may fail in up to one-third of individuals due to the wide variety of pathogenic organisms.\u003csup\u003e12\u003c/sup\u003e When treating individuals with dacryocystitis, collecting cultures at the time of initiating empiric antibiotic therapy is very beneficial to provide a better treatment course.\u003csup\u003e12,30\u003c/sup\u003e Previous swabs are usually used to guide the management as well, here we found 69.1% had multiple episodes of dacryocystitis but the previous swabs were available only in only 12.4% of patients. An interesting observation noted in this group of patients was that only 25% of the new culture results matched the previous pathogenic organism but 40.6% of cases were due to a different pathogen and 25% were cases of multi-organism infection, which supports the advice of using a swab for culture and sensitivity at each episode as it will provide a more accurate guide for treatment. We found that most (95.5%) patients had initially received empiric coverage therapy. In these patients, the sensitivity matched the empiric therapy in 19.6% of cases. Amoxicillin/clavulanic acid was the most common antibiotic used as empirical therapy in 68% patients.\u003c/p\u003e \u003cp\u003eThe recurrence rate of dacryocystitis in patients who underwent DCR for dacryocystitis is relatively low (12%).\u003csup\u003e31\u003c/sup\u003e It can be attributed to multiple factors including, surgeon experience, size and site of the osteotomy, deviated septum, synechiae formation and intranasal adhesions.\u003csup\u003e32\u003c/sup\u003e There are some studies of the presurgical colonization and failure of the lacrimal surgery due to infectious causes.\u003csup\u003e31\u003c/sup\u003e Dhar et al, reported 7 eyes of 7 patients were diagnosed with recurrent dacryocystitis after DCR, the most common isolates were \u003cem\u003eMRSA\u003c/em\u003e followed by \u003cem\u003eP. aeruginosa\u003c/em\u003e, \u003cem\u003eH. parainfluenzae\u003c/em\u003e, alpha-hemolytic \u003cem\u003eStreptococcus viridians\u003c/em\u003e, and \u003cem\u003eCitrobacter\u003c/em\u003e.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn our review, we had 10 (58.8%) patients with previous failed lacrimal procedures (dacryocystorhinostomy, dacryocystectomy, and post probing). In these patients, the infectious organisms were \u003cem\u003eS. aureus\u003c/em\u003e in 60% of cases, \u003cem\u003eMRSA in\u003c/em\u003e 20% of cases, and other isolated organisms including \u003cem\u003eS. pyogenes, S. constellatus, C. amycolatum, C. pseudodiphtheriticum, M. catarrhalis\u003c/em\u003e, and \u003cem\u003eH. influenza.\u003c/em\u003e The failure of the lacrimal procedure cannot be attributed directly to the bacterial infection/colonization, as other factors were not evaluated in these patients. Further studies evaluating the preoperative bacterial colonization and postoperative infection in relation to the failure rate of the lacrimal procedures might yield valuable results in guiding preventive measures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe evaluated the microbiological spectrum of dacryocystitis at a tertiary eye institute, as the spectrum of this entity has not been studied in our area before. The trend of the microbiological spectrum and the sensitivity to antimicrobial therapy can change over time as well. Hence, understanding the current data will help in directing the first line therapy when encountering such patients. Further studies to investigate acute versus chronic cases to determine a colonization pattern, as well as evaluating the cases with nasolacrimal duct obstruction without episodes of infection are warranted, as this might reflect isolates with low virulence, in addition to evaluating the detailed pattern of infection in patients of all age groups and the clinical response to empiric therapy can yield more informative results as it was outside the scope of this study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003eFunding details\u003c/h2\u003e\n\u003cp\u003eThe authors report no funding associated with the work featured in this article.\u003c/p\u003e\n\u003ch2\u003eDisclosure statement\u003c/h2\u003e\n\u003cp\u003eThe authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRA curated the research idea and supervised the research, AA, MA, GA, and FA wrote the manuscript, AA and MA were involved in data collection, AA and MA helped with the statistics, ANA and HA helped with extensive reviewing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLuo B, Li M, Xiang N, Hu W, Liu R, Yan X. The microbiologic spectrum of dacryocystitis. BMC Ophthalmol. 2021;21:29. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12886-020-01792-4\u003c/span\u003e\u003cspan address=\"10.1186/s12886-020-01792-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlaboudi A, Al-Shaikh O, Fatani D, Alsuhaibani AH. 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Case Rep Ophthalmol Med. 2016;2016:9630698. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2016/9630698\u003c/span\u003e\u003cspan address=\"10.1155/2016/9630698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiferaw B, Gelaw B, Assefa A, Assefa Y, Addis Z. Bacterial isolates and their antimicrobial susceptibility pattern among patients with external ocular infections at Borumeda hospital, Northeast Ethiopia. BMC Ophthalmol. 2015;15:103. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12886-015-0078-z\u003c/span\u003e\u003cspan address=\"10.1186/s12886-015-0078-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhar S, Allard F, Lee I, Lee J, Freitag S. Incidence of recurrent dacryocystitis after dacryocystorhinostomy in patients with presurgical dacryocystitis, a retrospective case series review. Invest Ophthalmol Vis Sci. 2010;51(13):3522\u0026ndash;3522.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin GC, Brook CD, Hatton MP, Metson R. Causes of dacryocystorhinostomy failure: External versus endoscopic approach. Am J Rhinol Allergy. 2017;31(3):181\u0026ndash;185. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2500/ajra.2017.31.4425\u003c/span\u003e\u003cspan address=\"10.2500/ajra.2017.31.4425\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"dacryocystitis, microbiological spectrum, antimicrobial susceptibility","lastPublishedDoi":"10.21203/rs.3.rs-4559567/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4559567/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: The purpose of this study is to determine the microbiological spectrum and the demographics of dacryocystitis patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective chart review on patients’ electronic medical records were utilized to collect data on patients who presented with dacryocystitis. A total of 97 patients were included and data were collected on the demographics, type of organisms, antibiotic sensitivity, response to antibiotics therapy, management, and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Gram-positive cultures predominated in all genders in both adult and pediatric age groups and accounted for 61.3% of the sample. In adults, \u003cem\u003eStaphylococcus aureus \u003c/em\u003ewas the leading gram-positive organism (25.7%) while \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e(7.9%)\u003cem\u003e \u003c/em\u003eand \u003cem\u003e\u003cstrong\u003eHaemophilus influenzae\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003e(6.9%) were the most common gram-negative organisms. In pediatric cases, \u003cem\u003eStaphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, and Streptococcus intermedius\u003c/em\u003e were equally prevalent and gram-negative infection was exclusively due to \u003cem\u003eHaemophilus species \u003c/em\u003e(26%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Comprehending the microbiologic spectrum and its trend is crucial for managing an infection and recommending suitable antibiotic therapy. Initial Empirical therapy for dacryocystitis cases is targeted toward the Gram-positive organisms due to its prevalence. As a result, we heartily advise conducting a local study from time to time to assess the trend in the microbiological spectrum and shift in epidemiology, along with the antimicrobial sensitivity.\u003c/p\u003e","manuscriptTitle":"Assessing the Microbiological Spectrum of Dacryocystitis Patients at a Tertiary Eye Hospital: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 10:07:57","doi":"10.21203/rs.3.rs-4559567/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed7c09c8-6abf-4a29-bb21-025b1b48abba","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-14T06:57:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-26 10:07:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4559567","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4559567","identity":"rs-4559567","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}