Dacryocystitis Caused by Anaerobic Bacteria in the Newborn

The predominant bacteria causing acute dacryocystitis in neonates are aerobic organisms such as Streptococcus pneumoniae andStaphylococcus aureus,1, 2 Anaerobic bacteria have been rarely recovered in these patients.3 Reported here are two newborns who developed dacryocystitis caused by anaerobic bacteria. Case reports.Patient 1. A 20-day-old male infant presented with severe inflammation and swelling over the left lacrimal sac that developed during the previous 4 days. He was the 3650-g product of a normal term pregnancy and delivery by a 20-year-old woman. Rectal temperature was 38°C and the white blood cell count was 12 500/mm3 with a normal differential count. He underwent incision and drainage of the lacrimal sac abscess, and specimens of the pus were cultured for aerobic and anaerobic bacteria. The cultures showed a heavy growth of Peptostreptococcus micros and Prevotella intermedia. A Gram-stained smear revealed numerous Gram-positive cocci and a few weakly stained Gram-negative bacilli. Blood cultures were sterile. The patient was treated with intravenous ticarcillin-clavulanate for 7 days, followed by oral amoxicillin-clavulanate for an additional 14 days. The dacryocystitis resolved within 72 h and no recurrence was noted on a follow-up at 9 months of age. Patient 2. An 11-day-old male infant presented with severe inflammation and swelling of the right lacrimal sac that developed during the previous 3 days. Temperature was 38°C and the white blood cell count was 14 600/mm3 with 82% segmented neutrophils, 10% monocytes, 8% lymphocytes, 8% band forms and 2 eosinophils. He was the product of a 31-year-old gravida 2 woman at 38 weeks of gestation and weighed 3250 g. Maternal membranes ruptured 24 h before delivery. The mother developed a fever of 38.2°C during the delivery and was given one dose of cefoxitin intravenously. The newborn had mild respiratory distress and an Apgar score of 6 at 5 min after delivery. However, his condition stabilized and he was released from the hospital at 4 days of age. He received no antimicrobial therapy. He underwent incision and drainage of the abscess. Probing of the duct did not reveal obstruction. Gram-stained smear of the pus revealed Gram-positive cocci in chains. Culture of the pus developed heavy growth of Peptostreptococcus magnus and Fusobacterium nucleatum. The patient was treated intravenously with ampicillin and gentamicin. Gentamicin was discontinued after 72 h, ampicillin was continued intravenously for a total of 8 days and amoxicillin was given orally for an additional 15 days. The patient's dacryocystitis resolved within 48 h. However, the patient needed probing of the lacrimal duct at the age of 9 months because of continuous epiphora. Discussion. This report describes the recovery of anaerobic bacteria in two newborns with acute dacryocystitis. The anaerobes isolated (Peptostreptococcus spp. and Gram-negative bacilli) are likely of endogenous origin because they are members of the normal oral and skin flora4 and normal conjunctival flora.5, 6 Colonization of the conjunctiva by anaerobic bacteria from the maternal birth canal occurs in most vaginally delivered newborns,7 and conjunctivitis caused by these organisms has been described.8 However, most of the anaerobic Gram-negative bacilli do not survive in the conjunctiva for >48 h.7 It is plausible that in the presence of the predisposition for dacryocystitis these organisms can survive longer and participate in the infectious process. The actual prevalence of these organisms in dacryocystitis in infants has yet to be investigated by prospective studies. This is of particular importance because these organisms are often resistant to the antimicrobials used for therapy of dacryocystitis. We elected to treat the patients for at least 21 days to achieve complete eradication of the infection. It is recommended, however, that specimens of dacryocystitis be cultured for both aerobic and anaerobic bacteria so that proper antimicrobial therapy can be directed against the pathogens. Itzhak Brook, M.D., M.Sc. Department of Pediatrics; Georgetown University; Washington, DC