Bacteriological profile in conjunctival, lacrimal sac, and nasal specimens and conjunctival normalization time following external, endoscopic, and transcanalicular multidiode laser dacryocystorhinostomy

Balikoglu-Yilmaz, Melike; Esen, Ayse Banu; Yilmaz, Tolga; Taskin, Umit; Taskapili, Muhittin; Oktay, M. Faruk; Sen, Emine; Kose, Timur

doi:10.5935/0004-2749.20160049

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Original Articles • Arq. Bras. Oftalmol. 79 (3) • May-Jun 2016 • https://doi.org/10.5935/0004-2749.20160049 copy

Bacteriological profile in conjunctival, lacrimal sac, and nasal specimens and conjunctival normalization time following external, endoscopic, and transcanalicular multidiode laser dacryocystorhinostomy

Perfil bacteriológico e tempo de normalização conjuntival de espécimes de conjuntiva, saco lacrimal e nasais após dacriocistorrinostomia externa, endoscópica e transcanalicular com laser de multi diodo

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

To compare the conjunctival, lacrimal sac, and nasal flora cultures and conjunctival normalization time following external (EX-), endoscopic (EN-), and transcanalicular multidiode laser (TC-) dacryocystorhinostomy (DCR) and to evaluate the relationship between culture positivity and surgical success. We further performed antibiotic sensitivity analyses for lacrimal sac culture samples.

Methods:

A total of 90 patients with primary acquired nasolacrimal duct obstruction were recruited and divided into EX-DCR (n=32), EN-DCR (n=28), and TC-DCR (n=30) groups. Conjunctival, nasal, and lacrimal sac cultures and antibiograms were analyzed.

Results:

In all three groups, coagulase-negative Staphylococcus (CNS) was predominantly isolated preoperatively from the conjunctiva, nose, and lacrimal sac and postoperatively from the conjunctiva. Preoperative and postoperative conjunctival culture positivity rates were similar between all the groups (p>0.05). A statistically significant difference in the growth rate of culture in the lacrimal sac was observed between the three groups (p=0.001). CNS and Staphylococcus aureus cultures were predominantly sensitive to linezolid, teicoplanin, tigecycline, vancomycin, and mupirocin. Conjunctival normalization times were similar between the three groups (p>0.05). Anatomical and functional success rates were not found to be significantly correlated with preoperative conjunctival and lacrimal sac culture positivity (p>0.05).

Conclusions:

Similar rates of preoperative and 1-week postoperative conjunctival culture positivity were observed in all the groups; a significantly lower bacterial growth rate was observed in postoperative conjunctival cultures. CNS was the most commonly isolated organism. Bacterial growth rates in the lacrimal sac samples were significantly higher in the EN-DCR group. Bacterial growth rates obtained preoperatively from the conjunctival and lacrimal sac culture samples were not correlated with DCR success.

Keywords:
Conjunctiva; Dacryocystorhinostomy; Nasolacrimal duct; Antibiotic sensitivity tests; Staphylococcus aureus, Transcanalicular multidiode laser

	EX-DCR (n=32)	EN-DCR (n=28)	TC-DCR (n=30)	Total (n=90)	p value
Age (years)^* * = Values are presented as mean ± standard deviation;	52.2 ± 16.5	46.8 ± 20.9	50.1 ± 19.8	49.8 ± 18.9	0.544^a a = One-way ANOVA;
Female: male	26:6	20:8	23:7	69:21	0.669^b b = Chi-square (χ2) test;
Laterality (right: left)	17:15	14:14	15:15	46:44	0.961^b b = Chi-square (χ2) test;
Follow-up time (months)^* * = Values are presented as mean ± standard deviation;	17.0 ± 2.1	13.9 ± 2.3^d d = p<0.001 compared with the EX-DCR group, Mann-Whitney U test; ,^e e = p<0.001 compared with the TC-DCR group, Mann-Whitney U test.	17.3 ± 1.3	16.1 ± 2.5	<0.001^c c = Kruskal-Wallis test;

	EX-DCR (n=32)		EN-DCR (n=28)		TC-DCR (n=30)		Total (n=90)
	I	c	I	c	I	c	I	c
Preoperative conjunctival culture
No bacteria isolated	17 (53.1)	21 (65.6)	16 ( 57.1)	20 (71.4)	21 ( 70.0)	28 (93.3)	54 (60.0)	69 (76.7)
MSSA	1 ( 3.1)	2 ( 6.3)	1 ( 3.6)	3 (10.7)	3 ( 10.0)	1 ( 3.3)	5 ( 5.6)	6 ( 6.7)
MRSA	-	-	1 ( 3.6)	1 ( 3.6)	1 ( 3.3)	1 ( 3.3)	2 ( 2.2)	2 ( 2.2)
Staph. epidermidis	6 (18.8)	7 (21.9)	6 ( 21.4)	4 (14.3)	1 ( 3.3)	-	13 (14.4)	11 (12.2)
Staph. hominis	-	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)
Staph. lugdunensis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Staph. haemolyticus	-	-	-	-	2 ( 6.7)	-	2 ( 2.2)	-
Staph. warneri	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)	-
Strep. pluranimalium	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Strep. sanguinis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Strep. pneumoniae	-	-	2 ( 7.1)	-	-	-	2 ( 2.2)	-
Haemophilus influenzae	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Pseudomonas aeruginosa	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Proteus mirabilis	1 ( 3.1)	1 ( 3.1)	-	-	1 ( 3.3)	-	2 ( 2.2)	1 ( 1.1)
Citrobacter koseri	1 ( 3.1)	-	-	-	1 ( 3.3)	-	2 ( 2.2)	-
Sphingomonas paucimobilis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Neisseria elongata	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)	-
Preoperative nasal culture
No bacteria isolated	-	1 ( 3.1)	1 ( 3.6)	1 ( 3.6)	-	-	1 ( 1.1)	2 ( 2.2)
MSSA	5 (15.6)	7 (21.9)	8 ( 28.6)	7 (25.0)	4 ( 13.3)	3 (10.0)	17 (18.9)	17 (18.9)
MRSA	-	-	-	-	3 ( 10.0)	3 (10.0)	3 ( 3.3)	3 ( 3.3)
Staph. epidermidis	25 (78.1)	23 (71.9)	16 ( 57.1)	19 (67.9)	20 ( 66.7)	19 (63.3)	61 (67.8)	61 (67.8)
Staph. hominis	1 ( 3.1)	1 ( 3.1)	1 ( 3.6)	-	-	-	2 ( 2.2)	1 ( 1.1)
Staph. haemolyticus	-	-	1 ( 3.6)	-	2 ( 6.7)	2 ( 6.7)	3 ( 3.3)	2 ( 2.2)
Strep. pneumoniae	-	-	1 ( 3.6)	1 ( 3.6)	-	1 ( 3.3)	1 ( 1.1)	2 ( 2.2)
Pseudomonas aeruginosa	-	-	-	-	1 ( 3.3)	1 ( 3.3)	1 ( 1.1)	1 ( 1.1)
Serratia marcescens	-	-	-	-	-	1 ( 3.3)	-	1 ( 1.1)
Sphingomonas paucimobilis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Lacrimal sac culture
No bacteria isolated	19 (59.4)	-	4 ( 14.3)	-	16 ( 53.3)	-	39 (43.3)	-
Aerobic bacteria
MSSA	1 ( 3.1)	-	6 ( 21.4)	-	4 ( 13.3)	-	11 (12.2)	-
MRSA	-	-	1 ( 3.6)	-	1 ( 3.1)	-	2 ( 2.2)	-
Staph. epidermidis	4 (12.5)	-	11 ( 39.3)	-	5 ( 16.7)	-	20 (22.2)	-
Staph. lugdunensis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Staph. haemolyticus	-	-	1 ( 3.6)	-	1 ( 3.1)	-	2 ( 2.2)	-
Corynebacterium jeikeium	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)	-
Strep. pluranimalium	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Strep. mitis	1 ( 3.1)	-	1 ( 3.6)	-	-	-	2 ( 2.2)	-
Strep. pneumonia	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)	-
Strep. pyogenes	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)	-
Haemophilus influenzae	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Pseudomonas aeruginosa	1 ( 3.1)	-	-	-	1 ( 3.1)	-	2 ( 2.2)	-
Serratia marcescens	-	-	-	-	1 ( 3.1)	-	1 ( 1.1)	-
Citrobacter koseri	1 ( 3.1)	-	-	-	1 ( 3.1)	-	2 ( 2.2)	-
Sphingomonas paucimobilis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
Kocuria kristinae	-	-	1 ( 3.6)	-	-	-	1 ( 1.1)
Anaerobic bacteria
Bacteroides fragilis	1 ( 3.1)	-	-	-	-	-	1 ( 1.1)	-
First postoperative week conjunctival culture
No bacteria isolated	26 (81.2)	-	27 ( 96.4)	-	26 ( 86.7)	-	79 (87.8)	-
Staph. aureus	-	-	-	-	1 ( 3.3)	-	1 ( 1.1)	-
Staph. epidermidis	6 (18.8)	-	1 ( 3.6)	-	3 ( 10.0)	-	10 (11.1)	-
Second postoperative week conjunctival culture^* * = at the second, third, and fourth postoperative week, conjunctival culture specimens of the involved side were taken from 86, 11, and 4 patients, respectively.
No bacteria isolated	27 (87.1)	-	25 (100.0)	-	29 ( 96.7)	-	81 (94.1)	-
Staph. aureus	-	-	-	-	1 ( 3.3)	-	1 ( 1.2)	-
Staph. epidermidis	3 ( 9.7)	-	-	-	-	-	3 ( 3.5)	-
Staph. hominis	1 ( 3.2)	-	-	-	-	-	1 ( 1.2)	-
Third postoperative week conjunctival culture^* * = at the second, third, and fourth postoperative week, conjunctival culture specimens of the involved side were taken from 86, 11, and 4 patients, respectively.
No bacteria isolated	4 (66.7)	-	2 (100.0)	-	3 (100.0)	-	9 (81.8)	-
Staph. epidermidis	2 (33.3)	-	-	-	-	-	2 (18.2)	-
Fourth postoperative week conjunctival culture^* * = at the second, third, and fourth postoperative week, conjunctival culture specimens of the involved side were taken from 86, 11, and 4 patients, respectively.
No bacteria isolated	2 (66.7)	-	-	-	1 (100.0)	-	3 (75.0)	-
Staph. aureus	1 (33.3)	-	-	-	-	-	1 (25.0)	-

	EX-DCR (n=32)	EN-DCR (n=28)	TC-DCR (n=30)	Total (n=90)	p value
Preoperative conjunctival site bacterial growth, n (%)
Involved side	15 ( 46.9)	12 (42.9)	9 ( 30.0)	36 (40.0)	0.372^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
Contralateral side	11 ( 34.4)	8 (28.6)	2 (6.7)	21 (23.3)	0.026^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
pvalue				0.004^b b = McNemar test; ,^e e = preoperative flora growth rate in the involved conjunctival side compared with that in the contralateral conjunctival side;
Preoperative nasal site bacterial growth, n (%)
Involved side	32 (100.0)	27 (96.4)	30 (100.0)	89 (98.9)	0.326^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
Contralateral side	31 ( 96.9)	27 (96.4)	30 (100.0)	88 (97.8)	0.596^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
pvalue				1.000^b b = McNemar test; .^f f = preoperative flora growth rate in the involved nasal side compared with that in the contralateral nasal side;
Intraoperative lacrimal sac bacterial growth, n (%)
Involved side	13 ( 40.6)	24 (85.7)	14 ( 46.7)	51 (56.7)	0.001^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
pvalue	0.727^b b = McNemar test; ,^g g = aerobic flora growth rate in the lacrimal sac sample compared with preoperative flora growth rate at the involved conjunctival side;	0.002^b b = McNemar test; ,^g g = aerobic flora growth rate in the lacrimal sac sample compared with preoperative flora growth rate at the involved conjunctival side;	0.180^b b = McNemar test; ,^g g = aerobic flora growth rate in the lacrimal sac sample compared with preoperative flora growth rate at the involved conjunctival side;	0.011^b b = McNemar test; ,^g g = aerobic flora growth rate in the lacrimal sac sample compared with preoperative flora growth rate at the involved conjunctival side;
First postoperative week conjuntival site bacterial growth, n (%)
Involved side	6 ( 18.8)	1 ( 3.6)	4 ( 13.3)	11 (12.2)	0.196^a a = Chi-square (χ2) test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
pvalue	0.022^b b = McNemar test; ,^h h = preoperative flora growth rate in the involved conjunctival side compared with the flora growth rate in the involved conjunctival side at the first postoperative week;	0.001^b b = McNemar test; ,^h h = preoperative flora growth rate in the involved conjunctival side compared with the flora growth rate in the involved conjunctival side at the first postoperative week;	0.267^b b = McNemar test; ,^h h = preoperative flora growth rate in the involved conjunctival side compared with the flora growth rate in the involved conjunctival side at the first postoperative week;	<0.001^b b = McNemar test; ,^h h = preoperative flora growth rate in the involved conjunctival side compared with the flora growth rate in the involved conjunctival side at the first postoperative week;
Conjunctival normalization time (weeks, mean ± S.D.)
Involved side	1.47 ± 1.08	1.04 ± 0.19	1.17 ± 0.46	1.23 ± 0.72	0.166^d d = Kruskal-Wallis test; ,^j j = comparison of external, endoscopic, and transcanalicular dacryocystorhinostomy;
Conjunctival flora growth
No growth	1.29 ± 0.85	1.00 ± 0.00	1.24 ± 0.54	1.19 ± 0.59
Growth	1.67 ± 1.29	1.08 ± 0.29	1.00 ± 0.00	1.31 ± 0.89
p value	0.292^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.248^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.168^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.659^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.
Lacrimal sac flora growth
No growth	1.26 ± 0.81	1.00 ± 0.00	1.06 ± 0.25	1.15 ± 0.59
Growth	1.77 ± 1.36	1.04 ± 0.20	1.29 ± 0.61	1.29 ± 0.81
p value	0.159^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.683^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.218^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.	0.264^c c = Mann-Whitney U test; ,^k k = comparison of groups without and with growth based on sterilization week.

		Preoperative conjunctival bacterial growth, n (%)			Lacrimal sac bacterial growth, n (%)
		+	-	p value	+	-	p value
EX-DCR (n=32)
Anatomical success	Successful	13 (86.7)	13 (76.5)	0.659^b b = Fisher’s exact test.	11 (84.6)	15 ( 78.9)	1.000^b b = Fisher’s exact test.
	Unsuccessful	2 (13.3)	4 (23.5)		2 (15.4)	4 ( 21.1)
Functional success	Successful	13 (86.7)	13 (76.5)	0.659^b b = Fisher’s exact test.	11 (84.6)	15 ( 78.9)	1.000^b b = Fisher’s exact test.
	Unsuccessful	2 (13.3)	4 (23.5)		2 (15.4)	4 ( 21.1)
EN-DCR (n=28)
Anatomical success	Successful	8 (66.7)	13 (81.3)	0.418^b b = Fisher’s exact test.	17 (70.8)	4 (100.0)	0.545^b b = Fisher’s exact test.
	Unsuccessful	4 (33.3)	3 (18.8)		7 (29.2)	-
Functional success	Successful	8 (66.7)	12 (75.0)	0.691^b b = Fisher’s exact test.	16 (66.7)	4 (100.0)	0.295^b b = Fisher’s exact test.
	Unsuccessful	4 (33.3)	4 (25.0)		8 (33.3)	-
TC-DCR (n=30)
Anatomical success	Successful	7 (77.8)	16 (76.2)	1.000^b b = Fisher’s exact test.	10 (71.4)	13 ( 81.2)	0.675^b b = Fisher’s exact test.
	Unsuccessful	2 (22.2)	5 (23.8)		4 (28.6)	3 ( 18.8)
Functional success	Successful	6 (66.7)	16 (76.2)	0.666^b b = Fisher’s exact test.	9 (64.3)	13 ( 81.0)	0.417^b b = Fisher’s exact test.
	Unsuccessful	3 (33.3)	5 (23.8)		5 (35.7)	3 ( 20.0)
Total (n=90)
Anatomical success	Successful	28 (77.8)	42 (77.8)	1.000^a a = Chi-square (χ2) test;	38 (74.5)	32 ( 82.1)	0.394^a a = Chi-square (χ2) test;
	Unsuccessful	8 (22.2)	12 (22.2)		13 (25.5)	7 ( 17.9)
Functional success	Successful	27 (75.0)	41 (75.9)	0.920^a a = Chi-square (χ2) test;	36 (70.6)	32 ( 82.1)	0.210^a a = Chi-square (χ2) test;
	Unsuccessful	9 (25.0)	13 (24.1)		15 (29.4)	7 ( 17.9)

	Sensitive for CNS	Sensitive for S. aureus	Sensitive for CNS and S. aureus
	n (%)	n (%)	n (%)
Clindamycin	16/21 ( 76.2)	11/12 ( 91.7)	27/33 ( 81.8)
Erythromycin	11/20 ( 55.0)	12/13 ( 92.3)	23/33 ( 69.7)
Fosfomycin	6/7 ( 85.7)	3/3 (100.0)	9/10 ( 90.0)
Fucidic acid	6/9 ( 66.7)	5/0 (100.0)	11/14 ( 78.6)
Gentamicin	13/18 ( 72.2)	11/11 (100.0)	24/29 ( 82.8)
Levofloxacin	9/12 ( 75.0)	9/9 (100.0)	18/21 ( 85.7)
Linezolid	7/7 (100.0)	3/3 (100.0)	10/10 (100.0)
Moxifloxacin	3/4 ( 75.0)	3/3 (100.0)	6/7 ( 85.7)
Oxacillin	5/18 ( 27.8)	9/11 ( 81.8)	14/29 ( 48.3)
Penicillin G	1/13 ( 7.7)	0/9 ( 0.0)	1/22 ( 4.5)
Rifampicin	8/13 ( 61.5)	3/4 ( 75.0)	11/17 ( 64.7)
Teicoplanin	5/5 (100.0)	3/3 (100.0)	8/8 (100.0)
Tetracycline	2/12 ( 16.7)	4/4 (100.0)	6/16 ( 37.5)
Tigecycline	2/2 (100.0)	2/2 (100.0)	4/4 (100.0)
Tobramycin	12/18 ( 66.7)	11/11 (100.0)	23/29 ( 79.3)
Trimethoprim Sulfamethoxazole	12/17 ( 70.6)	10/10 (100.0)	22/27 ( 81.5)
Vancomycin	6/6 (100.0)	3/3 (100.0)	9/9 (100.0)
Mupirocin	12/12 (100.0)	6/6 (100.0)	18/18 (100.0)

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[1] Corresponding author: Melike Balikoglu-Yilmaz. Department of Ophthalmology, Izmir Katip Celebi University. Faculty of Medicine. Izmir - Turkey - E-mail: drmelkebalkoglu@yahoo.com