The epidemiology and the pathogen distribution of pediatric dacryocystitis in Chinese population 2017–2022

Dacryocystitis is the most common ophthalmic disease among children, especially in neonate. Persistence of Hasner’s membrane is the most common cause of dacryostenosis [1, 2], with more than 90% of cases showing perforation during the first 4 to 6 weeks [3]. If no perforation occurs, the tears gather in the lacrimal duct and sac until the system is full and therefore may become infected [4]. The clinical manifestation is tear discharge, accompanied by increased viscous or purulent drainage, which could lead to keratitis, acute dacryocystitis, lacrimal sac abscess, and other serious consequences if not treated in time [4, 5]. Congenital dacryocyst is a cyan cystic mass in the inner canthus of newborns, and is caused by obstruction at both ends of the diversion channel [6]. Some study reported that in children, nearly 60% of patients with congenital dacryocyst eventually develop a peri-dacryocyst infection [7, 8]. Dacryocystitis is mainly caused by Gram-positive cocci, especially Streptococcus pneumoniae; due to the misuse of anti-Gram-positive cocci antibiotics, Gram-negative Enterobacteriaceae have risen in the proportion of dacryocystitis pathogens [9]. However, there is no data about the epidemiology of pediatric dacryocystitis and the distribution of dacryocystitis pathogens. We have presented the epidemiology and pathogen distribution of dacryocystitis in children in Henan, China over the past 6 years, providing a basis for ophthalmic infection prevention and clinical management strategies.

This study has compared the number and proportion of different pathogens over 6 years from January 1, 2017, to December 31, 2022 (including period of Coronavirus disease-19 (COVID-19) pandemic, early 2020 to 2022) in our Hospital. A total of 5791 cases were included, including 3391 males and 2400 females.

The data in this paper show that the incidence of dacryocystitis varies from year to year, and the distribution of pathogens in purulent drainage cultures from children’s eyes also varies. Among the 6 years of data analyzed in this paper, 3 years of the COVID-19 pandemic in China were included. As the largest public health event in recent years, this may provide a reference for pathogen changes in subsequent similar events (widespread respiratory epidemics or other events that require reduced human mobility). We need to continuously monitor the epidemiologic changes of various pathogens in the ophthalmic system and their impressionable factors.

The average age of children with dacryocystitis rose for the past few years, but the median age remained that of infancy. In a study by Daphna Prat et al. [11]. It was found that out of the 169 cases studied by them, 55% of the children were below 3 months of age, the mean age was 1.6 ± 2.9 years. Infancy and the neonatal period are the main groups in which dacryocystitis occurs in children and may be associated with the following factors: Congenital disorders of tear duct development are the main causes of dacryocystitis, including unruptured Hasner’s valves, blockage of the tear ducts or conjunctivitis due to obstetrical infections, or stenosis of the tear ducts at the bones [12]. Children in infancy and the neonatal period are more likely to become infected by touching their hands to the eye when exposed to their surroundings without good hygiene.

The male to female ratio of children with dacryocystitis was approximately 3:2 in all years, suggesting that the male to female incidence of dacryocystitis does not vary significantly and that events like the COVID-19 pandemic do not affect the gender of the incidence. And in Ali’s study, dacryocystitis have shown a strong female preponderance [13]. However, in Ban Luo’s study, although the adult population was predominantly female (71.9%), males were more prevalent among children (59.0%) [14]. Obstruction of the nasolacrimal duct in children is a major influence on the development of dacryocystitis, and in Bruce M Schnall’s study [15], dilation of the lacrimal sac due to valvular anomalies was more common in female children, and may be resolved in the obstetrics department. This may be a reason why there were more cases of dacryocystitis in boys in this study. The rate of multiple infections in this study was 13.6%, which is comparable to previous rates of polymicrobial infections (7–30%) [14]. The odds of multiple infections have had a significant impact in recent years.

The most common of the COVID-19 co-infections are Streptococcus pneumoniae, followed by Klebsiella pneumoniae and Haemophilus influenzae [16]. Nevertheless, in cultures of ocular secretions from children with dacryocystitis, the proportion of Streptococcus pneumoniae and Haemophilus influenzae decreased compared to before. Consistent and significant sustained reductions in invasive disease caused by Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis have been observed in every country that has adopted new crown pneumonia control measures [17]. Analyzing Streptococcus pneumoniae and Haemophilus influenzae commonality: they are both commensals of the human nasopharynx, are co-located within the biofilm to ensure that they are all persistent, and therefore often show the same tendency during the course of an epidemic [18]. Reduced transmission of new coronaviruses as a result of their introduction of respiratory management, restrictions on the movement of people and other measures, which may help to explain their downward trend. Streptococcus mitis belongs to the same genus Streptococcus as Streptococcus pneumoniae, and its and Streptococcus pneumoniae proteins cross-react [19]. Fungal infections account for a minority of dacryocystitis pathogens, but there has been an upward trend in recent smooth Candida infections since the COVID-19 pandemic, and fungal infections should be considered in the setting of suboptimal treatment. This study suggests that the COVID pandemic influences changes in the infectious flora of dacryocystitis in children.

Multidrug-resistant bacteria (MDRB) [20] refers to bacteria that are resistant to three or more commonly used antimicrobial drugs that are usually sensitive, making anti-infective treatment much more difficult. Multidrug-resistant bacteria in dacryocystitis are relatively rare in this region. The most common type of resistance is β-lactamase positive, catabolizing penicillin, cephalosporin, etc. Using other types of antibiotics or adding drugs containing enzyme inhibitors may have better therapeutic effects. MRSA also accounted for the major portion of drug-resistant bacteria,which proportion of MASA increased year by year. In most studies, Staphylococcus aureus is prevalent in young children, especially in the neonatal period and infancy [21]. The overall per-pathogen analysis shows significant increases in infections by MRSA [22], although this study was of blood specimen cultures, it suggests that MRSA is increasing in addition to bloodstream infections. In this paper, year-to-year changes in S. aureus were not statistically different, but the increased rate of MRSA infections may be related to the rapid spread of Staphylococcus aureus carrying pathogenic genes in the environment [23]. Effective antibiotic application and a reasonable course of treatment can help reduce the spread of drug-resistant bacteria.

Infants make up the majority of all patients with dacryocystitis, 91%. The common flora of positive secretion cultures were analyzed in all age groups: Streptococcus pneumoniae was consistently well represented in all age subgroups and was the most common culture-positive organism from 1 month to 6 years of age. The percentage of gram-negative bacteria such as Haemophilus influenzae and Cattamoeba was also high, consistent with the rising trend of gram-negative infections in neonates. Dacryocystitis is mainly caused by gram-positive bacteria, the proportion of gram-negative bacteria is on the rise due to the use of antibiotics [3, 14]. Although Gram-positive bacteria are still predominant, some rare Gram-negative bacteria have become increasingly common in dacryocystitis in recent years. Sulfonamide and quinolone antibiotics can be applied empirically for the pathogenic characteristics of each age group [24]. A proportion of children can be cured by massage plus antibiotic eye drop treatment, and if this is not possible, tear duct exploratory surgery can be performed in due course [25].

Generally speaking, dacryocystitis is treated empirically in outpatient settings without the need for cultivation. Obtaining secretion culture data and selecting appropriate antibiotics is an effective method for treating dacryocystitis, and can prevent delayed antibiotic replacement when facing drug-resistant microorganisms [14]. In addition, the inclusion of the 3 years affected by COVID-19 in the data studied herein informs the prediction of changes in the pathogen of dacryocystitis when similar public health events recur.

In conclusion, from January 1, 2017, to December 31, 2022, Streptococcus pneumoniae and Haemophilus influenzae are the most common Gram-positive and Gram-negative organisms in all age group there is a decreasing trend. However, Streptococcus mitis and Stenotrophomonas maltophilia have seen an increase in their incidence in recent years. During in the period of COVID - 19 pandemic, the number of cases of dacryocystitis in children decreased as the time passed, and the distribution of pathogens changed. For MDR, β - lactamase-positive bactexria are the most common type of drug resistance, followed by MRSA. And the incidence of MRSA is on the rise. Close monitoring of changes in pathogen distribution in ocular secretion cultures can help in early intervention and treatment of infectious dacryocystitis.