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Clinical Practice Guidelines

Periorbital and orbital cellulitis

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    PIC Endorsed

  • See also

    Febrile child 
    Sepsis 
    Local antimicrobial guidelines

    Key points

    1. Orbital cellulitis is an emergency with serious complications including intracranial infection, cavernous sinus thrombosis and vision loss 
    2. Urgent imaging and surgical consultation (ENT and ophthalmology) should be considered for any child with suspected orbital cellulitis
    3. Periorbital cellulitis in a well child can often be treated with oral antibiotics if follow-up is assured

    Background

    • Periorbital and orbital cellulitis are distinct clinical diseases, though have overlapping clinical features and therefore can be difficult to differentiate
    • Orbital cellulitis:
      • infection within the orbit, (ie postseptal, the structures posterior to the orbital septum)
      • surgical emergency with major complications including loss of vision, abscess formation, venous sinus thrombosis and extension to intracranial infection with subdural empyema, and meningitis
      • the majority (>80%) of cases relate to local sinus disease
    • Periorbital cellulitis:
      • infection of the eye lids and surrounding skin not involving the orbit (ie preseptal, the structures anterior to the orbital septum)
    • The globe is not involved in either infection

    Assessment

    Typical presentation of periorbital/orbital cellulitis

    • Unilateral eyelid swelling and erythema
    • Unilateral eye pain or tenderness

    Consider gonorrhoea and Chlamydia infections in neonatal presentation (send PCR swabs) see Acute red eye

    Red flags concerning for orbital cellulitis

    • Painful or restricted eye movements
    • Visual impairment:
      • reduced acuity
      • relative afferent pupil defect
      • diplopia
    • Proptosis
    • Severe headache or other features of intracranial involvement


    Differential diagnosis

    Bilateral findings and/or painless (or non-tender) swelling in a well looking child is more likely to be an allergic reaction

    Periorbital and orbital

      Management

      Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines; these may include advice regarding community acquired MRSA

      Orbital Cellulitis

      • Admission
      • Keep fasted until need for surgery clarified
      • Seek ENT and Ophthalmology advice urgently
      • Consider urgent contrast enhanced CT scan of orbits, sinuses +/- brain
      • Investigations:
        • FBE and blood culture
        • Lumbar Puncture (LP) is contraindicated due to risk of raised intracranial pressure (ICP) secondary to possible intracranial extension
      • Antibiotics (see below)
      • Treat underlying sinus disease eg nasal decongestants, steroids (often guided by ENT)

      Periorbital Cellulitis

      Severe

      Inpatient investigations and management as per orbital cellulitis

      Moderate

      Inpatient management or consider Hospital In The Home (HITH) admission if available locally

      • Consider blood culture if febrile and unwell
      • Antibiotics (see below)
      • Once improving change to oral antibiotics
      • If not improving or deteriorating within 24–48 hours, consider managing as severe periorbital cellulitis

      Mild

      • Antibiotics (see below)
      • Review

      Summary of antibiotic treatment

      Intravenous Therapy Oral Therapy Total Duration
         

      Orbital

      cellulitis

          

      3rd generation cephalosporin

      • Cefotaxime 50 mg/kg (max 2 g) IV 6 hourly OR
      • Ceftriaxone 50 mg/kg (max 2 g) IV daily

      PLUS

      Flucloxacillin 50 mg/kg (max 2g) IV 6 hourly OR

      If suspected MRSA: vancomycin (see link for dosing)

       

      Duration based on clinical severity and improvement. Usually at least 3-4 days, then switch to oral.

      		 Amoxicillin with clavulanic acid (doses based on amoxicillin component) 22.5 mg/kg (max 875 mg) oral bd
              		10–14 days


      Severe Periorbital cellulitis


      Moderate Periorbital cellulitis

      Flucloxacillin 50 mg/kg (max 2g) IV 6 hourly 

      OR

      Ceftriaxone 50 mg/kg (max 2g) IV daily (consider HITH)

      OR

      If suspected MRSA:

      • Clindamycin 15 mg/kg (max 600 mg) IV/oral 8 hourly OR
      • Trimethoprim with sulfamethoxazole (8/40 mg/mL) 4/20 mg/kg (max 320/1600 mg) oral bd 
       

      Duration based on clinical severity and improvement. Usually 1-2 days, then switch to oral.

      		When improving, switch to oral antibiotics as per mild periorbital cellulitis 7–10 days
           

      Mild Periorbital cellulitis

      		Not applicable
      • Cefalexin 33 mg/kg (max 1 g) oral tds                          
        OR
      • Cefuroxime
        3 months – 2 years: 10 mg/kg (max 125 g) oral bd                          
        2 – 12 years: 15 mg/kg (max 250 mg) oral bd 
      		 7-10 days

       

      Consider consultation with local paediatric team when

      • Orbital cellulitis suspected
      • Moderate-severe periorbital cellulitis present
      • No improvement or deterioration after 24–48 hrs of therapy 

      Consider transfer when

      • Severe periorbital cellulitis or orbital cellulitis present
      • Suspecting intracranial involvement with altered conscious state, seizures or focal neurological signs
      • Child requires care above the level of comfort of local hospital

      For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services 

      Consider discharge when

      Mild periorbital cellulitis:

      • oral antibiotic course prescribed
      • follow-up assured 

      Moderate periorbital cellulitis:

      • after 24–48 hrs of IV antibiotics and with improvement
      • able to tolerate oral antibiotics
      • follow-up assured

      Last updated December, 2021

    • Reference List

      1. Atfeh MS, Khalil HS. Orbital infections: five-year case series, literature review and guideline development. J Laryngol Otol. 2015;129(7):670-676.
      2. Australian Immunisation Handbook, accessed March 20th 2019. https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/haemophilus-influenzae-type-b-hib
      3. Australian Medicines Handbook, accessed May 2019
      4. Baring DE, Hilmi OJ. An evidence based review of periorbital cellulitis. Clin Otolaryngol. 2011;36(1):57-64.
      5. Buchanan MA, Muen W, Heinz P. Management of periorbital and orbital cellulitis. Paediatrics and Child Health. 2012;22(2):72-77.
      6. Crosbie RA, Nairn J, Kubba H. Management of paediatric periorbital cellulitis: Our experience of 243 children managed according to a standardised protocol 2012-2015. Int J Pediatr Otorhinolaryngol. 2016;87:134-138.
      7. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6):242-249.
      8. Ibrahim LF, Hopper SM, Babl FE, Bryant PA. Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis. Pediatr Infect Dis J. 2016;35(3):269-274.
      9. Ibrahim L. Hopper S, Orsini F et al. Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial. Lancet Infectious Diseases, 2019-05-01, Volume 19, Issue 5, Pages 477-486
      10. Mathew AV, Craig E, Al-Mahmoud R, et al. Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital. Br J Radiol. 2014;87(1033):20130503.
      11. McMullan B, Andresen D, Blyth C et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infectious Diseases, The, 2016-08-01, Volume 16, Issue 8, Pages e139-e152,
      12. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010;125(4):e719-726.
      13. Watts P. Preseptal and orbital cellulitis in children. Paediatrics and Child Health. 2015;26(1):1-8.