Clinical Practice Guidelines

Periorbital and Orbital Cellulitis

  • Presentation

    Orbital Cellulitis flowchart

    Management - Orbital Cellulitis

    This is a surgical emergency. After consultation with the ENT surgeons and ophthalmologists, an urgent CT scan should be arranged to differentiate those patients with an associated abscess (usually subperiosteal) from those without. This should be discussed with the radiologist who will ask for coronal views. Imaging should pay particular attention to the orbital and frontal regions as the abscess may be small.

    Surgical drainage of an abscess results in decompression of the orbit and obtains infected material for Gram stain and culture.

    Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Over 5 years Staph aureus is more common. Haemophilus influenzae type b is less common since HiB immunisation.

    Recommended antibiotics

    i.v. Ceftriaxone 50 mg/kg/dose (2g) iv 12H 
    and
    i.v. flucloxacillin 50 mg/kg/dose 6-hourly (maximum 2 g/dose).

    Lumbar puncture is contraindicated in patients with orbital cellulitis until after the CT scan has been performed, even in the absence of features of raised intracranial pressure, since intracranial extension may be silent.

    Management - Periorbital Cellulitis

    Investigation of these patients should include FBE, blood cultures.

    Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Strep pyogenes and Staph aureus are likely if there is a contiguous skin lesion. Rarely Haemophilus influenzae may be the cause particularly in children under five who are not fully immunised.

    Haemophilus bacteraemia-induced periorbital cellulitis and Haemophilus meningitis occasionally coexist. The decision as to whether a lumbar puncture should be performed should be a clinical one.

    Recommended antibiotics

    Mild  Amoxycillin/Clavulanate
    (400/57 mg per 5 mL)
    0.3 mL/kg (11 mL) po 12H
    Moderate Flucloxacillin 50 mg/kg (2 g) iv 6H
    Severe,
    or <5y & not Hib immunised
    Flucloxacillin 50 mg/kg (2 g) iv 6H
    and
    Ceftriaxone 50 mg/kg/dose (2g) iv 12H

    In children who are systemically unwell it may be reasonable to use both Ceftriaxone 50 mg/kg/dose (2g) iv 12H and flucloxacillin initially. Any child in whom there is a reasonable suspicion of primary skin infection, or who is not improving on Ceftriaxone 50 mg/kg/dose (2g) iv 12H alone should have flucloxacillin added. Failure to respond in 24-48 hours may indicate orbital cellulitis or underlying sinus disease. Treat as for orbital cellulitis.

    When improving, and no organism identified change to augmentin 25 mg/kg/dose, 8-hourly (maximum 500 mg/dose) for 7 days.

    Prophylaxis

    If Haemophilus influenzae type b is isolated, rifampicin prophylaxis should be given as for meningitis, that is, if a child aged 5 years or less lives in the same household as the index case or if the index case is < 2 yr, then prophylaxis should be given to the entire household, including the index case. Parents who are pregnant should not be given rifampicin. Patients should be warned that rifampicin will colour the urine tears and other secretions orange, orange tears may discolour contact lenses. Rifampicin induces the metabolism of the oral contraceptive pill making this form of contraception unreliable.

    Doses:

    • < 1 month: 10 mg/kg once daily for 4 days
    • > 1 month: 20 mg/kg once daily for 4 days
    • Adults: 600 mg once daily for 4 days

    All children aged < 5 yr who have not been immunised against Hib should be vaccinated. If children are < 2 yr and have had a documented Haemophilus infection they should be immunised.

    Local allergic reactions

    In the absence of local and systemic signs of infection eg temperature or tenderness, periorbital erythema may be an allergic reaction rather than periorbital cellulitis.