Periorbital and orbital cellulitis

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  • See also

    Febrile child 
    Sepsis 
    Antibiotics 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, (i.e. 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 (i.e. preseptal, the structures anterior to the orbital septum)
    • The globe is not involved in either infection

    Assessment 

    Red flag features in red

    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)

    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

      Antibiotic guidelines may vary depending on local resistance patterns

      • Check local guidelines; these may include advice regarding community acquired MRSA
      • If inadequate Haemophilus influenzae type B (Hib) vaccination, treat as severe periorbital cellulitis

      Orbital Cellulitis

      • Admission
      • Keep fasted until need for surgery clarified
      • Seek ENT & 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 e.g. 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

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

      PLUS

      • IV Flucloxacillin 50mg/kg (max 2g) every 6 hours OR
      • If suspected MRSA: IV 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)
        22.5mg/kg (max 875g), PO BD
       
      10-14 days


      Severe Periorbital cellulitis



      Moderate Periorbital cellulitis

      • IV Flucloxacillin 50mg/kg (max 2g), every 6 hours

      OR

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

      OR

      If suspected MRSA:

      • IV/PO Clindamycin 15mg/kg (max 600mg) every 8 hours OR
      • PO Trimethoprim with sulfamethoxazole (8/40 mg/mL), 4/20 mg/kg BD (max 320/1600mg)
       

      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 25mg/kg (max 1g) PO TDS
        OR
      • Cefuroxime
        3 months – 2 years: 10mg/kg (max 125g) PO BD
        2 – 12 years: 15mg/kg (max 250mg) PO BD
      7-10 days

      *dosing sourced from AMH, for children aged over 1 month

      Consider consultation with local paediatric team when

      • suspected orbital cellulitis
      • moderate-severe periorbital cellulitis
      • no improvement or deterioration after 24-48hrs of therapy 

      Consider transfer when

      • severe periorbital cellulitis or orbital cellulitis
      • suspicion of 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 antibiotics
      • follow up assured 

      Moderate periorbital cellulitis

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

      Last updated July, 2019

    • 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.