Periorbital and orbital cellulitis

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    Periorbital cellulitis is a common, usually benign, bacterial infection of the eyelids. It arises principally following trauma to the eyelids (insect bite or abrasion).

    Orbital cellulitis is a serious infection involving the contents of the orbit (fat and ocular muscles) that may lead to loss of vision or a brain abscess. It usually arises secondary to spread from sinusitis (e.g. as a complication of ethmoid sinusitis).

    Periorbital and orbital cellulitis are more common in children than in adults.

    The most common organisms causing periorbital and orbital cellulitis are Staphylococcus aureus, Streptococcus pneumoniae and other streptococci, as well as Haemophilus influenzae type b (Hib) in children living in countries where rates of immunisation with Hib remain low.

    Clinical features

    • Signs common to both periorbital and orbital cellulitis: acute eyelid erythema and oedema; the oedema has a violaceous hue if secondary to H. influenzae.
    • In case of orbital cellulitis only:
      • Pain with eye movements;
      • Ophthalmoplegia (paralysis of eye movements) often with diplopia (double vision);
      • Protrusion of the eye (eye bulges out of the socket);
      • High fever, systemic signs.

    Treatment

    • Hospitalize for the following: orbital cellulitis, children younger than 3 months, critically ill appearing patient a Citation a. Critically ill appearing child: weak grunting or crying, drowsy and difficult to arrouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia. , local complications, debilitated patient (chronic conditions, the elderly), if there is a risk of non-compliance with or failure of outpatient treatment. Treat the other patients as outpatients.

     

    • Outpatient antibiotic therapy b Citation b. For penicillin-allergic patients, clindamycin PO for 7 to 10 days:
      Children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily
      :
      cefalexin PO for 7 to 10 days
      Neonates 0 to 7 days: 25 mg/kg 2 times daily 
      Neonates 8 days to 1 month: 25 mg/kg 3 times daily 
      Children over 1 month: 25 mg/kg 2 times daily (max. 2 g daily)
      Children ≥ 40 kg and adults: 1 g 2 times daily
      or
      amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 to 10 days
      Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
      Children < 40 kg: 50 mg/kg 2 times daily
      Children ≥ 40 kg and adults:
      Ratio 8:1: 3000 mg daily (2 tab of 500/62.5 mg 3 times daily)
      Ratio 7:1: 2625 mg daily (1 tab of 875/125 mg 3 times daily)

     

    • Inpatient antibiotic therapy c Citation c. For penicillin-allergic patients, clindamycin IV infusion (doses as above). :
      ceftriaxone slow IV d Citation d. For administration by IV route, ceftriaxone powder should to be reconstituted in water for injection only. For administration by IV infusion, dilute each dose of ceftriaxone in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults. (3 minutes) or IV infusion (30 minutes; 60 minutes in neonates) for at least 5 days
      Children: one dose of 100 mg/kg on the first day, then 50 mg/kg 2 times daily
      Adults: 1 to 2 g once daily
      +
      cloxacillin IV infusion (60 minutes) e Citation e. Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in 5 ml/kg of 0.9% sodium chloride or 5 % glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
      Neonates 0 to 7 days (< 2 kg): 50 mg/kg every 12 hours
      Neonates 0 to 7 days (≥ 2 kg): 50 mg/kg every 8 hours
      Neonates 8 days to < 1 month (< 2 kg): 50 mg/kg every 8 hours
      Neonates 8 days to < 1 month (≥ 2 kg): 50 mg/kg every 6 hours
      Children 1 month and over: 25 to 50 mg/kg every 6 hours (max. 8 g daily)
      Children ≥ 40 kg and adults: 2 g every 6 hours
      If there is clinical improvement (patient afebrile and erythema and oedema have improved) after 5 days, change to amoxicillin/clavulanic acid PO at the doses indicated above to complete 7 to 10 days of treatment.

     

    If there is no improvement in the first 48 hours (suspicion of methicillin resistant S. aureus), replace cloxacillin with:
    clindamycin IV infusion (30 minutes) f Citation f. Dilute each dose of clindamycin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
    Neonates 0 to 7 days (< 2 kg): 5 mg/kg every 12 hours
    Neonates 0 to 7 days (≥ 2 kg): 5 mg/kg every 8 hours
    Neonates 8 days to < 1 month (< 2 kg): 5 mg/kg every 8 hours
    Neonates 8 days to < 1 month (≥ 2 kg): 10 mg/kg every 8 hours
    Children 1 month and over: 10 mg/kg every 8 hours (max. 1800 mg daily)
    Adults: 600 mg every 8 hours
    After 5 days, change to clindamycin PO at the same doses to complete 7 to 10 days of treatment.

     

    • If orbital cellulitis is unresponsive to IV antibiotics, consider an abscess. Transfer patient to a surgical centre for drainage.

     

    Footnotes
    • (a)Critically ill appearing child: weak grunting or crying, drowsy and difficult to arrouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia.
    • (b)For penicillin-allergic patients, clindamycin PO for 7 to 10 days:
      Children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily
    • (c)For penicillin-allergic patients, clindamycin IV infusion (doses as above).
    • (d)For administration by IV route, ceftriaxone powder should to be reconstituted in water for injection only. For administration by IV infusion, dilute each dose of ceftriaxone in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
    • (e)Cloxacillin powder for injection should be reconstituted in 4 ml of water for injection. Then dilute each dose of cloxacillin in 5 ml/kg of 0.9% sodium chloride or 5 % glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.
    • (f)Dilute each dose of clindamycin in 5 ml/kg of 0.9% sodium chloride or 5% glucose in children less than 20 kg and in a bag of 100 ml of 0.9% sodium chloride or 5% glucose in children over 20 kg and in adults.