Periorbital and orbital cellulitis


– 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 patient1 , 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 therapy2 :
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 therapy3 :
ceftriaxone slow IV4 (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)5
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)6
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
Ref Notes
1 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.
2 For penicillin-allergic patients, clindamycin PO for 7 to 10 days:
Children: 10 mg/kg 3 times daily; adults: 600 mg 3 times daily
3 For penicillin-allergic patients, clindamycin IV infusion (doses as above).
4 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.
5 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.
6 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.