From the CLINICAL INQUIRIES Family Physicians Inquiries Network Sarah Hennemann, MD, Paul Crawford, MD What is the best initial Eglin Air Force Base Family Medicine Residency, Eglin Air treatment for orbital cellulitis Force Base, Fla Loan Nguyen, MLS Baylor College of Medicine, in children? Houston, Tex Evidence-based answer Although antibiotics are the best initial [SOR]: C, based on patient-oriented treatment, surgical intervention is case-series studies). warranted when a child has: Target antimicrobial therapy toward • visual impairment, complete the common pathogens associated with ophthalmoplegia, or well-defined predisposing factors for orbital cellulitis, abscess on presentation, or such as sinusitis—and pay attention to • no clearly apparent clinical improvement local resistance patterns (SOR: C, based by 24 hours (strength of recommendation on patient-oriented case series). Clinical commentary Rare but serious risk factors When confronted by the rare case FAST TRACK The incidence of Haemophilus influenzae– of periorbital cellulitis, I always consider related periorbital cellulitis appears to have risk factors that may change my “I always consider plummeted with the advent of Hib vaccine. management, such as immunization status risk factors that And while no national data have been and asplenia. Also, meningitis is a rare may change published, case series support my clinical but serious complication, so I also keep observation that the overall incidence of meningitis risk factors in mind, such as management, such periorbital cellulitis has dropped as well. immunosuppression, coincident trauma, or as immunization The arrival of heptavalent a poor response to initial medical therapy. status, asplenia, pneumococcal vaccine may further Finally, any question of orbital and risk factors contribute to its welcome scarcity. Take involvement should prompt an emergent this changing bacteriology—in conjunction consultation. for meningitis” with local resistance patterns—into account Peter C. Smith, MD Rose Family Medicine Residency, University when considering antibiotic coverage. of Colorado Health Sciences Center, Denver z Evidence summary the periorbital soft tissues, usually sec- Orbital cellulitis is a serious soft-tissue ondary to external inoculation, but the infection of childhood with very differ- inflammation does not extend into the ent etiologies. bony orbit. • Periorbital (or preseptal) celluli- • Stages II, III, and IV orbital cel- tis is synonymous with stage I orbital lulitis are progressively more invasive cellulitis, in which there is induration, infections that generally arise from the erythema, warmth, and tenderness of sinuses; they may involve the retro-or- 662 VOL 56, NO 8 / AUGUST 2007 THE JOURNAL OF FAMILY PRACTICE TABLE Choose antibiotic based on cause and likely pathogen1,2,6–8 ANTECEDENT EVENt LIKELY PATHOGENS BEst DRUGS Acute sinusitis Streptococcus pneumoniae Penicillinase-resistant penicillins Haemophilus influenzae Moraxella catarrhalis Trauma Staphylococcus aureus Penicillinase-resistant penicillins Group A b-hemolytic streptococci First-generation cephalosporins Increasing concern for Consider drugs appropriate for methicillin-resistant S aureus methicillin-resistant S aureus Chronic sinusitis Anaerobes Metronidazole Clindamycin bital area. These stages of orbital cel- (n=9) found 21 children admitted to lulitis can cause proptosis, decrease hospital for preseptal cellulitis, of whom visual acuity, or appear as abscesses on 4 later were diagnosed with orbital cel- computed tomography scan.1,2 lulitis. There was a total of 9 cases of or- bital cellulitis; however, only 1 required Staged treatment operative management of orbital cel- Many retrospective studies of stage II–IV lulitis.3 In a prospective study to evalu- orbital cellulitis with relatively few sub- ate medical management (n=23), 87% jects and small prospective case series have of patients responded to intravenous been published with common themes for antibiotics.4 No statistically significant management recommendations: long-term difference in subperiosteal • early intravenous antibiotics (likely abscesses (as a complication of orbital for an inpatient), and cellulitis) was found in another retro- • involvement of otolaryngology and spective study comparing medical to FAST TRACK ophthalmology specialists. surgical management.5 Target common No head-to-head trials have been completed to evaluate efficacy of specific Target the likely pathogens pathogens for antimicrobial regimens. Direct antimicrobial therapy toward com- the likely source Oral antibiotics. First, treat stage I or- mon pathogens for likely sources of infec- of infection— bital cellulitis with oral antibiotics. tion, paying attention to local resistance and pay attention IV antibiotics. Modify treatment to patterns and the pathogens usually associ- intravenous antibiotics when there is no ated with sinusitis (TABLE).1,2,6–8 to local resistance improvement within 24 hours or if you A retrospective case series of 94 pa- patterns discover any characteristic of more severe tients of all ages in China implicated orbital cellulitis. Staphylococcus aureus and streptococcal Medical management of stage II–IV species based on cultures taken from eye orbital cellulitis with intravenous antibiot- purulence and abscesses.6 Another retro- ics is the current standard of care until it is spective case series from Vanderbilt (n=80) clear that one of the following is present: found streptococci as the most common • no improvement by 24 to 48 hours cause, based on blood and wound cultures • visual impairment in the Hib vaccination era; however, only • complete ophthalmoplegia, or 12 wounds returned positive cultures.7 • well-defined periosteal abscess.1,2 Surgery. For refractory cases, surgical Steroids have no proven benefit decompression will likely be required. Systemic steroids have no proven ben- The evidence. A small case series efit in the treatment of pediatric orbital www.jfponline.com VOL 56, NO 8 / AUGUST 2007 663 ES I R I QU N I cellulitis with subperiosteal abscess. Neither the American Academy of A small retrospective cohort study Ophthalmology nor the International AL C of the benefit of intravenous steroids in Council of Ophthalmology offers clinical addition to antibiotics showed no de- statements on orbital cellulitis. n crease in hospital stay or need for surgi- CLINI cal decompression (n=23, P=.26 and .20, Acknowledgments respectively).9 Without prospective data The opinions and assertions contained herein are the private views of the author and not to be construed as and a power analysis, lack of benefit of official, or as reflecting the views of the US Air Force steroids cannot be definitively shown. Medical Service or the US Air Force at large. Recommendations from others References Infectious Disease Society of America. The 1. Nageswaran S, Woods CR, Benjamin DK Jr, Givner LB, Shetty AK. Orbital cellulitis in children. Pediatr guidelines for the management of skin Infect Dis J 2006; 25:695–699. and soft-tissue infections implicate b- 2. Vayalumkal JV, Jadavji T. Children hospitalized with hemolytic streptococci as the most com- skin and soft tissue infections: a guide to antibac- terial selection and treatment. Paediatr Drugs 2006; mon cellulitis pathogen, but also recom- 8:99–111. mend empiric coverage against S aureus. 3. Starkey CR, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J 2001; 20:1002– Periorbital and orbital cellulitis are not 1005. specifically addressed in these guidelines, 4. Noel LP, Clarke WN, MacDonald N. Clinical man- but oral dicloxacillin, cephalexin, clinda- agement of orbital cellulitis in children. Can J Oph- mycin, or erythromycin are recommended thalmol 1990; 25:11–16. 5. Greenberg MF, Pollard ZF. Medical treatment of pe- for superficial cellulitis, provided there is diatric subperiosteal orbital abscess secondary to no known resistance to these antibiotics. sinusitis. J AAPOS 1998; 2:351–355. 6. Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu Intravenous penicillinase-resistant WM. Preseptal and orbital cellulitis: a 10-year re- penicillins (nafcillin) or a first-generation view of hospitalized patients. J Chin Med Assoc cephalosporin (cefazolin) may be used for 2006; 69:415–422. 7. Donohue SP, Schwartz G. Preseptal and orbital more severe infections. cellulitis in childhood. A changing microbiologic For penicillin-allergic patients, the spectrum. Ophthalmology 1998; 105:1902–1905. IDSA recommends clindamycin or vanco- 8. Gilbert DM, Eliopoulos GM, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy mycin.10 2006. 36th ed. Sperryville, Va: Antimicrobial Thera- py; 2006:12. Sanford Guide to Antimicrobial Therapy. 9. Yen MT, Yen KG. Effect of corticosteroids in the Nafcillin plus ceftriaxone and metronida- acute management of pediatric orbital cellulitis zole is the recommended treatment for or- with subperiosteal abscess. Ophthal Plast Recon- bital cellulitis. str Surg 2005; 21:363–366. 10. Stevens DL, Bisno AL, Chambers HF, et al. Infec- For patients allergic to penicillin, van- tious Diseases Society of America. Practice guide- comycin plus levofloxacin and metronida- lines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005; zole are recommended.8 41:1373–1406. Testosterone deficiency: Which patients should you screen and treat? FREE CE/CME CREDIT at JFPonline.com and APCToday.com A dialogue among • RICHARD SADOVSKY, MD, Program Chair • SANDEEP DHINDSA, MD • KATHERINE MARGO, MD Held on January 30, 2007 664 VOL 56, NO 8 / AUGUST 2007 THE JOURNAL OF SupportedFAMILY PRAC by anTICE unrestricted educational grant from Solvay Pharmaceutical, Inc. .