What is the diagnosis and treatment for periorbital (around the eye) cellulitis?

From the Guidelines

Periorbital cellulitis should be treated promptly with high-dose amoxicillin-clavulanate for comprehensive coverage, and patients with severe symptoms or signs of orbital involvement should be hospitalized for intravenous antimicrobial therapy and further evaluation. The diagnosis of periorbital cellulitis is based on the presence of signs or symptoms of orbital involvement, such as proptosis, impaired visual acuity, or impaired and/or painful extraocular mobility 1. Mild cases of preseptal cellulitis may be treated on an outpatient basis with oral antibiotic therapy, but patients who do not improve within 24 to 48 hours or have progressive infection should be admitted to the hospital for antimicrobial therapy 1. Key considerations in the management of periorbital cellulitis include:

• The use of contrast-enhanced CT scans to confirm intracranial or intraorbital suppurative complications 1
• Consultation with specialists, such as otolaryngologists, ophthalmologists, and infectious disease experts, to guide the need for surgical intervention and selection of antimicrobial agents 1
• The potential for intracranial complications, particularly in previously healthy adolescent males with frontal sinusitis 1
• The importance of monitoring for signs of orbital involvement and reevaluating patients who do not respond to initial treatment 1. In terms of antimicrobial therapy, vancomycin may be used to cover possible methicillin-resistant S pneumoniae, and treatment should be tailored to the results of culture and sensitivity studies when available 1.

From the Research

Causes of Periorbital Cellulitis

• The most common causes of periorbital cellulitis are organisms that originate in the upper respiratory tract or from the skin 2
• Sinusitis is a frequent disease associated with periorbital cellulitis, found in 43% of cases in one study 3
• Trauma and odontogenic infections are also common predisposing causes, found in 25% and 6% of cases, respectively 3

Treatment of Periorbital Cellulitis

• Antibiotics such as ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin are often used in the treatment of periorbital cellulitis 2
• The choice of antibiotic is important, and it is also crucial to dose antibiotics to optimize their pharmacodynamic target attainment 2
• Therapy can be transitioned from initial intravenous therapy to an oral regimen when there are clear signs of clinical and laboratory improvement 2
• The total duration of therapy for periorbital cellulitis has been decreasing in recent years, with durations of approximately 2 weeks becoming more common 2

Antibiotic Regimens

• A study compared two antibiotic combinations, penicillin plus chloramphenicol and sulbactam-ampicillin (SAM) with or without ornidazole, and found that SAM can be the first line of drug treatment for periorbital cellulitis 3
• Another study found that ceftriaxone was effective in treating periorbital cellulitis, with a mean duration of intravenous antibiotic therapy of 4.1 days 4
• Amoxicillin-clavulanic acid was the most commonly used antibiotic in a study of pediatric periorbital cellulitis cases 5

Outpatient Treatment

• Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness 4
• A study found that daily outpatient intravenous antibiotic therapy was effective in managing pediatric periorbital cellulitis, with a low rate of complications 4

Epidemiology and Outcomes

• A 10-year study found that the number of periorbital cellulitis cases increased over time, with the most affected age bracket being children under 5 years old 5
• The most frequent mode of entry was sinusitis, and preseptal cellulitis was the most common type of periorbital cellulitis 5
• A 20-year retrospective study found that the antibiotic efficacy against causative bacteria may change over time, and it is important to understand the appropriate antibiotic options for effective treatment in pediatric patients 6