What is the recommended management for orbital cellulitis?

Management of Orbital Cellulitis

The recommended management for orbital cellulitis includes prompt administration of broad-spectrum intravenous antibiotics with coverage for common pathogens (including S. aureus, Streptococcus species, and anaerobes), imaging with CT scan to evaluate for complications, and early ophthalmology consultation. While the evidence provided doesn't include specific orbital cellulitis guidelines, we can synthesize the available research to create a management approach.

Initial Assessment and Diagnosis

• Orbital cellulitis refers to infection of tissues posterior to the orbital septum
• Common presenting symptoms include:
  • Eyelid edema and erythema
  • Chemosis (conjunctival swelling)
  • Proptosis
  • Blurred vision
  • Fever
  • Headache
  • Double vision 1
• History often reveals preceding sinusitis, especially in children 2
• Distinguish from preseptal cellulitis (anterior to orbital septum)

Imaging

• CT scan of brain and orbits with and without contrast is critical to:
  • Confirm diagnosis
  • Evaluate for abscess formation
  • Detect intracranial extension
  • Guide surgical intervention decisions 1
• MRI should be considered if CT is non-diagnostic 1
• Point-of-care ultrasound may help differentiate preseptal from orbital cellulitis but cannot exclude intracranial extension 1

Antibiotic Therapy

Based on the available evidence, the following antibiotic regimens are recommended:

For Adults:

• Intravenous broad-spectrum antibiotics with coverage for Staphylococcus aureus (including MRSA), Streptococcus species, and anaerobes
• Vancomycin is a first-line option for severe infections, particularly when MRSA is suspected 3
• Alternative IV options include linezolid, daptomycin, ceftaroline 3
• Consider oral ciprofloxacin and clindamycin in less severe cases, as this combination has shown effectiveness comparable to IV therapy 4

For Children:

• Cloxacillin and chloramphenicol, or cefuroxime for children under 6 years 5
• Avoid doxycycline in children under 8 years due to risk of tooth discoloration 3

Surgical Management

• Surgical intervention is indicated for:
  • Subperiosteal or orbital abscess
  • Worsening vision despite medical therapy
  • No improvement after 24-48 hours of appropriate antibiotics
  • Evidence of intracranial extension 2
• CT findings of subperiosteal abscess alone may not necessitate immediate surgical drainage if the patient is responding to medical management 5

Monitoring and Follow-up

• Close monitoring for clinical improvement within 48-72 hours
• If no improvement is observed, consider:
  • Broadening antibiotic coverage
  • Repeat imaging
  • Surgical intervention 3
• Monitor for complications such as orbital compartment syndrome, cavernous sinus thrombosis, meningitis, and brain abscess 1

Special Considerations

• Staphylococcus aureus is a common pathogen in orbital cellulitis 6
• Consider MRSA coverage in patients with:
  • Previous MRSA infection or colonization
  • Injection drug use
  • Systemic inflammatory response syndrome (SIRS)
  • Failed initial antibiotic treatment
  • Immunocompromised status 3
• Amikacin and vancomycin have shown excellent bacterial susceptibility profiles with no resistance in some studies 6

Common Pitfalls to Avoid

• Delaying antibiotic therapy while waiting for imaging results
• Failing to recognize and manage orbital compartment syndrome, which requires immediate intervention
• Inadequate antibiotic coverage, particularly for MRSA
• Overlooking potential intracranial extension of infection
• Relying solely on clinical improvement without appropriate follow-up imaging in severe cases

The management of orbital cellulitis has improved significantly with early diagnosis, appropriate antibiotic therapy, and timely surgical intervention when indicated, resulting in better visual outcomes and reduced complications 2.