What are the treatment options for outpatient management of orbital cellulitis?

From the Guidelines

Orbital cellulitis can be managed on an outpatient basis in mild cases with reliable patients who can be closely monitored, using high-dose amoxicillin-clavulanate for comprehensive coverage of acute bacterial sinusitis. This approach is based on the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years, which suggests that mild cases of preseptal cellulitis (eyelid <50% closed) may be treated on an outpatient basis with appropriate oral antibiotic therapy 1.

Key Considerations for Outpatient Management

• The patient should have daily follow-up until definite improvement is noted, and should be instructed to seek immediate medical attention if vision changes, increasing pain, or worsening swelling occur.
• The recommended outpatient regimen would include broad-spectrum oral antibiotics such as amoxicillin-clavulanate 875/125 mg twice daily.
• Treatment duration is typically 2-3 weeks, and patients should also receive analgesics as needed and apply warm compresses to the affected area.
• If the patient does not improve within 24 to 48 hours or if the infection is progressive, it is appropriate to admit the patient to the hospital for antimicrobial therapy, and consultation with an otolaryngologist, an ophthalmologist, and an infectious disease expert may be necessary 1.

Important Factors to Consider

• The presence of proptosis, impaired visual acuity, or impaired and/or painful extraocular mobility requires hospitalization and a contrast-enhanced CT scan.
• Intracranial complications, such as epidural or subdural abscess, brain abscess, venous thrombosis, and meningitis, can occur and require prompt diagnosis and treatment.
• Appropriate antimicrobial therapy for intraorbital complications includes vancomycin to cover possible methicillin-resistant S pneumoniae, and should be tailored to the results of culture and sensitivity studies when they become available 1.

From the Research

Treatment Options for Outpatient Management of Orbital Cellulitis

• The treatment of orbital cellulitis typically involves the use of antibiotics, with the choice of antibiotic depending on the suspected or confirmed causative organism 2, 3, 4, 5.
• Commonly used antibiotics for the treatment of orbital cellulitis include ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin 2.
• The use of oral antibiotics, such as ciprofloxacin and clindamycin, has been shown to be effective in the management of orbital cellulitis, with advantages including rapid delivery of the first antibiotic dose, fewer interruptions in treatment, and simplified delivery of medication 3.
• The total duration of therapy for orbital cellulitis has been decreasing in recent years, with durations of approximately 2 weeks becoming more common, even for orbital or subperiosteal infections 2.
• Antimicrobial stewardship programs can play a crucial role in the management of orbital cellulitis, helping to optimize antibiotic use and reduce the risk of antibiotic resistance 2.
• The use of corticosteroids in the treatment of orbital cellulitis is not well established, with insufficient evidence to draw conclusions about their effectiveness and safety 6.
• Further research is needed to determine the optimal treatment approach for orbital cellulitis, including the use of corticosteroids and the most effective antibiotic regimens 6.