What is the treatment for orbital cellulitis?

Treatment of Orbital Cellulitis

For orbital cellulitis, treatment should include parenteral antibiotics that cover both streptococci and staphylococci, with options including nafcillin, cefazolin, or clindamycin/vancomycin for penicillin-allergic patients, along with appropriate imaging and specialist consultation. 1

Classification and Diagnosis

• Orbital cellulitis is diagnosed based on clinical presentation with signs including erythema, tenderness, and induration of the eyelid 1
• CT scan with IV contrast is the most useful imaging modality to differentiate preseptal from postseptal involvement and identify potential complications 1
• Paranasal sinus disease is the most common predisposing cause, especially in pediatric patients 2

Initial Treatment Approach

• For moderate to severe cases, inpatient management with parenteral antibiotics is recommended 1
• First-line parenteral therapy options include:
  • Penicillinase-resistant penicillin (nafcillin)
  • First-generation cephalosporin (cefazolin)
  • For patients with severe penicillin allergies: clindamycin or vancomycin 1, 3
• For mild cases with eyelid less than 50% closed, outpatient treatment with high-dose amoxicillin-clavulanate is appropriate, with daily follow-up until definite improvement is noted 1

Antimicrobial Coverage Considerations

• The most common causative organisms are Streptococcus species and Staphylococcus aureus, requiring coverage for both 1, 2
• If MRSA is suspected, appropriate coverage should include vancomycin, clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 1
• Recent research suggests that empirical oral ciprofloxacin and clindamycin combination may be as effective as IV therapy in some cases of orbital cellulitis 4

Treatment Duration and Monitoring

• Treatment duration typically ranges from 5-7 days but should be extended if infection has not improved 1
• Patients with mild cases treated as outpatients should be reassessed within 24-48 hours 1
• For hospitalized patients, daily assessment is necessary to monitor response to therapy 1

Surgical Intervention

• Surgical intervention may be required for orbital abscess drainage, often in conjunction with sinus surgery 2
• Consultation with otolaryngology, ophthalmology, and infectious disease specialists is recommended for orbital complications 1

Hospitalization Criteria

• Hospitalization is indicated if:
  • Patient does not improve within 24-48 hours of outpatient therapy
  • Infection is progressive
  • Presence of proptosis, impaired visual acuity, or impaired/painful extraocular mobility
  • Systemic signs of infection 1

Special Considerations

• For anaerobic orbital infections, which may occur with retained foreign bodies (especially wood), broad-spectrum antibiotic coverage including anaerobes should be provided 5
• Recent studies show that with appropriate treatment, complete recovery occurs in approximately 75% of pediatric cases 6

Common Pitfalls to Avoid

• Delaying appropriate imaging in cases with concerning features such as proptosis, visual changes, or ophthalmoplegia 1
• Not considering MRSA coverage when risk factors are present 1
• Inadequate duration of therapy or failure to reassess response after initial treatment 1
• Overlooking retained foreign bodies in penetrating orbital injuries, which may require surgical removal to prevent vision-threatening complications 5