What is the treatment for orbital cellulitis?

From the Guidelines

Orbital cellulitis treatment requires immediate hospitalization and intravenous antibiotics, such as vancomycin, to cover possible methicillin-resistant S pneumoniae, as recommended by the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years 1.

Key Considerations

• The treatment should be tailored to the results of culture and sensitivity studies when they become available 1.
• Patients with signs of severe infection, such as proptosis, impaired visual acuity, or impaired and/or painful extraocular mobility, should be hospitalized and undergo a contrast-enhanced CT scan to confirm intraorbital or intracranial suppurative complications 1.
• Consultation with an otolaryngologist, an ophthalmologist, and an infectious disease expert is crucial for guidance regarding the need for surgical intervention and the selection of antimicrobial agents 1.

Treatment Approach

• Broad-spectrum IV antibiotics, such as vancomycin, should be started immediately, and the treatment regimen should be adjusted based on the results of culture and sensitivity studies 1.
• Patients should be monitored closely for signs of improvement within 24-48 hours, and surgical drainage may be necessary if an abscess is present or if there is no improvement with antibiotic treatment 1.
• CT or MRI imaging is essential to evaluate the extent of infection and identify any collections requiring drainage 1.

Additional Considerations

• Patients with altered mental status, severe headache, or Pott’s puffy tumor (osteomyelitis of the frontal bone) should undergo a contrast-enhanced CT scan, and neurosurgical consultation should be obtained 1.
• Pain management with acetaminophen or NSAIDs and warm compresses may provide symptomatic relief during treatment.
• The aggressive antibiotic approach is necessary because orbital cellulitis can rapidly progress to serious complications, including vision loss, cavernous sinus thrombosis, meningitis, or brain abscess, if not properly treated 1.

From the Research

Orbital Cellulitis Treatment

• The treatment of orbital cellulitis typically involves the use of intravenous broad-spectrum antibiotics, with or without surgical intervention to drain orbital abscesses 2.
• In some cases, targeted therapy with antibiotics such as vancomycin and/or clindamycin may be necessary, particularly in cases of methicillin-resistant Staphylococcus aureus (MRSA) orbital cellulitis 3, 4.
• Surgical intervention may be required in cases of subperiosteal abscess or other complications, and can be effective in managing these complications and achieving favourable visual outcomes 3, 5.
• The use of corticosteroids has been explored, but their effectiveness in treating orbital cellulitis is unclear, and they may not be related to treatment failure 5.
• The duration of antibiotic therapy can vary, but treatment failure is uncommon in patients who receive ≤ 2 weeks of therapy, suggesting that shorter durations may be adequate in some patients 5.

Antibiotic Management

• The choice of antibiotics for orbital cellulitis depends on the suspected or confirmed causative organism, with broad-spectrum antibiotics often used empirically 2, 4.
• Vancomycin is often used in cases of suspected or confirmed MRSA orbital cellulitis, but its use can be high even in cases where MRSA is rare 3, 5.
• Combination antimicrobial agents are frequently used, but a simplified antibiotic regimen may help limit the development of resistant organisms and facilitate transition to an oral agent 4.

Complications and Outcomes

• Orbital cellulitis can lead to serious complications, including permanent visual impairment, ocular motility impairment, and intracranial extension 2, 3, 6.
• Despite these potential complications, adequately treated orbital cellulitis rarely has significant morbidity, and favourable visual outcomes can be achieved with early recognition and appropriate treatment 2, 3, 5.