Cellulitis periobital and orbital

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide Emergency Department (ED) staff with the assessment and management of periorbital and orbital cellulitis.

Background¹

Orbital cellulitis

Several conditions can present in a similar way, but all of these are ophthalmological emergencies and are approached in the same way:

Orbital cellulitis
Orbital abscess
Subperiosteal abscess
Cavernous sinus thrombosis.

Key signs - refer urgently to Ophthalmology if any of these signs are present

Decreased visual acuity
Proptosis
Ophthalmoplegia
Red eye
Papilloedema, meningism or cranial nerve involvement. Consider cavernous sinus thrombosis.

Likely organisms¹

Streptococcus pyogenes
Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae (HiB) in unimmunised children

Periorbital cellulitis

This involves pre-septal soft tissue infection. Likely infections are the same as for cellulitis, but the presence of a contiguous skin lesion (insect bite, scratch etc.) makes streptococcus pyogenes and staphylococcus aureus more likely.

Assessment

Severity

The assessment of the severity of the presentation will determine the management.

Consider Allergic reaction	Mild	Moderate	Severe/ophthalmological emergency
Localised swelling No tenderness No redness Afebrile	Mild redness and swelling Systemically well	Moderate redness and swelling +/- systemically unwell	Decreased visual acuity Proptosis Ophthalmoplegia Red eye

Management²

Management of children < 1 month of age

Admit for IV cefotaxime - Neonatal Medication Monograph (PDF).

For patients <3 months perform eye swab for Gonorrhoea and Chlamydia

Management of children ≥ 1 months of age

Allergic reaction	Mild	Moderate		Severe/ophthalmological emergency
Allergic reaction	Mild	(no sinusitis)	(with Sinusitis or HiB suspected)	Severe/ophthalmological emergency
Trial antihistamine	Oral - Amoxycillin/clavulanic acid ED/GP review within 24 hours	Admit under General Paediatrics Commence IV Flucloxacillin	Admit under General Paediatrics Commence IV Ceftriaxone	Computerised Tomography (CT) Urgent ophthalmology consult Urgent Ear, Nose and Throat (ENT) referral if sinusitis, abscess or cavernous sinus thrombosis Bloods culture and full blood count. Commence IV Vancomycin and Ceftriaxone

For dosing in children < 1 month, refer to Neonatal Medication Protocols.

Bibliography

Gappy C, Archer SM and Barza M (2014) Orbital Cellulitis. UpToDate (external site).
WA Health Child and Adolescent Health Service. ChAMP Eye Infections Paediatric Empiric Guidelines, October 2021

Endorsed by:	CAHS Drug and Therapeutics Committee	Date:	Apr 2022
		Review date:	Apr 2025

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