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Orbital Cellulitis Empiric Therapy

Empiric Therapy Regimens

Empiric therapy regimens

Orbital cellulitis is a serious condition with potentially devastating visual and life-threatening complications. It can result from the following:

Extension of an infection from the periorbital structures, most commonly from the paranasal sinuses

Direct inoculation of the orbit due to trauma or surgery

Hematogenous spread from bacteremia (less commonly)

Understanding the prevalence and antibiotic resistance patterns of pathogens in the community is necessary for adequate treatment. The most common organisms isolated from blood, paranasal sinuses, and abscesses include Streptococcus species, Staphylococcus aureus, and Haemophilus influenzae type B.
Thus, initial management should include intravenous broad-spectrum antibiotics.

Intravenous (IV) broad-spectrum antibiotics should be started immediately and administered until the choice of antibiotics can be tailored for specific pathogens based on cultures. Generally, IV antibiotic therapy should be continued until there is clinical improvement, then followed by oral antibiotics to complete a course of 2-3 weeks (longer if there is evidence of bone involvement).

Initial treatment recommendations

Initial treatment recommendations include the following:

Ampicillin-sulbactam 1.5-3 g IV q6h

Cefuroxime 1.5 g IV q8h

Ceftriaxone 1-2 g/day IV

Piperacillin-tazobactam 4.5 g IV q8h

If methicillin-resistant
Staphylococcus aureus (MRSA) is suspected, add
vancomycin 1 g (15 mg/kg) IV q12h to the above regimens

Oral treatment options

Oral treatment options include the following:

Amoxicillin-clavulanate 875 mg/125 mg (20-40 mg/kg) PO q12h

Cefpodoxime 200-400 mg (5 mg/kg) PO q12h

Cefdinir 600 mg/day (14 mg/kg/day) PO

Special considerations

Patients with orbital cellulitis frequently complain of fever and malaise and report a history of recent sinusitis or upper respiratory tract infection. Orbital signs include periorbital cellulitis, limitation in ocular movements, pain with ocular movements, and proptosis.

Imaging studies are crucial in defining the extent and nature of orbital involvement and determining management. Sino-orbital CT scanning with and without contrast is recommended.

Consider surgical drainage if the response to appropriate antibiotic therapy is poor within 48-72 hours or if CT scans show the sinuses to be completely opacified.

If the presence of a drainable fluid collection is evident on CT scan, surgical drainage should be considered.

Consider orbital surgery, with or without sinusotomy, in every case of subperiosteal or intraorbital abscess formation, leaving the drains in place for several days.

In cases of fungal infection, surgical debridement of the orbit is indicated and may rarely necessitate exenteration of the orbit and the sinuses.

Canthotomy and cantholysis should be performed on an emergent basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease.

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