Pre-septal ( peri-orbital ) and Orbital Cellulitis in Adults |
Publication: 31/03/2004 |
Next review: 26/04/2024 |
Clinical Guideline |
CURRENT |
ID: 450 |
Supported by: Improving Antimicrobial Prescribing Group Approved By: Drug and Therapeutics Committee |
Copyright© Leeds Teaching Hospitals NHS Trust 2021 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Pre-septal (peri-orbital) and Orbital Cellulitis in Adults
Summary Pre-septal ( peri-orbital ) and Orbital Cellulitis in Adults |
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Clinical diagnosis History
Examination Common to BOTH conditions:
Note:
Distinguishing orbital and pre-septal cellulitis Initial investigations
Non-antimicrobial management
Orbital cellulitis only
Antimicrobial management
Duration of therapy IV conversion to PO therapy
Referral pathwatys
Orbital cellulitis
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Background | ||||||||||||
Pre-septal cellulitis is also known as peri-orbital cellulitis. The former term is preferred and used throughout this guideline. Pre-septal cellulitis is common, and is characterised by acute eyelid erythema and swelling. Both conditions are caused by infection. The most common pathogens are shown in Table 4. Pre-septal cellulitis may result from
Pre-septal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues anterior to the orbital septum. Orbital cellulitis is infection of soft tissue posterior to the orbital septum, and may result from
Orbital cellulitis is rare, with a recently reported incidence of 0.1/100 000/year in Scotland.1 Immunosuppression is an important current risk factor.
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Clinical Diagnosis |
History The history for both is usually acute periorbital pain and redness. Clinical features that distinguish periorbital from orbital cellulitis are shown in Table 1 (see summary section above). Important considerations in the history include details of any trauma (?animal contact), including surgery and the mechanism of trauma. One should take a complete history, particularly considering the differential causes of such findings, listed in Table 6. It is important to elicit any antimicrobial use in this illness, including agent/dose and duration and their clinical effect. One should specifically enquire regarding any more worrying signs that might raise one’s concerns of a complication:
Examination Examination will include an assessment as to need for resuscitation and, if present, severe sepsis should be managed according to GL886. Examination should specifically include:
Additionally one should complete a general examination regarding differential diagnoses. Clearly document the area involved on casualty card and draw on skin, with skin pen, the extent of cellulitis to enable objective assessment of clinical i9mprovement or deterioration. Differential Diagnosis Pre-septal cellulitis Presentation:
Orbital cellulitis Presentation:
Distinguishing features of pre-septal and orbital cellulitis See Table 1 above. |
Investigation |
Diagnosis is clinical, but assessment of severity, duration of therapy and need for surgical intervention may be influenced by investigations. NOTE: Needle aspiration of the eye or peri-orbital tissues is contraindicated in pre-septal or orbital cellulitis.
Recommendation: Blood culture should be taken from patients with orbital/pre-septal cellulitis and symptoms or signs of systemic infection. Recommendation: A swab of the eye should be taken if there is any pus or exudate present. Recommendation: Lumbar puncture is indicated if there are any clinical concerns about meningeal irritation.
Recommendation: serum lactate should be measured if severe sepsis is present. Recommendation: Urea and electrolytes should be measured in patients requiring IV antimicrobials to ensure appropriate dosing. Recommendation: A full blood count and film should be undertaken if there is concern about haematological malignancy or underlying bone marrow disorders predisposing to infection. Recommendation: Thyroid function test and creatinine kinase are recommended to help exclude differential diagnoses (Table 4).
Recommendation: CT head is indicated for ALL patients with orbital cellulitis. Imaging is critical to establish a diagnosis of abscess, and to exclude venous sinus thrombosis where it is suspected. CT (with contrast) is the most commonly sought form of imaging. This may require additional MR imaging, if there are ongoing concerns, or evidence of venous sinus thrombosis. Repeat imaging will be required in the event of treatment failure (defined as continuing deterioration despite appropriate antimicrobial therapy). In the event of ethmoidectomy, fluid should be sent for culture and staining, specifically requesting extended anaerobic and aerobic culture. |
Treatment | |||||
Non-Antimicrobial Treatment | |||||
Fluid resuscitation, surgery, etc.
Recommendation: The need for fluid resuscitation should be determined, and addressed by following the resuscitation of patients with suspected severe sepsis guideline. Recommendation: Seizures should be managed in line with trust guidelines Contact the on call Consultant Ophthalmologist if you have any concerns, or the clinical presentation lacks clarity. Recommendation: If treating as presumed orbital cellulitis, patients should have both ENT and Ophthalmology review at or shortly after the time of admission. Paranasal sinus disease is the commonest cause of orbital cellulitis in adults. Recommendation: Analgesia should be given as required. Refer to Trust guidelines (Acute Pain Management in Adults Manual). Recommendation: Patients being treated for orbital cellulitis should be given a course of nasal decongestants to aid sinus drainage as sinus disease is a common cause of infection. [Evidence level D] Recommendation: Patient should be placed nil by mouth on admission until reviewed by both Ophthalmology and/or ENT. Surgery may well be required, particularly in the event of:
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Empirical Antimicrobial Treatment | |||||
Initial antimicrobial therapy prior to availability of microbiology results or if a microbiological diagnosis is not going to be possible. See Table 3 for summary. Orbital Cellulitis:
If true Penicillin / Cephalosporin allergy:
Immunocompromised patients:
Pre-septal Cellulitis:
If true Penicillin / Cephalosporin allergy:
NOTE: Risk of C. difficile infection (CDI) in over 65’s. Therefore, if over 65 or previous CDI AND true penicllin / cephalosporin allergy:
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Directed Antimicrobial Treatment (when microbiology results are known) | |||||
Antimicrobial therapy when microbiology results are available. Discuss with microbiology. |
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Duration of Treatment | |||||
Recommendation: Therapy should be continued for around 7-14 days according to clinical response. Antimicrobials can be stopped when patients are systemically well and cellulitis has resolved. |
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Switch to oral agent(s) | |||||
Recommendation: Oral switch should occur ONLY following discussion between the medical team and the respective surgical (Ophthalmology/ENT) teams involved in the patient’s treatment and care, and will depend on initial severity, speed of response, imaging findings (if performed), and whether any operative intervention has been undertaken.
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Treatment Failure | |||||
In the event of failure to improve on appropriate antimicrobials, then further neuroimaging and surgical review are required. |
Provenance
Record: | 450 |
Objective: | Aims
Objectives
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Clinical condition: | Pre-septal and orbital cellulitis |
Target patient group: | Adult patients with Pre-septal and orbital cellulitis |
Target professional group(s): | Secondary Care Doctors Secondary Care Nurses |
Adapted from: | N/A |
Evidence base
- Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust N Z J Ophthalmol 1999; 27:375-379.
- Moorfields Eye Hospital A&E Manual, 2011.
- Murphy C, Livingstone I, Foot B, Murgatroyd H, MacEwen CJ. Orbital cellulitis in Scotland: current incidence, aetiology, management and outcomes. Br J Ophthalmol 2014; 98(11): 1575-8.
- Cannon PS, Mc Keag D, Radford R, Ataullah S, Leatherbarrow B. Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre. Eye (Lond) 2009; 23(3): 612-5.
- Atkins MC, Harrison GA, Lucas GS. Pseudomonas aeruginosa orbital cellulitis in four neutropenic patients. J Hosp Infect. 1990 Nov;16(4):343-9.
- Yang SJ, Park SY, Lee YJ, Kim HY, Seo JA, Kim SG, Choi DS. Klebsiella pneumoniae orbital cellulitis with extensive vascular occlusions in a patient with type 2 diabetes. Korean J Intern Med. 2010 Mar;25(1):114-7. doi: 10.3904/kjim.2010.25.1.114. Epub 2010 Feb 26.
Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Approved By
Drug and Therapeutics Committee
Document history
LHP version 1.0
Related information
Not supplied
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