Pre-septal ( peri-orbital ) and Orbital Cellulitis in Adults

Publication: 31/03/2004  
Last review: 24/04/2018  
Next review: 24/04/2021  
Clinical Guideline
CURRENT 
ID: 450 
Supported by: Improving Antimicrobial Prescribing Group
Approved By: Drug and Therapeutics Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Pre-septal (peri-orbital) and Orbital Cellulitis in Adults

Summary
Pre-septal ( peri-orbital ) and Orbital Cellulitis in Adults

Clinical diagnosis

History

  • Onset and duration of symptoms?
  • Recent eyelid/orbital/facial trauma? If so, mechanism?
  • Recent eyelid/orbital/facial surgery? If so, what, when, where, and by who?
  • History of sinus disease?
  • History of recent respiratory tract infection? (e.g. coryza, adenitis).
  • Recent antimicrobial use? If so, what dose, frequency, duration, and why?

Examination

Common to BOTH conditions:

  • Eyelid swelling, erythema, and tenderness (may not be able to open eye much/at all).
  • Conjunctival injection.
  • Slight reduction in visual acuity (from watering eyes, and/or reduced palpebral aperture).

Note:

  • The above symptoms/signs can occur in OTHER ophthalmic conditions.
  • Severity/presence of the above symptoms/signs can vary and should NOT be used isolation to make/justify a diagnosis.
  • The presence of significant soft tissue eyelid and/or peri-orbital swelling can make it difficult to state if true proptosis exists without performing formal exophthalmometry.

Distinguishing orbital and pre-septal cellulitis

Table 1: Comparing features of pre-septal and orbital cellulitis

Comparative feature

Pre-septal cellulitis

Orbital cellulitis

True proptosis
Eye movements
Binocular diplopia
Visual acuity
Colour vision
Relative afferent pupillary defect
Conjunctival chemosis

Absent
Normal
Absent
Normal / slightly reduced
Normal
Normal
Absent

Present
Restricted +/- painful
May be present
Reduced in severe cases
Reduced in severe cases
Reduced in severe cases
May be present

Initial investigations

  • Mandatory investigations should be organized / performed in A+E as part of immediate management.
Table 2: Initial investigations

Investigations

Pre-septal cellulitis

Reasons

Orbital cellulitis

Reasons

Blood Tests

Nil

 

U+E

MANDATORY – baseline renal function
+/- for IV antibiotics

 

 

 

FBC

+/- suspicion of malignancy

 

 

 

Blood film

Only if suspicion of malignancy

 

 

 

Serum lactate

Only if suspicion of systemic sepsis

 

 

 

TFT

Only if suspicion of thyroid disease

Imaging

Nil

 

CT head/orbits

MANDATORY – assess spread of infection

Microbiology

Conjunctival swab

Only if discharge present

Conjunctival swab

Only if discharge present

 

 

 

Blood cultures

Only if suspicion of systemic sepsis

Other

Nil

 

Lumbar puncture

Only if signs of meningeal irritation present

 

Non-antimicrobial management
Pre-septal and orbital cellulitis

Orbital cellulitis only

  • 7 day course of xylometazoline 0.1% nasal spray, 1 spray into each nostril 3 times in 24 hours

Antimicrobial management

  • If pre-septal cellulitis is severe, consider treating as per orbital cellulitis.
  • If patients are immunocompromised, discuss with Microbiology.
  • If true allergy is present to any of the alternative first line antibiotics, discuss with Microbiology.

Table 3: First line anti-microbial management

 

Pre-septal cellulitis

Orbital cellulitis

First line

PO Flucloxacillin electronic Medicines Compendium information on Flucloxacillin
1g every 6 hours

IV Ceftriaxone electronic Medicines Compendium information on Ceftriaxone 2g (over 30 mins) every 24 hours
AND
IV Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 2g every 6 hours
AND
IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg every 8 hours

Alternative first line if penicillin or cephalosporin allergy present
If under 65

And NO history of C. difficile infection, use:

PO Clindamycin electronic Medicines Compendium information on Clindamycin
450mg every 6 hours

If patient is NOT vomiting (or if IV access is not possible), give:

PO Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
500mg every 12 hours
AND
PO Clindamycin electronic Medicines Compendium information on Clindamycin
450mg every 6 hours

Alternative first line if penicillin or cephalosporin allergy present
If over 65

And/or POSITIVE history of C. difficile infection, use:

PO Levofloxacin electronic Medicines Compendium information on Levofloxacin
500mg every 24 hours

If patient IS vomiting, give:

IV Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400mg every 8 hours
AND
IV Clindamycin electronic Medicines Compendium information on Clindamycin 600mg every 6 hours

Duration of therapy
See full guideline

IV conversion to PO therapy

  • IV Flucloxacillin electronic Medicines Compendium information on Flucloxacillin, Metronidazole electronic Medicines Compendium information on Metronidazole, Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin, and Clindamycin electronic Medicines Compendium information on Clindamycin can all be converted to their PO equivalents when required.
  • IV Ceftriaxone electronic Medicines Compendium information on Ceftriaxone does not have a direct PO equivalent, therefore PO cefaclor (500mg - 1g 8-hourly depending on clinical situation) should be used for conversion when required for the purpose of these guidelines.

Referral pathwatys
Pre-septal cellulitis

  • Refer to Ophthalmology on-call:
    • They will decide how quickly review is required and if any additional management is required based on history/examination findings.
  • May also need to discuss with ENT for prompt review depending on individual case presentation.

Orbital cellulitis

  • Refer to Ophthalmology on-call:
    • Who should arrange to see patient soon.
    • Who will decide if additional management/investigation is required based on history/examination findings.
  • May also need to discuss with ENT for prompt review depending on individual case presentation.

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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

  • Extension from adjacent sinus infection
  • Local eyelid infection (most common cause is chalazion)
  • Trauma to the eyelids

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

  • Extension from adjacent sinus infection
  • Extension from dental infection
  • Extension from pre-septal tissues
  • Direct inoculation (trauma)
  • Haematogenous spread

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.

Table 4: Causative organisms of pre-septal and orbital cellulitis.1,2

Pre-septal cellulitis

Orbital cellulitis

Streptococcus pneumonia

Staphylococcus aureus (more common following trauma)

Group A Streptococcus (GAS)

H influenzae type B (very uncommon in post vaccination era)
Anaerobes

Streptococcus species (including GAS, Streptococcus. pneumoniae and Streptococcus anginosus group)

S aureus (more common following trauma, including surgery)

Anaerobes

H influenzae type B (much less common in post vaccination era)

Pseudomonas (rare)
Klebsiella (rare)

Polymicrobial infections with aerobic & anaerobic bacteria are more common in those over 16years of age

Fungal infections with Mucor and Aspergillus are most common, usually associated with being immunocompromised

 

Table 5: Complications of orbital cellulitis

Pre-septal cellulitis

Orbital cellulitis

Progession to orbital cellulitis

Extension along tissue planes, causing

  • sub-periosteal abscess
  • orbital abscess
  • cavernous sinus thrombosis

Intracranial infection, particularly associated with:

  • subperiosteal abscess
  • persisting headache & fever despite IV antimicrobials
  • orbital extension &/or fungal infection, particularly associated with immunocompromised patients

Sub-periosteal abscess

Orbital abscess

Permanent vision loss (secondary to corneal or optic nerve damage)

Cavernous sinus thrombosis

Intracranial abscess

Meningitis

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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:

  • Neurological symptoms - these may suggest venous sinus thrombosis.
  • Orbital pain.
  • Visual disturbance (may include impaired colour visual perception).

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:

  • Assessment of the presence of proptosis.
  • Degree of eyelid oedema (complicating one’s ability to clinically assess the eye).
  • Eye movement (?conjugate, ?painful).
  • Pupillary responses (?equal, ?afferent pupillary defect).
  • ?conjunctivitis, or conjunctival chemosis.
  • Cranial nerve examination.
  • General neurological examination, including an assessment for meningeal irritation/ meningitis.
  • Respiratory examination, including evaluation of sinusitis.

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

Table 6: Differential diagnoses in acute ocular inflammation

Pre-septal cellulitis

Orbital cellulitis

Allergic reaction
Conjunctivitis

 

Thyroid eye disease
Orbital pseudotumour
Orbital myositis
Neoplasia
Neuroblastoma
Rhabdomyosarcoma

Pre-septal cellulitis

Presentation:

  • Pain.
  • Conjunctivitis.
  • Periorbital oedema & erythema.
    • This may be so severe that one is unable (or barely able) to open the eye.
  • Features of a respiratory tract infection:
    • Coryza.
    • Adenitis.
    • Sinus tenderness.

Orbital cellulitis

Presentation:

  • Conjunctival chemosis.
  • Lid oedema.
  • Rhinorrhoea, or frank purulent nasal discharge.
  • Orbital pain and tenderness (present early).
  • Dark red discolouration of eyelid (can look similar to pre-septal cellulitis erythema).
  • Proptosis and ophthlmoplegia (+/- binocular diplopia) develop as the infection progresses.

Distinguishing features of pre-septal and orbital cellulitis

See Table 1 above.

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Severity Assessment

This is a clinical judgment.

Non-severe pre-septal cellulitis:

  • Patients who do not appear systemically unwell, are not vomiting and who do not have a systemic inflammatory response can usually be managed with oral antimicrobials.

Severe pre-septal cellulitis:

  • Associated with signs of severe sepsis
  • Should be managed according to the severe sepsis pathway and with the antimicrobials recommended for orbital cellulitis.

Orbital cellulitis should be considered as severe irrespective of the presence or absence of symptoms or signs of systemic infection.

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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.


Microbiology

Recommendation: Blood culture should be taken from patients with orbital/pre-septal cellulitis and symptoms or signs of systemic infection.
[Evidence level C]

Recommendation: A swab of the eye should be taken if there is any pus or exudate present.
[Evidence level C]

Recommendation: Lumbar puncture is indicated if there are any clinical concerns about meningeal irritation.
[Evidence level C]


Blood tests

Recommendation: serum lactate should be measured if severe sepsis is present.
[Evidence level C]

Recommendation: Urea and electrolytes should be measured in patients requiring IV antimicrobials to ensure appropriate dosing.
[Evidence level D]

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.
[Evidence level D - Although measurement of White blood cell count and C-reactive protein may support the diagnosis of infection , they lack sensitivity and specificity and do not alter patient management]

Recommendation: Thyroid function test and creatinine kinase are recommended to help exclude differential diagnoses (Table 4).
[Evidence level D]


Imaging

Recommendation: CT head is indicated for ALL patients with orbital cellulitis.
[Evidence level C]

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.

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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.
[Evidence level C]

Recommendation: Seizures should be managed in line with trust guidelines
[Evidence level C]

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.
[Evidence level D]

Paranasal sinus disease is the commonest cause of orbital cellulitis in adults.

Recommendation: Analgesia should be given as required.
[Evidence level D]

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.
[Evidence level D]

Surgery may well be required, particularly in the event of:

  • A sinus collection.
  • Subperiosteal abscess.
  • Orbital abscess.
  • Ongoing proptosis (despite appropriate antimicrobials).
  • Visual acuity deterioration.
  • Afferent pupillary defect.
  • Fungal orbital cellulitis.

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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:

Ceftriaxone electronic Medicines Compendium information on Ceftriaxone IV 2g (over 30 minutes) every 24 hours (first dose MUST be given as a bolus in A&E)
AND
IV Flucoxacillin 2g every 6 hours
AND
IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg every 8 hours
  • IV treatment should be used for AT LEAST 3 days.

If true Penicillin / Cephalosporin allergy:

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg every 12 hours orally
AND
Clindamycin electronic Medicines Compendium information on Clindamycin 450mg every 6 hours orally
  • Oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and Clindamycin electronic Medicines Compendium information on Clindamycin have similar bioavailability as IV route and a good spectrum of antibacterial coverage, but may be less reliable against some staphylococci and streptococci because of resistance.
  • This regimen can be considered as an alternative  to first line of treatment if IV access is difficult and patients do not have severe sepsis.1 However, this regimen may be less effective than first line therapy.
  • Conversely, If patient is vomiting treat by intravenous route (400mg 8-hourly Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin, 600mg 6-hourly Clindamycin electronic Medicines Compendium information on Clindamycin).

Immunocompromised patients:

  • Discuss with microbiology

Pre-septal Cellulitis:

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin 1g every 6 hours orally 
  • As the common pathogens are Staphylococcals and Streptococcals, high dose Flucloxacillin electronic Medicines Compendium information on Flucloxacillin should be effective in most cases.
    [Evidence level D]

If true Penicillin / Cephalosporin allergy:

Clindamycin electronic Medicines Compendium information on Clindamycin 450mg every 6 hours orally

NOTE: Risk of C. difficile infection (CDI) in over 65’s.

Therefore, if over 65 or previous CDI AND true penicllin / cephalosporin allergy:

Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg 24-hourly orally

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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.
[Evidence level D]

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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.
[Evidence level D]

  • Minimum requirements would include significant clinical response to treatment, and being afebrile > 24hours.
  • Commonly, IV treatment is switched to oral after 3 days if the above requirements are met.
  • As IV Ceftriaxone electronic Medicines Compendium information on Ceftriaxone does not have a direct oral antimicrobial equivalent, oral Cefaclor (500mg - 1g 8-hourly depending on clinical situation) would be the recommended oral switch.

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Treatment Failure

In the event of failure to improve on appropriate antimicrobials, then further neuroimaging and surgical review are required.

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Provenance

Record: 450
Objective:

Aims

  • To improve the diagnosis and management of pre-septal (peri-orbital) and orbital cellulitis, and their complications

Objectives

  • To provide evidence-based recommendations for appropriate diagnosis and investigation of pre-septal and orbital cellulitis, and their complications
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of pre-septal and orbital cellulitis, and their complications.
  • To provide evidence-based recommendations for appropriate antimicrobial therapy of pre-septal and orbital cellulitis.
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
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

  1. Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust N Z J Ophthalmol 1999; 27:375-379.
  2. Moorfields Eye Hospital A&E Manual, 2011.
  3. 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.
  4. 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.
  5. Atkins MC, Harrison GA, Lucas GS. Pseudomonas aeruginosa orbital cellulitis in four neutropenic patients. J Hosp Infect. 1990 Nov;16(4):343-9.
  6. 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)

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Approved By

Drug and Therapeutics Committee

Document history

LHP version 1.0

Related information

Not supplied

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