Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

periorbital cellulitis: causative organism not identified

1st line – empiric intravenous antibiotic therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: hospitalization required
1st line – 

empiric intravenous antibiotic therapy

Patients should be followed daily for signs and symptoms of developing orbital cellulitis. Patients with severe infection may require admission and intravenous antibiotics.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Senior colleagues should be involved as indicated, and local sepsis protocols followed.

In communities with low antibiotic resistance, empiric regimens include beta-lactamase resistant penicillins (e.g., ampicillin/sulbactam), a third-generation cephalosporin (e.g., cefotaxime), or clindamycin, or alternatively, metronidazole plus cefuroxime.[1][9][11]​​[13][39]

Treatment course: 7-10 days. It is recommended that regimens are checked with an infectious disease specialist.

Primary options

ampicillin/sulbactam: children ≥1 year of age and <40 kg body weight: 300 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; children ≥1 year of age and ≥40 kg body weight and adults: 1.5 to 3 g intravenously every 6 hours, maximum 12 g/day

More

OR

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

OR

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

OR

cefuroxime sodium: children ≥3 months of age: 50-150 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day; adults: 750-1500 mg intravenously every 6-8 hours

and

metronidazole: children: 30 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day; adults: 500 mg intravenously every 6-8 hours

Consider – incision, drainage, and culture of periocular abscess

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: hospitalization required
Consider – 

incision, drainage, and culture of periocular abscess

Treatment recommended for SOME patients in selected patient group

If present, a periocular abscess should be incised and drained, and a swab of contents sent for culture and sensitivities.

Consider – empiric antifungal therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: hospitalization required
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

1st line – empiric intravenous antibiotic therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: hospitalization required
1st line – 

empiric intravenous antibiotic therapy

Patients should be followed daily for signs and symptoms of developing orbital cellulitis. Patients with severe infection may require admission and intravenous antibiotics.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Senior colleagues should be involved as indicated, and local sepsis protocols followed.

If MRSA is suspected, consider intravenous vancomycin plus cefotaxime and clindamycin, or alternatively, vancomycin plus piperacillin/tazobactam. Daptomycin, linezolid, and telavancin are potential alternatives for patients who are allergic to vancomycin. However, there is little experience using these agents for orbital or intracranial infections, and they should be given under the guidance of an infectious disease specialist.

Treatment course: 7-10 days.

Primary options

vancomycin: children: 40-60 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 500 mg intravenously every 6 hours, or 1000 mg every 12 hours

and

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

and

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

OR

vancomycin: children: 40-60 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 500 mg intravenously every 6 hours, or 1000 mg every 12 hours

and

piperacillin/tazobactam: children: 80-100 mg/kg (maximum 4 g/dose) intravenously every 8 hours; adults: 3.375 to 4.5 g intravenously every 6 hours

More

Secondary options

daptomycin: children: consult specialist for guidance on dose; adults: 4 mg/kg intravenously once daily

or

linezolid: children <12 years of age: 10 mg/kg (maximum 600 mg/dose) intravenously every 8 hours; children ≥12 years of age; and adults: 600 mg intravenously every 12 hours

or

telavancin: children: consult specialist for guidance on dose; adults: 10 mg/kg intravenously once daily

-- AND --

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

-- AND --

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

Consider – incision, drainage, and culture of periocular abscess

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: hospitalization required
Consider – 

incision, drainage, and culture of periocular abscess

Treatment recommended for SOME patients in selected patient group

If present, a periocular abscess should be incised and drained, and a swab of contents sent for culture and sensitivities.

Consider – empiric antifungal therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: hospitalization required
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

1st line – empiric oral antibiotic therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: suitable for outpatient therapy
1st line – 

empiric oral antibiotic therapy

Adults with less severe periorbital cellulitis who are stable may receive oral antibiotics as outpatients with daily follow-up. In children, empiric oral therapy may be initiated with reliable daily follow-up.

In communities with low antibiotic resistance, empiric regimens include amoxicillin/clavulanate or a third-generation cephalosporin, or alternatively, metronidazole plus cefuroxime.[1][9][11]​​[13]

Treatment course: 7-10 days. It is recommended that regimens are checked with an infectious disease specialist.

Primary options

amoxicillin/clavulanate: children <3 months of age: 30 mg/kg/day orally given in divided doses every 12 hours: children ≥3 months of age: 20-40 mg/kg/day orally given in divided doses every 8 hours; adults: 875 mg orally twice daily, or 500 mg three times daily

More

OR

cefpodoxime proxetil: children ≥2 months of age: 10 mg/kg/day orally given in divided doses every 12 hours; adults: 100-400 mg orally twice daily

OR

cefuroxime axetil: children ≥3 months of age: 20-30 mg/kg/day orally given in divided doses every 12 hours, maximum 1 g/day; adults: 250-500 mg orally twice daily

and

metronidazole: children: 30 mg/kg/day orally given in divided doses every 6 hours, maximum 4 g/day; adults: 500 mg orally every 6-8 hours

Consider – incision, drainage, and culture of periocular abscess

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: suitable for outpatient therapy
Consider – 

incision, drainage, and culture of periocular abscess

Treatment recommended for SOME patients in selected patient group

If present, a periocular abscess should be incised and drained, and a swab of contents sent for culture and sensitivities.

Consider – empiric antifungal therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA not suspected: suitable for outpatient therapy
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

1st line – empiric oral antibiotic therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: suitable for outpatient therapy
1st line – 

empiric oral antibiotic therapy

Adults with less severe periorbital cellulitis who are stable may receive oral antibiotics as outpatients with daily follow-up. In children, empiric oral therapy may be initiated with reliable daily follow-up.

If MRSA is suspected, consider use of a third-generation cephalosporin or amoxicillin/clavulanate plus either clindamycin or trimethoprim/sulfamethoxazole.

Treatment course: 7-10 days. It is recommended that regimens are checked with an infectious disease specialist.

Primary options

cefpodoxime proxetil: children ≥2 months of age: 10 mg/kg/day orally given in divided doses every 12 hours; adults: 100-400 mg orally twice daily

or

amoxicillin/clavulanate: children <3 months of age: 30 mg/kg/day orally given in divided doses every 12 hours: children ≥3 months of age: 20-40 mg/kg/day orally given in divided doses every 8 hours; adults: 875 mg orally twice daily, or 500 mg three times daily

More

-- AND --

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-12 mg/kg/day orally given in divided doses every 12 hours; adults: 160 mg orally twice daily

More

or

clindamycin: children: 8-40 mg/kg/day orally given in divided doses every 6-8 hours; adults: 150-450 mg orally every 6 hours

Consider – incision, drainage, and culture of periocular abscess

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: suitable for outpatient therapy
Consider – 

incision, drainage, and culture of periocular abscess

Treatment recommended for SOME patients in selected patient group

If present, a periocular abscess should be incised and drained, and a swab of contents sent for culture and sensitivities.

Consider – empiric antifungal therapy

Back
ACUTE
|
periorbital cellulitis: causative organism not identified
|
MRSA suspected: suitable for outpatient therapy
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

periorbital cellulitis: causative organism identified

1st line – switch to targeted oral antibiotic or antifungal therapy

Back
ACUTE
|
periorbital cellulitis: causative organism identified
1st line – 

switch to targeted oral antibiotic or antifungal therapy

If cultures are positive and antibiotic sensitivities become known, the patient should be switched from empiric therapy to targeted therapy. Antibiotic and antifungal selection will depend on current local policy and sensitivities.

Consider – incision, drainage, and culture of periocular abscess

Back
ACUTE
|
periorbital cellulitis: causative organism identified
Consider – 

incision, drainage, and culture of periocular abscess

Treatment recommended for SOME patients in selected patient group

Recommended upon diagnosis of drainable abscess on periocular surface. May be performed at any stage of diagnosis and/or treatment, but preferably as part of early treatment. Drainage is required to evacuate the pus, release the pressure on the eyelid, and to obtain a culture.[13]

orbital cellulitis: causative organism not identified

1st line – empiric intravenous antibiotic therapy

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
1st line – 

empiric intravenous antibiotic therapy

All patients with orbital cellulitis should be admitted for empiric intravenous antibiotic therapy.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Senior colleagues should be involved as indicated, and local sepsis protocols followed.

Early specialist involvement is recommended, particularly for children, including ophthalmology and ear, nose and throat, with input from other specialties as needed (e.g., pediatrics, infective diseases).[15][19][20]​​[35]​​[36]​​​​​​

Antibiotics should cover sinus pathogens that exhibit beta-lactamase resistance and should penetrate cerebrospinal fluid.[1][9][10][11]​​[12][13][16] There are no standard rules on the type of treatment in adults or children because of the great decline in culture-positive isolates. Therefore, empiric antibiotic treatment should be targeted against the typical pathogens, including Staphylococcus aureus, the Streptococcusspecies (Streptococcus milleri,Streptococcus pyogenes, and Streptococcus pneumoniae), and anaerobic bacteria.[37]

In immunized adults and children, Haemophilus influenzae is less of a concern. Polymicrobial infection is possible, and includes infection with aerobic and anaerobic bacteria, fungal species and mycobacteria.[38]

In communities with low antibiotic resistance, empiric regimens include beta-lactamase-resistant penicillins (e.g., ampicillin/sulbactam), a third-generation cephalosporin (e.g., cefotaxime), or clindamycin, or alternatively, metronidazole plus cefuroxime.[1][9][11]​​[13][39]​​

It is recommended that regimen type and duration are checked with an infectious disease specialist.

Primary options

ampicillin/sulbactam: children ≥1 year of age and <40 kg body weight: 300 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day; children ≥1 year of age and ≥40 kg body weight and adults: 1.5 to 3 g intravenously every 6 hours, maximum 12 g/day

More

OR

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

OR

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

OR

cefuroxime sodium: children ≥3 months of age: 50-150 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day; adults: 750-1500 mg intravenously every 6-8 hours

and

metronidazole: children: 30 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4 g/day; adults: 500 mg intravenously every 6-8 hours

Consider – nasal decongestant

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
Consider – 

nasal decongestant

Treatment recommended for SOME patients in selected patient group

A nasal decongestant (e.g., oxymetazoline) may be used to reduce nasal edema and improve drainage, although the role of decongestants in the treatment of sinusitis has not been shown.[13]

Should not be used for more than 3-5 days, owing to the risk of rebound congestion.

Primary options

oxymetazoline nasal: (0.05%) children ≥6 years of age and adults: 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

Consider – corticosteroid

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

Systemic corticosteroids (e.g., prednisone) may reduce swelling of the sinus ostia and improve drainage in some patients.[19][32][33]​​

Primary options

prednisone: children and adults: consult specialist for guidance on dose

Consider – empiric antifungal therapy

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

Consider – lateral canthotomy and cantholysis

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
Consider – 

lateral canthotomy and cantholysis

Treatment recommended for SOME patients in selected patient group

May be required for urgent release of high orbital pressure, in the presence of decreased vision and a relative afferent pupillary defect. May also be necessary before orbitotomy can be performed.

Consider – orbitotomy and surgical drainage of orbital abscess

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA not suspected
Consider – 

orbitotomy and surgical drainage of orbital abscess

Treatment recommended for SOME patients in selected patient group

Most surgeons favor an initial trial of medical management unless the abscess is large (greater than 1 cm in length or 0.4 cm in width) or there is elevated intraocular pressure, significant limitation of extraocular motility, or frontal sinusitis. Patients who fail to respond within 48 hours or who are developing increasing proptosis or ocular dysfunction while on medical management should undergo coordinated sinus and orbital abscess drainage. Sometimes medial orbital abscesses may be drained as part of ethmoid sinus drainage, but orbital roof or floor abscesses generally require a separate incision to adequately drain.[28][29]

If there are multiple foci of subperiosteal abscess (with the potential to rapidly cause optic neuropathy), a large abscess, or frontal sinus involvement, early drainage is warranted. Drainage serves to evacuate the pus, release the pressure on the orbit, and provide a specimen of pus for culture.[13] Lateral canthotomy and cantholysis may be required to reduce intraocular pressure before orbitotomy can be performed.

1st line – empiric intravenous antibiotic therapy

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
1st line – 

empiric intravenous antibiotic therapy

All patients with orbital cellulitis should be admitted for empiric intravenous antibiotic therapy.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Senior colleagues should be involved as indicated, and local sepsis protocols followed.

Early specialist involvement is recommended, particularly for children, including ophthalmology and ear, nose and throat, with input from other specialties as needed (e.g., pediatrics, infective diseases).[15][19][20]​​[35]​​[36]​​

If MRSA is suspected, or there is concern for antibiotic resistance, treat with vancomycin plus cefotaxime and clindamycin, or alternatively, vancomycin plus piperacillin/tazobactam. Daptomycin, linezolid, and telavancin are potential alternatives for patients who are allergic to vancomycin. However, there is little experience using these agents for orbital or intracranial infections, and they should be given under the guidance of an infectious disease specialist.

Primary options

vancomycin: children: 40-60 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 500 mg intravenously every 6 hours, or 1000 mg every 12 hours

and

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

and

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

OR

vancomycin: children: 40-60 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 500 mg intravenously every 6 hours, or 1000 mg every 12 hours

and

piperacillin/tazobactam: children: 80-100 mg/kg (maximum 4 g/dose) intravenously every 8 hours; adults: 3.375 to 4.5 g intravenously every 6 hours

More

Secondary options

daptomycin: children: consult specialist for guidance on dose; adults: 4 mg/kg intravenously once daily

or

linezolid: children <12 years of age: 10 mg/kg (maximum 600 mg/dose) intravenously every 8 hours; children ≥12 years of age; and adults: 600 mg intravenously every 12 hours

or

telavancin: children: consult specialist for guidance on dose; adults: 10 mg/kg intravenously once daily

-- AND --

cefotaxime: children: 50-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day; adults: 1-2 g intravenously every 6-8 hours

-- AND --

clindamycin: children: 20-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 600-2700 mg/day intravenously given in divided doses every 6-12 hours

Consider – nasal decongestant

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
Consider – 

nasal decongestant

Treatment recommended for SOME patients in selected patient group

A nasal decongestant (e.g., oxymetazoline) may be used to reduce nasal edema and improve drainage, although the role of decongestants in the treatment of sinusitis has not been shown.[13]

Should not be used for more than 3-5 days, owing to the risk of rebound congestion.

Primary options

oxymetazoline nasal: (0.05%) children ≥6 years of age and adults: 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

Consider – corticosteroid

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

Systemic corticosteroids (e.g., prednisone) may reduce swelling of the sinus ostia and improve drainage in some patients.[19][32][33]​​

Primary options

prednisone: children and adults: consult specialist for guidance on dose

Consider – empiric antifungal therapy

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
Consider – 

empiric antifungal therapy

Treatment recommended for SOME patients in selected patient group

Although uncommon, fungal infections (mucormycosis or invasive aspergillosis) have been seen, particularly in patients with diabetic ketoacidosis or immunosuppression, and are typically very aggressive and may be fatal. Therefore, consideration should be given to empiric antifungal therapy in immunosuppressed or ketoacidotic patients, and patients with a suspicious (viscid, dark brown-black) nasal discharge.

Primary options

amphotericin B deoxycholate: children and adults: consult specialist for guidance on dose

Consider – lateral canthotomy and cantholysis

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
Consider – 

lateral canthotomy and cantholysis

Treatment recommended for SOME patients in selected patient group

May be required for urgent release of high orbital pressure, in the presence of decreased vision and a relative afferent pupillary defect. May also be necessary before orbitotomy can be performed.

Consider – orbitotomy and surgical drainage of orbital abscess

Back
ACUTE
|
orbital cellulitis: causative organism not identified
|
MRSA suspected
Consider – 

orbitotomy and surgical drainage of orbital abscess

Treatment recommended for SOME patients in selected patient group

Most surgeons favor an initial trial of medical management unless the abscess is large (greater than 1 cm in length or 0.4 cm in width) or there is elevated intraocular pressure, significant limitation of extraocular motility, or frontal sinusitis. Patients who fail to respond within 48 hours or who are developing increasing proptosis or ocular dysfunction while on medical management should undergo coordinated sinus and orbital abscess drainage. Sometimes medial orbital abscesses may be drained as part of ethmoid sinus drainage, but orbital roof or floor abscesses generally require a separate incision to adequately drain.[28][29]

If there are multiple foci of subperiosteal abscess (with the potential to rapidly cause optic neuropathy), a large abscess, or frontal sinus involvement, early drainage is warranted. Drainage serves to evacuate the pus, release the pressure on the orbit, and provide a specimen of pus for culture.[13] Lateral canthotomy and cantholysis may be required to reduce intraocular pressure before orbitotomy can be performed.

orbital cellulitis: causative organism identified

1st line – switch to targeted intravenous antibiotic or antifungal therapy

Back
ACUTE
|
orbital cellulitis: causative organism identified
1st line – 

switch to targeted intravenous antibiotic or antifungal therapy

If cultures are positive and antibiotic sensitivities become known, the patient should be switched from empiric therapy to targeted therapy. Antibiotic and/or antifungal selection will depend on current local policy and sensitivities.

However, positive culture rates are between 0% and 33%.[22] Therefore, in the majority of cases, cultures are likely to be negative,​ and patients should continue on the empiric regimen they were started on presumptively.[21][23]

In children less than 9 years old with isolated medial subperiosteal orbital abscess due to ethmoid sinusitis and without visual dysfunction, urgent surgical drainage is not usually required. In this age group, intravenous antibiotic therapy and nasal decongestion may suffice in clearing the abscess.[30]

However, in older children and adults, polymicrobial and anaerobic infection risk is higher, which may warrant prompt drainage.[30] Furthermore, if there are multiple foci of subperiosteal abscess (with the potential to rapidly cause optic neuropathy), or if there is associated frontal sinusitis (with potential for intracranial spread), early drainage is warranted, even in young children. Drainage serves to evacuate the pus, release the pressure on the orbit, and provide a specimen of pus for culture.[13] Lateral canthotomy and cantholysis may be required to reduce intraocular pressure before orbitotomy can be performed. In head and neck surgery literature, the size of the abscess serves as an important factor for the need of urgent surgical drainage regardless of the patient's age.

Consider – nasal decongestant

Back
ACUTE
|
orbital cellulitis: causative organism identified
Consider – 

nasal decongestant

Treatment recommended for SOME patients in selected patient group

A nasal decongestant (e.g., oxymetazoline) may be used to reduce nasal edema and improve drainage, although the role of decongestants in the treatment of sinusitis has not been shown.[13]

Should not be used for more than 3-5 days, owing to the risk of rebound congestion.

Primary options

oxymetazoline nasal: (0.05%) children ≥6 years of age and adults: 2-3 sprays into each nostril every 10-12 hours when required, maximum 6 sprays per nostril/day

Consider – corticosteroid

Back
ACUTE
|
orbital cellulitis: causative organism identified
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

Systemic corticosteroids (e.g., prednisone) may reduce swelling of the sinus ostia and improve drainage in some patients.[19][32][33]​​

Primary options

prednisone: children and adults: consult specialist for guidance on dose

Consider – lateral canthotomy and cantholysis

Back
ACUTE
|
orbital cellulitis: causative organism identified
Consider – 

lateral canthotomy and cantholysis

Treatment recommended for SOME patients in selected patient group

May be required for urgent release of high orbital pressure, in the presence of decreased vision and a relative afferent pupillary defect. May also be necessary before orbitotomy can be performed.

Consider – orbitotomy and surgical drainage of orbital abscess

Back
ACUTE
|
orbital cellulitis: causative organism identified
Consider – 

orbitotomy and surgical drainage of orbital abscess

Treatment recommended for SOME patients in selected patient group

Most surgeons favor an initial trial of medical management unless the abscess is large (greater than 1 cm in length or 0.4 cm in width) or there is elevated intraocular pressure, significant limitation of extraocular motility, or frontal sinusitis. Patients who fail to respond within 48 hours or who are developing increasing proptosis or ocular dysfunction while on medical management should undergo coordinated sinus and orbital abscess drainage. Sometimes medial orbital abscesses may be drained as part of ethmoid sinus drainage, but orbital roof or floor abscesses generally require a separate incision to adequately drain.

If there are multiple foci of subperiosteal abscess (with the potential to rapidly cause optic neuropathy), a large abscess, or frontal sinus involvement, early drainage is warranted. Drainage serves to evacuate the pus, release the pressure on the orbit, and provide a specimen of pus for culture.[13] Lateral canthotomy and cantholysis may be required to reduce intraocular pressure before orbitotomy can be performed.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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