Preseptal and Orbital Cellulitis Management in Adults

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

The differentiation between preseptal and deep orbital cellulitis is difficult, based on clinical observation and clinical presentation may not always reflect the underlying disease severity. Subtle pathology may evolve into severe pathology very quickly. Joint ENT and Ophthalmology decision to proceed to CT scan, if impaired on eye examine or different or difficult to assess.

Preseptal Cellulitis

Likely organisms: Staphycococcus aureus Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis, anaerobes

Examination and Recommendation

Antibiotic Treatment

Proptosis is absent,
The following are unimpaired

Visual Activity or Visual Acuity
Pupillary Reactions
Ocular Motility

Oral Co‐amoxiclav 625 mg
8 hourly
for 7 days
If true penicillin allergy
Oral Clindamycin 600 mg 8 hourly
Plus
Oral Ciprofloxacin 500mg 12 hourly
for 7 days
If sepsis or rapid progression:
IV Co‐amoxiclav 1.2g 8 hourly
if true penicillin allergy
IV Clindamycin 600mg 6 hourly
Plus
Oral Ciprofloxacin 500mg 12 hourly
Switch to oral therapy following clinical improvement

Orbital Cellulitis

Likely organisms: Staphycococcus aureus Streptococcus pneumoniae, Streptococcus. pyogenes, Streptococcus milleri, H. influenzae,
Moraxella catarrhalis, anaerobes.

Examination and Recommendations

Antibiotic Treatment

Orbital Cellulitis Presentation

Severe pain
Tense, red orbit with lid closure
Pyrexia

Examination

Visual Activity or Visual Acuity
Colour vision
Pupillary reactions
Ocular motility
Optic disc
Chemosis
Diplopia
Proptosis
Skin sensation
Bloods (FBC with differential, CRP, bloodcultures)
Send Swabs, Pus to microbiology
Contact ENT on call
consider CT scan (brain/orbits/sinuses)
if intracranial infection refer to neurosurgeons
If orbital abscess present external drainage and IV antibiotics
if orbital abscess absent IV antibiotics
4-hourly neuro observations
daily ophthalmic review

If MRSA discuss with microbiology

IV Clindamycin 600 mg 6 hourly
Plus
IV Ceftriaxone 2 g every 24 hours
Duration 21 days IV / Oral
If true penicillin allergy
IV Vancomycin (see GG&C dosing guidelines, NB loading dose )
Plus
Oral Ciprofloxacin 750mg 12 hourly
Plus
IV Clindamycin 600 mg 6 hourly
Duration 21 days IV / Oral
Patients without abscess, clearly improving and afebrile for at least 48 hours, consider change from IV to oral antibiotics
Change
IV ceftriaxone to oral co‐amoxiclav 625 mg
IV Clindamycin to Oral Clindamycin 600 mg 8 hourly
IV Vancomycin to oral clindamycin 600mg 8 hourly.