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

• Summary
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• Background
• Clinical Diagnosis
• Severity Assessment
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Duration of Treatment
• Switch to oral agent(s)
• Treatment Failure

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

Initial investigations

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

Non-antimicrobial management
Pre-septal and orbital cellulitis

• Appropriate analgesia (as per Trust guidelines - Acute Pain Management in Adults Manual).

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.

Duration of therapy
See full guideline

IV conversion to PO therapy

• IV Flucloxacillin , Metronidazole , Ciprofloxacin , and Clindamycin can all be converted to their PO equivalents when required.
• IV 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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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.

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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

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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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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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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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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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 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 500mg every 8 hours

• IV treatment should be used for AT LEAST 3 days.

If true Penicillin / Cephalosporin allergy:

Ciprofloxacin 500mg every 12 hours orally AND Clindamycin 450mg every 6 hours orally

• Oral Ciprofloxacin and 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 , 600mg 6-hourly Clindamycin ).

Immunocompromised patients:

• Discuss with microbiology

Pre-septal Cellulitis:

Flucloxacillin 1g every 6 hours orally

• As the common pathogens are Staphylococcals and Streptococcals, high dose Flucloxacillin should be effective in most cases.
  [Evidence level D]

If true Penicillin / Cephalosporin allergy:

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 500mg 24-hourly orally

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Antimicrobial therapy when microbiology results are available. Discuss with microbiology.

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

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