TREATMENT OF ORBITAL CELLULITIS

By MUHAMMAD HARIS FADILLAH BIN MUHAMAD [65] Medical Care The patient with orbital cellulitis should be promptly hospitalized for treatment. Hospitalization should be continued until the patient is afebrile and is clearly improved clinically. Historically, the presence of subperiosteal or intraorbital abscess was an indication for surgical drainage in addition to antibiotic therapy; however, medical management alone is successful in many cases. Medical care of orbital cellulitis consists of the proper use of the appropriate antibiotics. Intravenous broad-spectrum antibiotics should be started immediately until the choice of antibiotics can be tailored for specifically identified pathogens identified on cultures. Typically, intravenous antibiotic therapy should be continued for 1-2 weeks and then followed by oral antibiotics for an additional 2-3 weeks. Fungal infection requires intravenous antifungal therapy along with surgical debridement. Regarding pediatric care, Emmett et al found that the length of intravenous therapy associated with successful nonsurgical management of children selected for the study with subperiosteal abscess is considerably shorter than what is normally recommended in pediatric infectious disease literature, suggesting that clinical judgment, as regards each patients initial CT findings and evolving signs, symptoms, and laboratory profile, should be taken into account when scheduling intravenous intervals. Surgical Care Consider surgical drainage if the response to appropriate antibiotic therapy is poor within 48-72 hours or if the CT scan shows the sinuses to be completely opacified. If the presence of a drainable fluid collection is evident on CT scan, surgical drainage should be considered in patients older than 16 years. Consider orbital surgery, with or without sinusotomy, in every case of subperiosteal or intraorbital abscess formation, leaving the drains in place for several days. In cases of fungal infection, surgical debridement of the orbit is indicated and may require exenteration of the orbit and the sinuses. Canthotomy and cantholysis should be performed on an emergency basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease. Surgical drainage of an orbital abscess is indicated if any of the following occurs: A decrease in vision occurs. An afferent pupillary defect develops. Proptosis progresses despite appropriate antibiotic therapy. The size of the abscess does not reduce on CT scan within 48-72 hours after appropriate antibiotics have been administered. If brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.

Medication Summary Antibiotics Class Summary Appropriate antibiotics may include nafcillin (for Staphylococcus or Streptococcusspecies), cefotaxime (for gram-negative organisms, nontypeable H influenzae,Moraxella, and resistant pneumococci), and metronidazole (for anaerobes). Ticarcillin-clavulanate would cover most gram-positive and gramnegative organisms and most anaerobes. Nafcillin in combination with ceftazidime is also appropriate,

although chloramphenicol may be substituted for ceftazidime. Cefazolin can be used in place of nafcillin in cases of mild allergy to penicillin and vancomycin in cases of severe allergy to penicillin. Vancomycin, cefotaxime, clindamycin, and trimethoprim/sulfamethoxazole double-strength would be appropriate for susceptible penicillinase and nonpenicillinase-producing strains of methicillin-resistant S aureus. Vancomycin (Vancocin) Tricyclic glycopeptide antibiotic for intravenous administration. Indicated for the treatment of susceptible strains of methicillin-resistant (beta-lactam resistant) staphylococci in penicillin-allergic patients. Clindamycin (Cleocin) Inhibits bacterial protein synthesis at the bacterial ribosomal lever, binding with preference to the 50S ribosomal subunit and affects the peptide chain initiation process. Cefotaxime (Claforan) Semisynthetic broad-spectrum antibiotic for parenteral use. Effective against gram-positive aerobes, such as S aureus (does not cover methicillin-resistant strains), including penicillinase and nonpenicillinaseproducing strains, and S pyogenes, gram-negative aerobes (eg, H influenzae), and anaerobes (eg, Bacteroidesspecies). Nafcillin (Unipen) Semisynthetic penicillin effective against a wide gram-positive spectrum, includingStaphylococcus, pneumococci, and group A beta-hemolytic streptococci. Ceftazidime (Fortaz, Ceptaz) Semisynthetic, broad-spectrum, beta-lactam antibiotic for parenteral injection. Has broad spectrum of effectiveness against gram-negative aerobes, such as H influenzae, gram-positive aerobes, such as S aureus (including penicillinase and non-penicillinaseproducing strains) and S pyogenes, and anaerobes, includingBacteroides species. Chloramphenicol (Chloromycetin) Exerts bacteriostatic effect on a wide range of gram-negative and gram-positive bacteria and is particularly effective against H influenzae. Ticarcillin (Ticar) Semisynthetic injectable penicillin that is bactericidal against both gram-positive and gram-negative organisms, including H influenzae, S aureus (non-penicillinaseproducing), beta-hemolytic streptococci (group A), S pneumoniae, and anaerobic organisms, including Bacteroides and Clostridium species. Cefazolin (Ancef, Kefzol, Zolicef) Semisynthetic cephalosporin for IM or IV administration. Has bactericidal effect against S aureus (including penicillinase-producing strains), group A beta-hemolytic streptococci, and H influenzae.

Antifungals Class Summary Fungal orbital cellulitis is a potentially lethal condition, and the principal organisms involved, Mucor and Aspergillus, require the use of antifungals. Amphotericin B deoxycholate (AmBisome) Antifungal of choice in treatment of fungal orbital cellulitis. Administered IV and may be appropriately administered before laboratory confirmation of fungal infection in cases of severe infection. References http://emedicine.medscape.com/article/1217858-medication#showall http://emedicine.medscape.com/article/214222-treatment#a1156