Orbital cellulitis medical therapy: Difference between revisions

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Latest revision as of 23:26, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Faizan Sheraz, M.D. [2]; Tarek Nafee, M.D. [3]

Overview

Orbital cellulitis is considered an ophthalmologic emergency. The mainstay of therapy for orbital cellulitis involves prompt intravenous antimicrobial therapy with either beta-lactams or clindamycin. Patients suspected to have MRSA-induced orbital cellulitis require more extensive antimicrobial therapy.

Medical Therapy

Antimicrobial Regimens

1. Causative pathogens

Methicillin-sensitive staphylococcus aureus
Methicillin-resistant staphylococcus aureus
Staphylococcus epidermidis
Streptococcus spp.
Moraxella spp.
Anaerobes

2. Empiric antimicrobial therapy

Preferred regimen (1): Ampicillin/Sulbactam 3 g IV q6h for 1 week
Preferred regimen (2): Ceftriaxone 1-2 g IV q12h for 1 week
Preferred regimen (3): Clindamycin 300 mg IV q6h for 1 week
Preferred regimen (4): Nafcillin 2 g IV q4h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided in 3 doses for 1 week
Alternative regimen (1), MRSA suspicion: Vancomycin 1 g IV q12h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
Alternative regimen (2), MRSA suspicion: Vancomycin 1 g IV q12h for 1 week AND Levofloxacin 750 mg IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
Alternative regimen (3), pediatric: Ampicillin/Sulbactam 200-300 mg/kg/d IV divided q6h for 1 week
Alternative regimen (4), pediatric: Ceftriaxone 100 mg/kg/d IV divided q12h for 1 week
Alternative regimen (5), pediatric: Clindamycin 20-40 mg/kg/d IV divided q12 for 1 week
Note (1): Oral antibiotic therapy may be extended beyond 2-3 weeks if the clinical presentation is consistent with either severe sinusitis or bony destruction
Note (2): Consider surgical intervention if the patient has either visual loss, complete ophthalmoplegia, large abscess > 1 cm, or no clinical improvement following 1-2 days of antibiotic administration

3. Pathogen-directed antimicrobial therapy

3.1 Methicillin-resistant staphylococcus aureus (MRSA)

Preferred regimen (1): Vancomycin 1 g IV q12h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week
Preferred regimen (2): Vancomycin 1 g IV q12h for 1 week AND Levofloxacin 750 mg IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided q8h for 1 week

3.2 Non-MRSA organisms

Preferred regimen (1): Ampicillin/Sulbactam 3 g IV q6h for 1 week
Preferred regimen (2): Ceftriaxone 1-2 g IV q12h for 1 week
Preferred regimen (3): Clindamycin 300 mg IV q6h for 1 week
Preferred regimen (4): Nafcillin 2 g IV q4h for 1 week AND Ceftriaxone 2 g IV q24h for 1 week AND Metronidazole 30-35 mg/kg/d IV divided in 3 doses for 1 week

References

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Orbital cellulitis}}
-{{CMG}}
+{{CMG}}; {{AE}} {{Faizan}}; {{TarekNafee}}
 ==Overview==
-Because of concern for spread of infection, patients must be admitted to the hospital to receive intravenous antibiotics.
+Orbital cellulitis is considered an ophthalmologic emergency. The mainstay of therapy for orbital cellulitis involves prompt intravenous [[Antimicrobial|antimicrobial therapy]] with either [[beta-lactam]]s or [[clindamycin]]. Patients suspected to have [[Methicillin resistant staphylococcus aureus|MRSA]]-induced orbital cellulitis require more extensive [[Antimicrobial|antimicrobial therapy]].
-Orbital cellulitis is considered an ophthalmological emergency.
+==Medical Therapy==
+===[[Antimicrobial]] Regimens===
+*'''1. Causative [[pathogens]]'''
+:*Methicillin-sensitive [[staphylococcus aureus]]
+:*[[Methicillin-resistant staphylococcus aureus]]
+:*[[Staphylococcus epidermidis]]
+:*[[Streptococcus]] spp.
+:*[[Moraxella]] spp.
+:*[[Anaerobes]]
+*'''2. Empiric [[Antimicrobial|antimicrobial therapy]]'''
+:*Preferred regimen (1): [[Ampicillin]]/[[Sulbactam]] 3 g IV q6h for 1 week
+:*Preferred regimen (2): [[Ceftriaxone]] 1-2 g IV q12h for 1 week
+:*Preferred regimen (3): [[Clindamycin]] 300 mg IV q6h for 1 week
+:* Preferred regimen (4): [[Nafcillin]] 2 g IV q4h for 1 week  {{and}} [[Ceftriaxone]] 2 g IV q24h for 1 week  {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided in 3 doses for 1 week
+:* Alternative regimen (1), [[MRSA]] suspicion: [[Vancomycin]] 1 g IV q12h for 1 week {{and}} [[Ceftriaxone]] 2 g IV q24h for 1 week {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided q8h for 1 week
+:* Alternative regimen (2), [[MRSA]] suspicion: [[Vancomycin]]  1 g IV q12h for 1 week {{and}} [[Levofloxacin]] 750 mg IV q24h for 1 week {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided q8h for 1 week
+:*Alternative regimen (3), pediatric: [[Ampicillin]]/[[Sulbactam]] 200-300 mg/kg/d IV divided q6h for 1 week
+:*Alternative regimen (4), pediatric: [[Ceftriaxone]] 100 mg/kg/d IV divided q12h for 1 week
+:*Alternative regimen (5), pediatric: [[Clindamycin]] 20-40 mg/kg/d IV divided q12 for 1 week
+:*Note (1): Oral [[antibiotic therapy]] may be extended beyond 2-3 weeks if the clinical presentation is consistent with either severe [[sinusitis]] or bony destruction
+:*Note (2): Consider surgical intervention if the patient has either [[visual loss]], complete [[ophthalmoplegia]], large [[abscess]] > 1 cm, or no clinical improvement following 1-2 days of [[antibiotic]] administration
+*'''3. [[Pathogen]]-directed antimicrobial therapy'''
+:*'''3.1 [[MRSA|Methicillin-resistant staphylococcus aureus (MRSA)]]'''
+::*Preferred regimen (1): [[Vancomycin]] 1 g IV q12h for 1 week {{and}} [[Ceftriaxone]] 2 g IV q24h for 1 week {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided q8h for 1 week
+::*Preferred regimen (2): [[Vancomycin]]  1 g IV q12h for 1 week {{and}} [[Levofloxacin]] 750 mg IV q24h for 1 week {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided q8h for 1 week
+:*'''3.2 Non-MRSA organisms'''
+::*Preferred regimen (1): [[Ampicillin]]/[[Sulbactam]] 3 g IV q6h for 1 week
+::*Preferred regimen (2): [[Ceftriaxone]] 1-2 g IV q12h for 1 week
+::*Preferred regimen (3): [[Clindamycin]] 300 mg IV q6h for 1 week
+::*Preferred regimen (4): [[Nafcillin]] 2 g IV q4h for 1 week  {{and}} [[Ceftriaxone]] 2 g IV q24h for 1 week  {{and}} [[Metronidazole]] 30-35 mg/kg/d IV divided in 3 doses for 1 week
-Prompt treatment is vital for a patient when fighting orbital cellulitis. Treatment typically involves IV antibiotics in the hospital and frequent observation (every 4-6 hours). Along with this several laboratory tests are run including a complete blood count, differential, and blood culture.
-==Medical Therapy==
-* '''Antibiotic Therapy''' - Since orbital cellulitis is commonly caused by Staphylococcus and Streptococcus species both penicillins and cephalosporins are typically the best choices for IV antibiotics. However, due to the increasing rise of [[MRSA]] (methicillin-resistant Staphylococcus aureus) orbital cellulitis can also be treated with [[Vancomycin]], [[Clindamycin]], or [[Doxycycline]]. If improvement is noted after 48 hours of IV antibiotics, healthcare professions can then consider switching a patient to oral antibiotics (which must be used for 2-3 weeks).
 ==References==
 {{Reflist|2}}
-[[Category:Needs content]]
-[[Category:Infectious disease]]
-[[Category:Bacterial diseases]]
-[[Category:Disease stubs]]
-[[Category:Ophthalmology]]
 {{WH}}
 {{WS}}
+[[Category:Disease]]
+[[Category:Ophthalmology]]
+[[Category:Emergency mdicine]]
+[[Category:Up-To-Date]]
+[[Category:Infectious disease]]