Paediatric Pathways

Pre-septal and postseptal (orbital) cellulitis pathway for children presenting to hospital

DIAGNOSIS

  • Unilateral eyelid oedema and erythema
  • Unilateral eye pain or tenderness

Consider differentials*
Check for red flags suggesting CNS complications**

*DIFFERENTIALS

  • Neonatal; consider gonorrhoea/ chlamydial infections
  • Bilateral findings and/or painless swelling; consider allergic reaction
  • Hordeolum (stye)
  • Acute blepharitis
  • Conjunctivitis
  • Angioneurotic oedema
  • Insect bite
  • Cavernous sinus thrombosis
  • Leukaemia or late presentation of a rhabdomyosarcoma/retinoblastoma
  • Non-accidental injury
  • If swelling exclusively below eye, consider facial cellulitis or dacrocystitis. If swelling at cheek level, consider dental origin and conduct visual inspection for decayed teeth (esp. upper canine teeth). Consider dental/maxfax review and/or odontogram

 

** RED FLAGS suggesting CNS complications
URGENT senior review if:

  • Increasing drowsiness
  • Meningism / irritability
  • Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
  • Persistent vomiting
  • Severe retroorbital pain
  • New onset squint or diplopia - covering up one eye
  • Deteriorating vision - complaining of blurred vision
  • New limb weakness– may exhibit change of hand preference
  • Unsteady gait or coordination issues

If signs of intracranial infection, consider urgent neuroimaging

ASSESSING SEVERITY

CLINICAL SIGNS (not all signs need to be present for a diagnosis of postseptal (orbital) cellulitis to be made) POSTSEPTAL (ORBITAL) PRESEPTAL
Proptosis Yes No
Hypoglobus (downward displacement of eye) YES (if large collection) No
Double vision (if both eyes open) Yes No
Eye movements Painful & restricted Normal
Vision (acuity, fields, colour) Worse in severe Normal
Relative Afferent Pupillary Defect Yes in severe Absent i.e. normal
Severe or persistent headache Yes in severe No

FACTORS ASSOCIATED WITH INCREASED DISEASE SEVERITY#

  • Clinical suspicion of orbital cellulitis or unable to assess eye due to swelling
  • Systemically unwell including fever AND persisting tachycardia / tachypnoea
  • Immunocompromised
  • Worsening despite 36-48 hours of oral antibiotics
  • If features of sepsis, for urgent senior input / paediatric input

FACTORS ASSOCIATED WITH MILDER DISEASE SEVERITY

  • Normal eye assessment
  • History of insect bite or mild trauma

INVESTIGATIONS

  • For MILD or MODERATE pre-septal cellulitis, no investigations required.
  • If INCREASED disease severity#, perform FBC, CRP & blood culture
  • If nasal endoscopy performed by ENT team, collect sinus swab (endonasal swab)

MANAGEMENT

PRESEPTAL CELLULITIS

  • MILD preseptal cellulitis can be managed with oral antibiotics +- topical decongestant.1
  • Optimise analgesia (paracetamol or ibuprofen).
  • Choice of oral Abx as per local / national empirical antimicrobial guidelines.
  • Total duration of antibiotics = 5 days.
  • Provide verbal and written safety netting information.

If significant periorbital swelling or fever, or unable to tolerate/absorb oral Abx, start IVAbx +- topical decongestant (in children aged >6 years) as per local empirical antimicrobial guidelines. Optimise analgesia (paracetamol or ibuprofen).

ENT and ophthalmology review if moderate / severe pre-septal cellulitis. Consider early ambulation9 on IVAbx from ED or assessment unit (admission avoidance) unless:

  • Clinical risk factors: haemodynamically unstable, acutely worsening eye signs or concerns about postseptal (orbital) cellulitis
  • Social / caregiver risk factors

If admitted, should be under general paediatric team or paediatric ENT team. Daily review whilst on IVAbx2 – if no improvement after 48 hours, consider neuroimaging. Consider sinus drainage to remove reservoir of infection if poor response rate to IVAbx and collection on imaging.

Ensure robust clinical governance systems and documentation in place for children being ambulated. Provide verbal and written safety netting information and suggest daily photos taken by parents.

IV to oral switch when clinically improving and apyrexial. Choice of oral Abx as per local / national guidelines. Total antibiotic course (IV+oral) = 7 days.1

If clinical suggestion of postseptal (orbital) cellulitis, perform FBC, CRP & blood culture, for senior review and neuroimaging3 ##

##INDICATION FOR IMAGING (AFTER STARTING EMPIRIC ANTIBIOTIC THERAPY)
Contrast enhanced CT orbit, sinuses and brain if:

  • CNS involvement / focal neurology / meningism
  • Unable to examine eye/open eyelids
  • Clinical signs of postseptal (orbital) cellulitis
  • Clinical progression despite 24 hours treatment or no improvement after 48 hours
  • Continued pyrexia after 48 hours IV antibiotics

MANAGEMENT

POSTSEPTAL (ORBITAL) CELLULITIS

  • If no orbital collection on neuroimaging, manage as pre-septal cellulitis (see above)
  • Admit under general paediatric team or paediatric ENT team. Involve ENT and ophthalmology +- maxfax teams as per local pathways3,4 - ENT team for consideration of surgical drainage, ophthalmology for ongoing visual assessment.
  • Commence IVAbx and topical decongestants as per local / national empirical antimicrobial guidelines. If immunocompromised, discuss with microbiology. Optimise analgesia (paracetamol or ibuprofen).
  • Drainage generally indicated for larger, non-medial subperiosoteal or orbital collections, significant proptosis, concerns about visual compromise and restricted eye movements. Small collections can be managed conservatively.5-8
  • 4 hourly eye & neuro-observations with head of bed elevation.
  • Daily ophthalmology review whilst on IVAbx and suggest daily photos taken by parents.
  • If no improvement after 48 hours, consider repeat neuroimaging.
  • If clinically stable and no risk factors**, consider ambulation9 on IVAbx. IV to oral switch when clinically improving and apyrexial. Choice of oral Abx as per local / national guidelines. Total antibiotic course (IV+oral) = 14 days.
  • If CNS complications, prolonged IVAbx course will be required; discuss with paediatric ID/microbiology.
  • Provide verbal and written safety netting information

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. McMullan BJ, Andresen D, Blyth CC et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Di 2016; 16: e139-52.
  2. Tritt A, Kay-Rivest E, Paradis T et al. Daily outpatient intravenous antibiotic therapy for the management of paediatric periorbital cellulitis, a retrospective case series. Clin Otolaryngol 2019; 44: 273-8.
  3. Crosbie RA, Nairn J, Kubba H. Management of paediatric periorbital cellulitis: Our experience of 243 children managed according to a standardised protocol 2012-2015. Int J Pediatr Otorhinolaryngol 2016; 87: 134-8.
  4. Amin N, Syed I, Osborne S. Assessment and management of orbital cellulitis. Br J Hosp Med (Lond) 2016; 77: 216-20.
  5. Cossack MT, Herretes SP, Cham A et al. Radiographic Course of Medically Managed Pediatric Orbital Subperiosteal Abscesses. J Pediatr Ophthalmol Strabismus 2018; 55: 387-92.
  6. Le TD, Liu ES, Adatia FA et al. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS 2014; 18: 271-7.
  7. Quintanilla-Dieck L, Chinnadurai S, Goudy SL et al. Characteristics of superior orbital subperiosteal abscesses in children. The Laryngoscope 2017; 127: 735-40.
  8. Wan Y, Shi G, Wang H. Treatment of Orbital Complications Following Acute Rhinosinusitis in Children. Balkan Med J 2016; 33: 401-6.
  9. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.