Periorbital and orbital cellulitis

PIC Endorsed

 See also
Febrile child   
Sepsis   
Local antimicrobial guidelines 

Key points
1. Orbital cellulitis is an emergency with serious complications including intracranial
infection, cavernous sinus thrombosis and vision loss 
2. Urgent imaging and surgical consultation (ENT and ophthalmology) should be considered
for any child with suspected orbital cellulitis
3. Periorbital cellulitis in a well child can often be treated with oral antibiotics if follow-up is
assured 

Background
 Periorbital and orbital cellulitis are distinct clinical diseases, though have overlapping
clinical features and therefore can be difficult to differentiate
 Orbital cellulitis:
 infection within the orbit, (ie postseptal, the structures posterior to the orbital
septum)
 surgical emergency with major complications including loss of vision, abscess
formation, venous sinus thrombosis and extension to intracranial infection with
subdural empyema, and meningitis
 the majority (>80%) of cases relate to local sinus disease
 Periorbital cellulitis:
 infection of the eye lids and surrounding skin not involving the orbit (ie preseptal,
the structures anterior to the orbital septum)
 The globe is not involved in either infection  

Assessment 
Typical presentation of periorbital/orbital cellulitis

 Unilateral eyelid swelling and erythema

 Unilateral eye pain or tenderness  

Consider gonorrhoea and Chlamydia infections in neonatal presentation (send PCR
swabs) see Acute red eye

Red flags concerning for orbital cellulitis

 Painful or restricted eye movements

 Visual impairment:
 reduced acuity
 relative afferent pupil defect
 diplopia

 Proptosis

 Severe headache or other features of intracranial involvement

Differential diagnosis
Bilateral findings and/or painless (or non-tender) swelling in a well looking child is more likely to
be an allergic reaction 
Management
Antimicrobial recommendations may vary according to local antimicrobial susceptibility
patterns; please refer to local guidelines; these may include advice regarding community
acquired MRSA

 If inadequate  Haemophilus influenzae  type B (Hib) vaccination, treat as severe

periorbital cellulitis  

Orbital Cellulitis

 Admission 

 Keep fasted until need for surgery clarified

 Seek ENT and Ophthalmology advice urgently

 Consider urgent contrast enhanced CT scan of orbits, sinuses +/- brain

 Investigations:
 FBE and blood culture 
 Lumbar Puncture (LP) is contraindicated due to risk of raised intracranial
pressure (ICP) secondary to possible intracranial extension 

 Antibiotics (see below)

 Treat underlying sinus disease eg nasal decongestants, steroids (often guided by ENT)  

Periorbital Cellulitis 
Severe
Inpatient investigations and management as per orbital cellulitis  

Moderate
Inpatient management or consider Hospital In The Home (HITH) admission if available locally

 Consider blood culture if febrile and unwell 

 Antibiotics (see below)

 Once improving change to oral antibiotics

 If not improving or deteriorating within 24–48 hours, consider managing as severe

periorbital cellulitis
Mild

 Antibiotics (see below)

 Review  
Summary of antibiotic treatment
Intravenous Therapy Oral Therapy

     3  generation cephalosporin
rd
 Amoxicillin with clavulanic acid
on amoxicillin component) 22.5
Orbital   Cefotaxime 50 mg/kg (max 2 g) IV 6 875 mg) oral bd
hourly OR   
cellulitis
      Ceftriaxone 50 mg/kg (max 2 g) IV
daily
PLUS
Severe Periorbital
cellulitis Flucloxacillin 50 mg/kg (max 2g) IV 6
hourly OR
If suspected MRSA: vancomycin (see link
for dosing)
  
Duration based on clinical severity and
improvement. Usually at least 3-4 days,
then switch to oral.

Flucloxacillin 50 mg/kg (max 2g) IV 6 When improving, switch to oral

hourly  per mild periorbital cellulitis 
Moderate
Periorbital OR
cellulitis
Ceftriaxone 50 mg/kg (max 2g) IV daily
(consider HITH)
OR
If suspected MRSA:

 Clindamycin 15 mg/kg (max 600

mg) IV/oral 8 hourly OR

 Trimethoprim with sulfamethoxazole

(8/40 mg/mL) 4/20 mg/kg (max
320/1600 mg) oral bd 
  
Duration based on clinical severity and
improvement. Usually 1-2 days, then
switch to oral.
        Not applicable   Cefalexin 33 mg/kg (max
Mild Periorbital
cellulitis OR 

 Cefuroxime  
3 months – 2 years: 10 m
125 g) oral bd                 
2 – 12 years: 15 mg/kg (m
oral bd 
  

Consider consultation with local paediatric team when

 Orbital cellulitis suspected

 Moderate-severe periorbital cellulitis present

 No improvement or deterioration after 24–48 hrs of therapy   

Consider transfer when

 Severe periorbital cellulitis or orbital cellulitis present

 Suspecting intracranial involvement with altered conscious state, seizures or focal

neurological signs

 Child requires care above the level of comfort of local hospital  

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services  

Consider discharge when

Mild periorbital cellulitis:

 oral antibiotic course prescribed

 follow-up assured   
Moderate periorbital cellulitis:

 after 24–48 hrs of IV antibiotics and with improvement

 able to tolerate oral antibiotics

 follow-up assured  
Last updated December, 2021