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Abstract & Commentary
Orbital Cellulitis in Children
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine, is Associate Editor for Infectious Disease Alert.
Synopsis: A retrospective review of 94 children treated at a children's hospital between 2004 and 2009 for orbital infections was performed. A true pathogen was recovered from 31% of patients. Streptococcus anginosus was most commonly identified (14 patients). Staphylococcus aureus was present in 8 patients with methicillin-resistant Staphylococcus aureus (MRSA) in 1 case. Other pathogens encountered in > 1 case included Group A streptococci, Streptococcus pneumoniae, Haemophilus influenzae, and Fusobacterium species.
Source: Seltz LB, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics 2011;127:e566-e572.
A retrospective chart review of all patients admitted to a tertiary care children's hospital in Denver between 2004 and 2009 with orbital infections confirmed by CT scan was performed. Patients with preseptal cellulitis, preceding surgery or trauma, malignancy, and immunodeficiency were excluded. Ninety-four children's records met criteria for inclusion. The median age of children in the series was 72 months. Ophthalmoplegia and proptosis were documented in 48% and 38% of patients, respectively. Median hospital stay was 4 days.
A true pathogen was identified in 31% of patients. Streptococcus anginosus group was isolated in 14 patients, Stapholococcus aureus in 8 (including 1 with MRSA). Other pathogens present in ≥ 2 cases each included Group A streptococci, Streptococcus pneumoniae, Haemophilus influenzae, and Fusobacterium species. Single cases of infection due to seven other pathogens were seen.
A variety of antibiotics were used in the inpatient setting to treat these infections, including ampicillin/sulbactam in 34% of cases, two- or three-drug combination therapy was used in 80% of patients, vancomycin was used in 36% of children with increasing frequency of vancomycin use observed between 2004 and 2008. Surgical procedures performed included sinus drainage procedures and drainage of subperiosteal and orbital abscesses. Isolation of a true pathogen was more common in patients who underwent surgery. Serious complications observed included residual visual impairment (3 patients), recurrent orbital cellulitis (1 patient), and death (1 patient, after presenting with meningitis, subdural empyema, and cerebral edema). Numerous antibiotic regimens were selected to be continued at the time of discharge from the hospital.
While retrospective studies have many obvious limitations, a large case series such as this from an excellent tertiary care children's hospital is a useful addition to the literature and should be helpful to clinicians who manage this common serious infection seen in children. Some obvious factors influenced the results of the study. One of these factors is the likelihood that pathogens such as Streptococcus pneumoniae (which are likely to be susceptible to empiric antibiotics) probably are under-represented in the series. However, notorious pus-forming pathogens like Streptococcus anginosus/milleri group organisms would seem to be more likely to cause serious infections, which would require surgical drainage and, therefore, yield a pathogen on culture. While only one microbiologically confirmed case of orbital cellulitis due to MRSA was seen, it is possible that several early cases of orbital cellulitis due to this pathogen may have been adequately treated with effective empiric antibiotics. It certainly seems prudent to continue to include coverage of MRSA in addition to streptococci, Haemophilus influenzae, and anaerobes when empiric antibiotics are chosen to treat this disease.