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Should a child with preseptal periorbital cellulitis be treated with intravenous or oral antibiotics?

Three Part Question

In [a child with preseptal periorbital cellulitis] are [intravenous antibiotics better than oral antibiotics] at [decreasing the time to recovery and preventing secondary complications]?

Clinical Scenario

A 5-year-old boy presents to the emergency department with the signs and symptoms of uncomplicated preseptal periorbital cellulitis. There is no obvious precipitant and the child is otherwise well. You wonder whether it is appropriate to manage the boy with oral antibiotics or whether a period of intravenous therapy would improve outcome.

Search Strategy

OVID via Medline interface 1966 November 2006.
[Best Bets paediatric search filter] AND [(orbital.mp. OR exp Orbit/OR exp Orbital Diseases/OR periorbital.mp. OR exp Eye Infections, Bacterial/OR preseptal.mp. OR exp Eyelid Diseases/) AND (cellulitis.mp. OR exp Cellulitis/OR exp Streptococcal Infections/OR exp Skin Diseases, Bacterial/OR exp Staphylococcal Infections/OR skin infection.mp. or exp Staphylococcal Skin Infections/)] LIMIT to humans and English language. Cochrane library issue 4 2006 periorbital [ti, ab, kw].

Search Outcome

395 papers were found, none of which answered the specific question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses

Comment(s)

There is no published evidence that can assist in answering this question. Preseptal cellulitis is differentiated from orbital cellulitis by the absence of signs of orbital involvement i.e. proptosis, ophthalmoplegia and visual loss. The presence of the tough, fibrous orbital septum reduces but does not completely remove the risk of spread of infection to the orbital structures. Reynolds et al(1) presented a retrospective study looking at the characteristics of patients who had presented to one hospital with the diagnosis of preseptal or orbital cellulitis over a seven year period. Out of 243 patients reviewed, 4 patients with preseptal cellulitis went on to develop intracranial infection. Infections were due to staphylococcus or streptococcus bacteria or in two cases both pathogens.

Clinical Bottom Line

There is no evidence to determine whether intravenous antibiotics are better than oral antibiotics in the management of simple preseptal periorbital cellulitis in the paediatric population. Given this and that preseptal periorbital cellulitis can be difficult to distinguish from the more serious postseptal variety local advice should be sought and followed.

References

  1. Reynolds, D; Kodsi, S; Rubin, S; Rodgers, I. Intracranial Infection Associated with Preseptal and Orbital Cellulitis in the Pediatric Patient. Journal of AAPOS (American Association for Paediatric Ophthalmology and Strabismus) 2003;7(6):413-7.