1. No category

Microbiology and Antibiotic Management of Orbital Cellulitis
L Barry Seltz, Jesse Smith, Vikram D Durairaj, Robert Enzenauer and James Todd
Pediatrics; originally published online February 14, 2011;
DOI: 10.1542/peds.2010-2117
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2011/02/14/peds.2010-2117
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Microbiology and Antibiotic Management of Orbital
Cellulitis
WHAT’S KNOWN ON THIS SUBJECT: Recent reports suggest that
Staphylococcus aureus may be an increasing cause of pediatric
orbital infections. However, the risk of methicillin-resistant
infections and current antibiotic management practices in these
patients are unclear.
AUTHORS: L Barry Seltz, MD,a Jesse Smith, MS,b Vikram D
Durairaj, MD,b Robert Enzenauer, MD, MPH,a and James
Todd, MDa
WHAT THIS STUDY ADDS: The Streptococcus anginosus group is
an emerging cause of pediatric orbital infections. Although cases
caused by methicillin-resistant Staphylococcus aureus seem
uncommon, vancomycin and combination antibiotics are
frequently used. A more simplified antibiotic regimen may be
warranted in many patients.
KEY WORDS
orbital cellulitis, microbiology, child
a
Department of Pediatrics and bDepartment of Ophthalmology,
University of Colorado School of Medicine, The Children’s
Hospital, Aurora, Colorado
ABBREVIATIONS
MRSA—methicillin-resistant Staphylococcus aureus
CT—computed tomography
Parts of this article were presented in abstract form at the 2010
Pediatric Academic Societies Annual Meeting; May 1– 4, 2010;
Vancouver, Canada.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-2117
doi:10.1542/peds.2010-2117
abstract
Accepted for publication Nov 29, 2010
OBJECTIVES: Orbital infections caused by methicillin-resistant Staphylococcus aureus may be increasing. Because Staphylococcus aureus
infections have important treatment implications, our objective was to
review the microbiology and antibiotic management of children hospitalized with orbital cellulitis and abscesses.
PATIENTS AND METHODS: This study was a retrospective chart review
of all patients admitted to a tertiary care children’s hospital between
2004 and 2009 with orbital infections confirmed by a computed tomography scan. Patients with preceding surgery or trauma, anatomic eye
abnormalities, malignancy, immunodeficiency, or preseptal infections
were excluded.
RESULTS: There were 94 children with orbital infections. A true pathogen was recovered in 31% of patients. The most commonly identified
bacteria was the Streptococcus anginosus group (14 of 94 patients
[15%]). Staphylococcus aureus (1 patient with methicillin-resistant
Staphylococcus aureus) was identified in 9% of patients. Combination
antimicrobial agents were frequently used (62%), and vancomycin use
increased from 14% to 57% during the study period. Patients treated
with a single antibiotic during hospitalization (n ⫽ 32), in contrast to
combination therapy (n ⫽ 58), were more likely to be discharged on a
single antibiotic (P ⬍ .001). Twenty-five (27%) patients were discharged on combination antibiotics. Thirteen (14%) patients were discharged on intravenous therapy.
CONCLUSIONS: The Streptococcus anginosus group is an emerging
pathogen in pediatric orbital infections. Although methicillin-resistant
Staphylococcus aureus was uncommon, patients frequently received vancomycin and combination antibiotics. A simplified antibiotic regimen may
help limit the development of resistant organisms and facilitate transition
to an oral agent. Pediatrics 2011;127:e560–e566
e560
SELTZ et al
Address correspondence to L Barry Seltz, MD, Department of
Pediatrics, Section of Hospital Medicine, University of Colorado
School of Medicine, The Children’s Hospital, 13123 East 16th Ave,
B302, Aurora, CO 80045. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated that they
have no personal financial relationships relevant to this article
to disclose.
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ARTICLES
Orbital cellulitis is a serious infection
of the orbit that involves the tissues
posterior to the orbital septum and
can result in significant complications,
including visual loss, cavernous sinus
thrombosis, meningitis, carotid occlusion, and intracranial abscess.1 Ethmoid sinusitis is the most common
predisposing factor, and causative
bacteria typically depend on the etiology of sinusitis.2– 4 The bacteria most
commonly implicated in pediatric orbital
cellulitis include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, group A ␤-hemolytic
streptococci, Staphylococcus aureus, other streptococcal species,
and anaerobes.4
The microbiology of orbital cellulitis
seems to be changing. Haemophilus influenzae type B was previously a prevalent cause of orbital infections.5 Studies conducted subsequent to universal
vaccination against Haemophilus influenzae type B showed a marked decrease in its incidence, and a greater
diversity of bacterial etiologies have
been reported.4– 6 Viridans streptococci were the most frequently recovered isolate obtained from sinus cultures in a recent series of children
with periorbital infections.6 Other
studies reported that Staphylococcus
aureus was the most predominant
pathogen,7–9 which raises concern
for community-associated methicillinresistant infection.10–13 Yet, methicillinresistant Staphylococcus aureus (MRSA)
orbital cellulitis seems uncommon,14
and few cases exist in the pediatric
literature.15
Concern regarding MRSA may be leading to the increased use of vancomycin, combination antimicrobial therapy, and peripherally inserted central
catheters for home intravenous antibiotics. However, the risk of MRSA in children with orbital infections remains
uncertain. The objective of our study
was to review the microbiology and anPEDIATRICS Volume 127, Number 3, March 2011
timicrobial management of children
hospitalized with orbital cellulitis
and/or abscess.
PATIENTS AND METHODS
Study Design
A retrospective chart review was performed for all children (aged ⱕ18 years)
hospitalized at the Children’s Hospital
(Aurora, CO) from January 1, 2004,
through June 30, 2009, with a discharge
diagnosis of orbital cellulitis or abscess.
The Children’s Hospital is a 294-bed tertiary care academic children’s hospital
with a catchment area throughout Colorado and into parts of Wyoming and
Nebraska. The study protocol was approved by the institution’s review board.
Study Population
All patients with a discharge diagnosis of
orbital cellulitis and/or abscess, confirmed by an orbital computed tomography (CT) scan, were included in the study
population. Patients with nonorbital or
preseptal infections, absence of radiologic confirmation, underlying anatomic
abnormalities, malignancy, or immunodeficiency were excluded. Cases occurring after surgery or other penetrating
trauma also were excluded to focus on
those most likely resulting as a complication of sinusitis.
Case Identification
Patients were identified from the hospital database using a hospital discharge
diagnosis, based on the International
Classification of Disease Ninth Revision,
of orbital cellulitis or abscess (376.01),
orbital periostitis (376.02), orbital
osteomyelitis (376.03), orbital myositis
(376.12), acute inflammation of orbit, unspecified (376.00), or face (682.0).
Data Extraction
Data were abstracted from the hospital’s electronic medical record system
(Epic) and entered into a standardized
collection form. The following records
were reviewed: emergency department, hospital admission, ophthalmology consultation, otolaryngology
consultation, operating room, daily
progress notes, and discharge summaries. Data abstracted included age,
gender, ethnicity, presence of fever,
and duration of eye symptoms. Physical examination findings (ophthalmoplegia, proptosis, chemosis, afferent
pupillary defect, or visual impairment), CT results, procedures, complete white blood cell count, microbiologic results, and antibiotic use
(inpatient and on discharge) also were
recorded. Orbital CT scans obtained
from the emergency departmen, from
the inpatient wards, and from outside
hospitals were included. If an outside
CT was not read by the hospital’s radiology department, physician readings
of the scan and/or outside reports
were recorded. Medical records were
screened for return visits to the hospital within 1 month of the index visit.
Definitions
Fever was defined as any temperature
38.0°C or higher on admission; presence of fever also was accepted if a
parent reported a history of fever
within 24 hours before admission.
Physical examination eye findings
were considered present or absent; if
no finding was recorded in the chart, it
was considered to be absent. Current
antibiotic use was considered present
if a patient was on oral antibiotics for
more than 24 hours before arrival or if
a patient was transferred to the hospital on intravenous antibiotics. The following definitions were used to categorize surgical specimen culture
results: true pathogen (any growth of
Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Streptococcus anginosus, or
group A ␤-hemolytic streptococci) or
moderate to heavy growth of any bacteria not considered a contaminant;
possible pathogen (rare to few colo-
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e561
nies of bacteria not considered a true
pathogen or contaminant); and probable
contaminant (coagulase-negative Staphylococcus, lactobacillus, or yeast). Combination antibiotics were defined as any
combination of more than 1 antibiotic
used simultaneously. Vancomycin use
was defined as vancomycin used for at
least 24 hours.
CT Classification
Imaging findings were categorized as
orbital cellulitis, subperiosteal abscess, orbital abscess, or cavernous
sinus thrombosis (Chandler clinical
classification II, III, IV, or V) based on
the initial CT performed.16
Outcome Measures
Primary outcomes were rates of readmission with the same diagnosis
(within 1 month of discharge), vision
impairment, and death. Rates of adverse drug reactions and peripherally
inserted central catheter complications after hospital discharge were analyzed. The following trends were described: vancomycin use; inpatient
combination antibiotic use; and use of
combination antibiotics after hospital
discharge.
Statistical Analysis
Rates of vancomycin, single-antibiotic,
and combination-antibiotic use were
calculated, and comparisons were
performed using 2 ⫻ 2 tables. A
2-sided P value of less than 0.05 calculated with Fisher’s exact test was considered statistically significant. Statistical analysis was performed using
OpenEpi (version 2.3; Atlanta, GA).
RESULTS
Charts (n ⫽ 489) from 484 patients
were reviewed. Patients were excluded (n ⫽ 291) because of facial abscess (n ⫽ 119), dental abscess (n ⫽
78), neck abscess or adenitis (n ⫽ 41),
malignancy (n ⫽ 9), conjunctivitis or
dacryocystitis (n ⫽ 7), allergic reace562
SELTZ et al
tion (n ⫽ 3), immunosuppression (n ⫽
2), orbital implants (n ⫽ 1), postoperative infection (n ⫽ 1), and other (n ⫽
30). Of the remaining 198 encounters
of acute periorbital infection, 150
(76%) were evaluated with an orbital
CT scan. A clinical and/or radiologic diagnosis of preseptal cellulitis was
made in 104 of 198 (53%) patients; 1
patient who was initially diagnosed
with preseptal cellulitis later returned
to the emergency department with infection of the orbit. A total of 94 children with orbital infections were identified. All cases were suspected to have
been caused by sinusitis; no cases of
orbital infection resulting from other
etiologies were identified.
A summary of patient demographics
and clinical characteristics are shown
in Table 1. The median age was 72
months (range: 2 months to 18 years),
and 64% were male. Ophthalmoplegia
and proptosis were documented in
48% and 38% of patients, respectively.
The median hospital stay was 4 days
(range: 2–21 days). Thirty-three patients (35%) underwent a surgical
procedure.
The median ages of patients with orbital cellulitis, subperiosteal abscess,
and orbital abscess were 42 months,
91 months, and 114 months, respectively. The proportion of male patients,
presence of fever, and duration of eye
symptoms were similar in patients
with each type of orbital infection. At
presentation, of those with an orbital
abscess, 88% had an abnormal eye examination (proptosis, ophthalmoplegia, chemosis, afferent pupillary defect, or vision impairment), compared
with 68% of children with a subperiosteal abscess and 40% with orbital
cellulitis.
A true pathogen was recovered in 31%
of patients, which included 4% of patients with blood cultures and 81%
of patients with surgical specimens.
One patient had methicillin-sensitive
TABLE 1 Patient Demographics and Clinical
Characteristics
Parameter
Value
n
Median age, mo (range)
Male, n (%)
Ethnicity, n (%)
Caucasian
Latino
African American
Other
Median duration of eye
symptoms, d (range)
Pretreated with antibiotics,
n (%)
Presence of fever, n (%)
Affected eye, n (%)
Left
Right
Both
Ophthalmoplegia, n (%)
Proptosis, n (%)
Chemosis, n (%)
Vision impairment, n (%)
Afferent pupillary defect, n (%)
Sinus involvement, n (%)
Any sinus
Ethmoid
Maxillary
Frontal
Sphenoid
Multiple
Subperiosteal abscess, n (%)
Orbital cellulitis/phlegmon
without abscess, n (%)
Orbital abscess, n (%)
94
72 (2 m to 18 y)
57 (64)
66 (70)
10 (11)
10 (11)
8 (8)
2 (1–14)
50 (53)
63 (67)
54 (57)
40 (43)
0 (0)
45 (48)
36 (38)
10 (11)
11 (12)
3 (3)
91 (97)
87 (93)
84 (89)
33 (35)
30 (32)
83 (88)
44 (47)
42 (45)
8 (8)
Staphylococcus aureus cultured from
an orbital abscess that spontaneously
drained through the conjunctiva during examination under procedural sedation. As seen in Table 2, the most
common true pathogen was Streptococcus anginosus group, followed in
decreasing frequency by Staphylococus aureus, group A ␤-hemolytic streptococci, Streptococcus pneumoniae,
and Haemophilus influenzae. The median age of patients in the Streptococcus anginosus group (132 months)
was similar to those with documented
infection with other bacteria (132
months). Of 3 patients with true pathogens recovered from blood cultures, 1
child with Haemophilus influenzae
bacteremia had moderate growth of
Actinomyces from a sinus culture; no
surgical specimens were obtained in
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ARTICLES
TABLE 2 Organisms Recovered From Culture Specimens
Organism
True pathogen
Streptococcus anginosus group
Staphylococcus aureus
Methicillin-sensitive
Staphylococcus aureus
MRSA
Group A ␤-hemolytic streptococci
Streptococcus pneumoniae
Haemophilus influenzae
Fusobacterium species
Eikenella species
Arcanobacterium species
Actinomyces species
Possible pathogen
Propionibacterium species
Burkholderia cepacia
Gemella species
Klebsiella pneumoniae
Enterobacter species
Corynebacterium species
Eikenella species
Other β streptococcus
Contaminants
Coagulase-negative Staphylococcus
Yeast
Viridans streptococcus
n (%)a
Blood, n
Sinus/Orbit, n
Subdural, n
14 (15)
8 (9)
7
0
1
1
14
7
6
0
0
0
1
6 (6)
4 (4)
3 (3)
2 (2)
1 (1)
1 (1)
1 (1)
0
1
0
1
0
0
0
0
1
5
4
2
1
1
0
1
0
0
0
0
1
0
1
0
3 (3)
1 (1)
1 (1)
1 (1)
1 (1)
1 (1)
1 (1)
1 (1)
0
0
0
0
0
0
0
0
3
1
1
1
1
1
1
1
0
0
0
0
0
0
0
0
10 (11)
2 (2)
2 (2)
0
0
1
10
2
1
0
0
0
a Percentage (%) of total patients (n ⫽ 94) from which organism was recovered. Listed organisms may be part of a mixed
infection.
the other 2 patients with bacteremia.
Eleven patients had evidence of a
mixed infection. Of 8 Staphylococcus
aureus isolates, 7 were methicillin
susceptible. MRSA was identified in 1
child presenting with an orbital
infection.
A single inpatient antibiotic, most commonly ampicillin-sulbactam, was used
in 34% of children. Combination antibiotics, usually a cephalosporin plus
clindamycin or vancomycin plus
ampicillin-sulbactam, were used in
62% of patients; 18% of patients received at least 3 concurrent intravenous antibiotics. In 4 patients the
inpatient antibiotic could not be determined from the chart review. As illustrated in Fig 1, both inpatient combination antibiotics and vancomycin
therapy increased during the study period. Vancomycin was used in 36% of
FIGURE 1
Combination antibiotics and inpatient vancomycin therapy trends.
PEDIATRICS Volume 127, Number 3, March 2011
children; its use increased from 14% of
patients in 2004% to 57% of patients in
2008. Most patients (73%) were discharged on 1 antibiotic, most commonly amoxicillin-clavulanic acid; 27%
of patients were discharged on combination antimicrobial therapy. Children
initially treated with inpatient monotherapy, compared with those receiving combination antimicrobial agents,
were more likely to be discharged on a
single antibiotic (97% vs 59%; P ⬍
.001). Patients treated with vancomycin, compared with those not receiving
vancomycin, were more likely to be discharged on combination antimicrobial
agents (P ⬍ .001). Thirteen patients
were discharged on intravenous
antibiotics.
Surgical procedures performed included endoscopic sinus surgery, ethmoidectomy, drainage of subperiosteal/orbital abscess, orbitotomy, sinus
trephination, and craniectomy. General indications for surgery were progressive orbital signs and/or symptoms after 48 hours of antibiotic
therapy. A true pathogen was recovered more often in patients who underwent surgery (P ⬍ .001). Surgical
patients were more likely to receive inpatient vancomycin (55% vs 26%; P ⫽
.01) and home intravenous antibiotics
(36% vs 7%; P ⫽ .02); rates of inpatient
and home combination antibiotics
were similar between surgical and
nonsurgical patients.
Table 3 compares antibiotic management strategies on the basis of
whether a pathogen was identified. In
children with a true pathogen (n ⫽
29), vancomycin was used in 55% of
inpatients; 14% were discharged on
vancomycin. In children without a true
pathogen (n ⫽ 65), vancomycin was
begun on 28% of patients but continued in only 1 child after hospital discharge. Compared with inpatient treatment, fewer children (with or without
a positive culture) were discharged
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e563
TABLE 3 Antibiotic Management Based on Recovery of a Pathogen
True Pathogen,
n ⫽ 29
Vancomycin, n (%)
Combination
antibiotics, n (%)
Single antibiotic, n (%)
Home
Inpatient
Home
Inpatient
Home
16 (55)
21 (72)
4 (14)
11 (39)
2 (67)
2 (67)
0 (0)
1 (33)
16 (26)
36 (58)
1 (2)
14 (23)
7 (24)
17 (61)
1 (33)
2 (67)
23 (37)
48 (77)
Significant complications occurred in
5 children, including recurrent orbital
cellulitis (n ⫽ 1), residual visual impairment (n ⫽ 3), and 1 death. Compared with children with a favorable
course, these 5 patients were more
likely to have presented with chemosis
(80% vs 7%; P ⬍ .001) or vision impairment (60% vs 9%; P ⫽ .01). Complications occurred in both patients with
documented infections with Fusobacterium; 1 child had left-eye blindness
and the other died after presenting
with meningitis, subdural empyema,
and cerebral edema. No central venous catheter complications were
identified. Two patients, both discharged on multiple antibiotics despite negative cultures, were rehospitalized with fever and rash. The first
patient, initially discharged on vancomycin, ceftriaxone, and clindamycin,
was diagnosed with an adverse drug
reaction and subsequently treated
with linezolid, metronidazole, and levofloxacin. The second child, initially
discharged on clindamycin and
trimethroprim-sulfamethoxazole, was
subsequently hospitalized twice with a
SELTZ et al
No Pathogen or
Contaminant, n ⫽ 62
Inpatient
on combination antibiotics. Patients
with a true pathogen, compared with
children with a negative culture, contaminant, or possible pathogen, were
discharged on a similar rate of combination antibiotics (P ⫽ .18) and were
more likely to be discharged on intravenous medication (P ⬍ .001). As an
example, a patient with heavy growth
of group A ␤-hemolytic streptococci
from both the sinus and orbit was discharged on ceftriaxone, metronidazole, and rifampin.
e564
Possible Pathogen,
n⫽3
diagnosis of toxic shock syndrome and
treated with intravenous fluids, dopamine, immunoglobulin, and intravenous antibiotics (first vancomycin plus
ceftriaxone and then vancomycin plus
clindamycin).
DISCUSSION
In this large study of pediatric orbital
infections at a tertiary care children’s
hospital, the Streptococcus anginosus
group was the most common pathogen identified, accounting for 44% of
positive cultures and 15% of all patients. Although only 1 case of MRSA
was documented, vancomycin and
combination antibiotics were frequently used, and a third of our patients were discharged on therapy
useful against community-associated
MRSA. To our knowledge, this is the
first study of children with orbital infections demonstrating frequent use
of antibiotics aimed at MRSA infection.
Current studies on the microbiology of
orbital cellulitis implicate a wide spectrum of bacteria with a decrease in the
incidence of Haemophilus influenzae
infection.4– 6 Staphylococcal species
recently have been reported as predominant pathogens. In a case series
of 35 patients, Staphylococcus aureus
(all methicillin susceptible) accounted
for 7 of 11 (64%) positive isolates.9 Another study of 38 children, which included cultures of eye discharge and
nasal swabs, reported 11 positive
Staphylococcus aureus (8 MRSA)
isolates.7 In contrast, our study documented the emergence of the Streptococcus anginosus group (Streptococcus
anginosus, Streptococcus constella-
tus, and Streptococcus intermedius),
which are part of the normal flora of
the respiratory, gastrointestinal, and
genitourinary tracts.17 These organisms can cause invasive disease, including brain abscesses, bacteremia,
endocarditis, intraabdominal and lung
infections,17 and orbital and periorbital infections.6,18
Small sample sizes, unreliable cultures, and the inclusion of patients
without orbital involvement (Chandler
stage 1) have limited microbiologic
findings in other studies.6–9 Culture results from nasal swabs should be interpreted with caution because a significant discordance rate may exist
between the infecting agent and the
nasal colonizing agent.19,20 Recovery of
bacteria from surgical specimens is
high, in contrast to blood cultures.6,7
Microbiologic results in our study, all
from patients with confirmed orbital
involvement, were obtained from
blood and surgical specimens with
predetermined criteria for classifying
a true pathogen.
Reports of orbital infections caused by
Staphylococcus aureus may heighten
concern for methicillin resistance because greater numbers of children are
being hospitalized with invasive disease due to MRSA.13 Antibiotics commonly used to treat orbital infections
such as ampicillin-sulbactam or cephalosporins do not effectively treat
MRSA, which may explain why broader
coverage may be increasing. Intensification of antibiotic therapy, however,
may contribute to the development of
resistant organisms and potentially increase the risk of medication adverse
reactions, which contributed to at
least 1 of our patients’ rehospitalizations. In addition, patients discharged
on home intravenous antibiotics may
have complications of central venous
catheters, including phlebitis, exit-site
infections, bloodstream infections,
accidental removal, malpositioning,
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ARTICLES
catheter embolization, thrombosis,
and mechanical tears or leaks.21,22
Therapy for children with orbital infections should be aimed at the suspected
pathogens. Initial treatment with parenteral antibiotics is generally recommended,2,4 although effective primary
treatment with oral antibiotics has
been reported.23 In our patients, vancomycin and combination antibiotics
were frequently used as initial therapies likely because of concern for
MRSA and/or multiple organisms. Patients treated with a single antibiotic
may have been felt to be at low risk of
having the MRSA infection. In addition,
children who underwent surgical procedures may have been deemed sicker
and were therefore more often treated
with inpatient vancomycin.
In this era of resistant bacteria, identification of a pathogen is important in
narrowing antibiotic coverage and
transitioning to oral therapy. Interestingly, microbiologic results in our patients did not always seem to affect
antibiotic treatment decisions. For example, many patients were initially
treated with vancomycin but then discharged on amoxicillin-clavulanic acid
(which does not treat MRSA) even without positive cultures to direct therapy.
Reasons for clinician comfort in narrowing coverage (discontinuing vancomycin) in children without a positive
culture were unclear; clinicians
seemed to have less concern for MRSA
at the time of discharge when a patient
showed a favorable clinical course even
when initial treatment included coverage for MRSA. A significant number of
children also were discharged on combination antimicrobial agents when a single agent seemed appropriate based on
positive culture results. Continuing combination regimens in these patients may
have been because of fear of missing an
additional organism that did not grow
from the culture source.
This study has several limitations. A
positive microbiologic result was
found in the minority of patients (34%),
and it is possible that some patients
with MRSA infection were not identified. Patients with orbital cellulitis
without abscess were especially unlikely to have a positive culture because of the lack of surgical intervention. However, most patients were not
discharged on antimicrobial therapy
that was useful against MRSA, and only
1 known patient returned with recurrent orbital symptoms (a child with
Haemophilus influenzae). If additional
patients had MRSA infection, but were
not discharged on appropriate treatment, we would have expected more children to return to the hospital with signs
of worsening or recurrent disease.
Our patients were all treated at a tertiary care children’s hospital, and results may therefore not be applicable
to patients managed in other settings.
Our findings also may not be applicable to orbital cellulitis after trauma or
surgery, in which the risk of MRSA may
differ. In addition, the predominance of
methicillin resistance among community Staphylococcus aureus isolates
varies by geographical location; areas
where MRSA accounts for a greater
proportion of these isolates may have
a higher incidence of MRSA orbital infections. In our region in 2007, more
than 50% of community-associated
Staphylococcus aureus isolates were
resistant to methicillin.
CONCLUSIONS
The Streptococcus anginosus group
is an emerging pathogen in children
with orbital infections. Because MRSA
is an uncommon cause, empiric vancomycin and combination therapy may
not be routinely indicated in all children. A simplified antibiotic regimen
(ampicillin-sulbactam) may help facilitate the transition to an oral agent and
prevent development of resistant organisms, adverse drug reactions, and
central venous catheter complications. Because surgical specimens
provide the greatest yield for pathogen
identification, more patients may benefit from a drainage procedure so that
culture results may help tailor antimicrobial therapy.
REFERENCES
1. Jain A, Rubin PA. Orbital cellulitis in children. Int Ophthalmol Clin. 2001;41(4):71– 86
crobiologic spectrum. Ophthalmology.
1998;105(10):1902–1906
2. Givner L. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21(12):
1157–1158
6. Rudloe T, Harper M, Prabhu S, Rahbar R,
VanderVeen D, Kimia A. Acute periorbital
infections: who needs emergent imaging?
Pediatrics. 2010;125(4). Available at: www.
pediatrics.org/cgi/content/full/125/4/e719
3. Aabideen K, Munshi V, Kumar V, Dean F. Orbital cellulitis in children: a review of 17
cases in the UK. Eur J Pediatr. 2007;166(11):
1193–1194
4. Nageswaran S, Woods C, Benjamin D, Givner
L, Shetty A. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25(8):695– 699
5. Donahue S, Schwartz G. Preseptal and orbital cellulitis in childhood: a changing mi-
PEDIATRICS Volume 127, Number 3, March 2011
7. McKinley S, Yen M, Miller A, Yen K. Microbiology of pediatric orbital cellulitis. Am J
Ophthalmol. 2007;144(4):497–501
8. Ho C-F, Huang Y-C, Wang C-J, Chiu C-H, Lin T-Y.
Clinical analysis of computed tomographystaged orbital cellulitis in children. J Microbiol
Immunol Infect. 2007;40(6):518–524
9. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases: a retrospective review of 262 cases. Int J Pediatr
Otorhinolaryngol. 2008;72(3):377–383
10. Kaplan S, Hulten K, Gonzalez B, et al. Threeyear surveillance of community-acquired
Staphylococcus aureus infections in children. Clin Infect Dis. 2005;40(12):1785–1791
11. Gorwitz R. A review of communityassociated methicillin-resistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J. 2008;27(1):1–7
12. Naseri I, Jerris R, Sobol S. Nationwide
Downloaded from pediatrics.aappublications.org by guest on September 9, 2014
e565
trends in pediatric Staphylococcus aureus
head and neck infections. Arch Otolaryngol
Head Neck Surg. 2009;135(1):14 –16
13. Gerber J, Coffin S, Smathers S, Zaoutis T.
Trends in the incidence of methicillinresistant Staphylococcus aureus infection
in children’s hospitals in the United States.
Clin Infect Dis. 2009;49(1):65–71
14. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and
orbit. Trans Am Ophthalmol Soc. 2006;104:
322–345
15. Vazan D, Kodsi S. Community-acquired
methicillin-resistant Staphylococcus aureus orbital cellulitis in a non-immunocompromised
child. J AAPOS. 2008;12(2):205–206
16. Chandler JR, Langenbrunner DJ, Stevens
e566
SELTZ et al
ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970;
80(9):1414 –1428
17. Asmah N, Eerspacher B, Regnath T, Arvand
M. Prevalence of erythromycin and clindamycin resistance among clinical isolates of
the Streptococcus anginosus group in Germany. J Med Microbiol. 2009;58(pt 2):
222–227
18. Hatton M, Durand M. Orbital cellulitis with
abscess formation following surgical treatment of canaliculitis. Ophthal Plast Reconstr Surg. 2008;24(4):314 –316
19. Chen A, Cantey J, Carroll K, Ross T, Speser S,
Siberry G. Disconcordance between Staphylococcus Aureus nasal colonization and
skin infections in children. Pediatr Infect
Dis J. 2009;28(3):244 –246
20. Barkin R, Todd J, Amer J. Periorbital cellulitis in children. Pediatrics. 1978;62(3):
390 –392
21. Levy I, Bendet M, Samra Z, Shalit I, Katz J.
Infectious complications of peripherally inserted central venous catheters in children.
Pediatr Infect Dis J. 2010;29(5):426 – 429
22. Ruebner R, Keren R, Coffin S, Chu J, Horn D,
Zaoutis T. Complications of central venous
catheters for the treatment of acute hematogenous osteomyelitis. Pediatrics. 2006;
117(4):1210 –1215
23. Cannon PS, Mc Keag D, Radford R, Ataullah
S, Leatherbarrow. Our experience using primary oral antibiotics in the management of
orbital cellulitis in a tertiary referral centre. Eye. 2009;23(3):612– 615
Downloaded from pediatrics.aappublications.org by guest on September 9, 2014
Microbiology and Antibiotic Management of Orbital Cellulitis
L Barry Seltz, Jesse Smith, Vikram D Durairaj, Robert Enzenauer and James Todd
Pediatrics; originally published online February 14, 2011;
DOI: 10.1542/peds.2010-2117
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