Periorbital cellulitis in the era of Haemophilus influenzae type B vaccine: predisposing factors and etiologic agents in hospitalized children

Management of periorbital cellulitis at the Pediatric Emergency Department: A ten years study

Periorbital cellulitis is a diagnostic and therapeutic emergency, jeopardizing the prognosis for vision and survival.

PURPOSE

The goal of this study was to analyze the epidemiological and therapeutic features and outcomes of periorbital cellulitis cases treated in the pediatric emergency department.

PATIENTS AND METHODS

A retrospective study including all the children aged between 1 month and 15 years treated for periorbital cellulitis in the Pediatric Emergency Department of the Mohamed VI University Teaching Hospital in Marrakech over a period of 10 years (January 1, 2010-December 31, 2019).

RESULTS

In all, 168 cases of periorbital cellulitis were recorded, with an increasing of the number of cases, from 2 in 2010 to 39 in 2019. The most affected age bracket was the group under 5 years of age (62.5%). The most frequent mode of entry was sinusitis (22%). Preseptal cellulitis was most common (76.7%). The main clinical signs found in orbital cellulitis were proptosis (64%) and chemosis (35.8%), versus conjunctival hyperemia (78%) in preseptal cellulitis. Ophthalmoplegia was present in two cases of orbital cellulitis. The right side was most affected (44%). An orbital CT scan was performed in all cases in our study, showing preseptal cellulitis in 129 patients (76.7%), orbital cellulitis in 14 cases (8.3%), subperiosteal abscess in 20 cases (12%) and orbital abscess in 5 cases (3%). Prior treatment with non-steroidal anti-inflammatory medication was noted in 6%. The most commonly used antibiotic was amoxicillin-clavulanic acid. Steroid treatment was prescribed in 6% of cases. Surgical treatment was indicated in 12 patients (7.1%). The mean hospital length of stay was 3 days for the preseptal cases and 8 days for the orbital cases. All patients had good outcomes with medical and/or surgical treatment. With follow-up of over one year, no complications were noted.

CONCLUSION

The majority of our cases had positive outcomes, highlighting the advantage of early diagnosis, adapted antibiotic treatment and multidisciplinary care, rendering surgery rarely necessary.

Microbiology and outcome of pediatric orbital cellulitis in a Tertiary Eye Care Center in Saudi Arabia after the routine administration of Haemophilus influenzae Type B vaccine

PURPOSE

To evaluate the incidence of pediatric Haemophilus influenzae related orbital cellulitis after the routine administration of the H. influenzae vaccine in Saudi Arabia and to identify the most common pathogens, predisposing factors, related complications, and the need for surgical intervention.

METHODS

A retrospective chart review was performed of patients with a discharge diagnosis of orbital cellulitis who presented to the King Abdul Aziz University Hospital, Riyadh, Saudi Arabia. Saudi children born between 2000 and 2016 were included.

RESULTS

Thirty-one cases were included and 8 had positive cultures. No cases of H. influenzae were found. Of all the positive culture, the most common pathogens isolated were Staphylococcus aureus, Streptococcus pneumoniae and group A Streptococcus in 3 cases (37.5%), 2 cases (25%) and 2 cases (25%). The most common predisposing factor was sinusitis in 90.3% of cases. Sixteen patients (51.6%) developed complications. Fifteen patients (48.3%) developed subperiosteal abscesses, 1 patient (3.22%) developed a lid abscess, 2 patients (6.45%) developed recurrent orbital cellulitis, and 1 patient (3.22%) developed persistent strabismus. Only 10 (31.25%) patients underwent surgical intervention during admission.

CONCLUSION

The vaccine seems to be effective at eliminating the orbital cellulitis potentially related to H. influenzae. The most common current pathogens were Gram-positive Staphylococcus and Streptococcus species. Sinusitis remains the most common cause of orbital cellulitis in children. In select cases, medical treatment can resolve the infections however, close observation is warranted.

Corticosteroids for periorbital and orbital cellulitis

BACKGROUND

Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection.

OBJECTIVES

To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020.

SELECTION CRITERIA

We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis: protocol for a multicentre, retrospective cohort study

INTRODUCTION

Skin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis.

METHOD AND ANALYSIS

This is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay.

ETHICS AND DISSEMINATION

Approval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.

Pediatric orbital cellulitis in the Haemophilus influenzae vaccine era

PURPOSE

To evaluate the microbiology of pediatric orbital cellulitis in blood cultures and abscess drainage cultures following the introduction of the Haemophilus influenzae serotype b (Hib) vaccine.

METHODS

The medical records of all pediatrics patients (aged <18 years) at a tertiary pediatric hospital during the period January 2000 to July 2011 with a computed tomography orbital imaging querying "orbital cellulitis," "periorbital cellulitis," "preseptal cellulitis," or "post-septal cellulitis" were retrospectively reviewed. The records, microbiology, and radiology of these patients were reviewed to assess the rates and complications of H. influenzae orbital cellulitis, including bacteremia and meningitis.

RESULTS

A total of 149 patients were diagnosed with preseptal or orbital cellulitis, of whom 101 (mean age, 7.2 ± 4.0) had true orbital cellulitis. No patients grew H. influenzae from blood cultures. Of the 101 patients, 30 (29.7%) required surgical drainage and had abscess drainage fluid sent for microbiology. Of these, 18 (64.3%) had a positive culture: 4 (13.3%) grew H. influenzae from their abscess drainage fluid samples; 1 grew H. influenzae alone; and 3 had mixed growth that included H. influenzae. The patients positive for H. influenzae were significantly older and had significantly larger abscesses.

CONCLUSIONS

Although there were no cases of H. influenzae bacteremia or meningitis in our cases of orbital cellulitis, abscess drainage fluid microbiology indicated that H. influenzae remains a cause of orbital cellulitis. H. influenzae abscess volume was significantly larger than other bacterial abscesses and was associated with abscesses of mixed bacterial growth in older children.