Trust Guideline for the Management of Children with Periorbital Cellulitis

A Clinical Guideline
For use in: Jenny Lind Paediatric Department
By: Jenny Lind Paediatric Department
Children (1 month - 16 years) presenting with the
For:
symptoms and signs of periorbital cellulitis
Divisions responsible for
Divisions 2 and 3
document:
Key words: Cellulitis; Periorbital; Children
Dr Dipali Shah (ST7 Paediatrics)
Names and job titles
of document authors:
Dr Vipan Datta (Consultant Paediatrician)
Name of document author’s
David Booth
Line Manager:
Job title of author’s Line
Chief of Women’s and Children’s Services
Manager:
Mr Puvanachandra (Consultant Ophthalmologist)

Supported by: Mr Prinsely, Mr. Andy Bath (Consultant ENT Surgeons)

Dr Tremlett (Consultant Microbiologist)
Dr MacIver and Dr Pickworth (Consultant Radiologists)
Assessed and approved by: Clinical Guidelines Assessment Panel (CGAP)
Date of approval: 22 December 2015
Ratified by or reported as
Clinical Standards Group and Effectiveness Sub-Board
approved to:
To be reviewed before: 22 December 2018
To be reviewed by: Dr.Vipan Datta
Reference and/or Trustdocs
ID No: 1279
ID No:
Version No: 3
Description of changes: No changes to document
Compliance links: None
If Yes – does the
strategy/policy deviate from
the recommendations of N/A
NICE?
If so, why?

This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of
relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline
must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available
and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from
relevant guidance should be documented in the patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare
through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this
document.

Trust Clinical Guideline for: Management of Children with Periorbital Cellulitis

Author/s: D. Shah & V. Datta Author/s title: ST7 Paediatrics & Consultant Paediatrician
Approved by: CGAP Date approved: 22/12/2015 Review date: 22/12/2018
Available via Trust Docs Version: 3 Trust Docs ID:1279 Page 1 of 4
 Trust Guideline for the Management of Children with Periorbital Cellulitis

Quick Reference Guideline

PERIORBITAL
OEDEMA/ERYTHEMA AND ONE
PERIORBITAL OR MORE OF:
OEDEMA/ERYTHEMA ONLY Proptosis†, chemosis, pain on eye
AND 3 YEARS OLD OR OVER movement, pyrexial ≥380C,
<3 years old, altered vision†,
decreased eye movements†,
bilateral oedema†
Upper lid only affected
White eye with full range of
normal eye movements
Admit under paediatrics & seek early ENT,
Ophthalmology opinion
(ophthalmology to r/v within 2 hours of CAU
admission)
Oral co-amoxiclav 7days IV Ceftriaxone (within one hour of decision) and oral
Home with open access Metronidazole after FBC,CRP,blood cultures and if
< 12 months or possible meningitis consider LP, R/V
by Paeds, Oph, ENT at 4-12 hr (depending upon
severity) and 24, 48 hrs

Improving at 24 hrs Worsening/ no Worsening

better at 24hrs Improving
(at any stage)

Home Admit IV antibiotics until joint

Oral co-amoxiclav IV ceftriaxone (within (paed/opth/ent) decision fit
for total 7 days one hour of decision) for home
Open access to and oral Oral co-amoxiclav or d/w
CAU Metronidazole microbiology if culture +ve
Early Ophth/ENT Total of 10 days antibiotics
review

Review 24 and 48
hours

Improving Worsening (at any

stage) / no better
at 48 hours †Indications for CT Scan
IV antibiotics until joint CNS signs
(paed/opth) decision fit for home Gross proptosis or
Oral co-amoxiclav CT Scan (decision by
ophthalmoplegia
For total of 10 days antibiotics oph/paeds consultant)
Deteriorating visual acuity
Follow up in Eye clinic 1-2 weeks Continue IV antibiotics
Bilateral oedema
post discharge No improvement at 48 hrs
Swinging pyrexia not
resolved by 48 hours

Trust Clinical Guideline for: Management of Children with Periorbital Cellulitis

Author/s: D. Shah & V. Datta Author/s title: ST7 Paediatrics & Consultant Paediatrician
Approved by: CGAP Date approved: 22/12/2015 Review date: 22/12/2018
Available via Trust Docs Version: 3 Trust Docs ID:1279 Page 2 of 4
 Trust Guideline for the Management of Children with Periorbital Cellulitis

2 Rationale
Periorbital cellulitis (the infection of the soft tissues surrounding the eye) is a fairly common
presenting problem in the Children’s Assessment Unit, and is most commonly seen in
childhood. Whilst most cases resolve uneventfully with treatment, a small proportion of
patients may go on to develop potentially serious complications – e.g. blindness or brain
abscess.1 We would, however, also wish to avoid unnecessary admissions to the ward.

Periorbital cellulitis has tended to be managed by paediatricians alone, with sporadic

involvement of other specialties when deemed necessary. Increasingly, however, there is
a swing towards so-called “integrated” management of the condition with earlier
involvement of ophthalmologists and ENT surgeons, as this has been found to be a useful
approach in optimising standards of care.2

Imaging plays an important role in the management of the condition. CT scan can be a
very useful investigation, but due to the time, cost, and high doses of radiation involved it
is not suitable for every patient.

The guideline assumes that patients will be seen by a paediatric doctor in the first
instance. It therefore aims to give assistance in helping staff to determine which patients
need admission, which teams to involve and when, and in making the difficult decision of
when to, or not to, perform a CT scan.

3 Summary of development and consultation process undertaken

before registration and dissemination
This guideline was drafted by the authors listed above on behalf of the Department of
Paediatrics following a review of the literature. It has been circulated in draft form to a
Consultant Ophthalmologists, ENT Surgeons, Microbiologist and Radiologists, as well as
to the Consultant Paediatricians, for comment, and was discussed at the paediatric and
ophthalmology departmental audit meetings (March and April 2012).

4 References/ source documents

1. Howe L and Jones NS (2004); Guidelines for the management of periorbital
cellulitis/abscess. Clin. Otolaryngol 29 725 – 728
2. Davis JP and Stearns MP (1994); Orbital complications of sinusitis: avoid delays
in diagnosis. Postgrad. Med. J. 70 108 – 110.
3. Schramm VL et al (1982); Evaluation of orbital cellulitis and results of treatment.
Laryngoscope 92 732 – 738.
4. Mills R (1987); Orbital and periorbital sepsis. J. Laryngol. Otol. 101 1242 – 1247.
5. Dudin A and Othman A (1996) Acute Periorbital Swelling: Evaluation of
management protocol; Paediatr. Emerg. Care 12 16 – 20.
6. Uzcátegui N et al (1998) Clinical practice guidelines for the management of orbital
cellulitis Journal Pediatr. Opthalmol. Strabismus 35 73 – 79.
7. Joshua Bedwell and Nancy M.Bauman,(2011)current opinion in otolaryngology ,
head and neck surgery 19 467 – 473
8. Andrea Hauser, Simone Fogarasi( 2010), periorbital and orbital cellulitis,
paediatrics in review 31 242-249

Trust Clinical Guideline for: Management of Children with Periorbital Cellulitis

Author/s: D. Shah & V. Datta Author/s title: ST7 Paediatrics & Consultant Paediatrician
Approved by: CGAP Date approved: 22/12/2015 Review date: 22/12/2018
Available via Trust Docs Version: 3 Trust Docs ID:1279 Page 3 of 4
 Trust Guideline for the Management of Children with Periorbital Cellulitis

Antibiotics

Ceftriaxone Child 1 month – 12 years: 80mg/kg od IV over 30 mins

(Body weight >50kg as for Child 12-18 years)

Child 12-18 years: 4g od IV over 30 mins

Metronidazole Child 1month – 12 years: 7.5mg/kg (max 400mg) tds PO

Child 12 – 18 years: 400mg tds PO

Metronidazole may be given intravenously if the child is vomiting, by

infusion over 20-30 minutes:

Child 1month – 18 years: 7.5mg/kg (max 500mg) IV tds

Co-amoxiclav Child 1 month -1 year: 0.25mL/kg tds PO 125/31 susp

Child 1 – 6 years: 5mL tds PO 125/31 susp

Child 6 -12 years: 5mL tds PO 250/62 susp

Child 12 – 18 years: One 250/125 tablet tds PO

In case of penicillin allergy, oral co-amoxiclav may be substituted by oral cefradine and
oral clarithromycin together as follows:

Cefradine Child 1 month – 12 years: 12.5-25mg/kg bd PO

Child 12 – 18 years: 0.5-1g bd PO

Clarithromycin Child 1 month – 12 years:

Body weight < 8kg: 7.5mg/kg bd PO

Body weight 8 – 11kg: 62.5mg bd PO

Body weight 12 – 19 kg: 125mg bd PO

Body weight 20 – 29 kg: 187.5mg bd PO

Body weight 30 – 40 kg: 250mg bd PO

Child 12-18 years: 250mg bd PO

NB Please discuss with microbiology in case of any uncertainty

Swabbing the eye itself should be avoided as results can be misleading 1

Trust Clinical Guideline for: Management of Children with Periorbital Cellulitis
Author/s: D. Shah & V. Datta Author/s title: ST7 Paediatrics & Consultant Paediatrician
Approved by: CGAP Date approved: 22/12/2015 Review date: 22/12/2018
Available via Trust Docs Version: 3 Trust Docs ID:1279 Page 4 of 4
 Trust Guideline for the Management of Children with Periorbital Cellulitis

Trust Clinical Guideline for: Management of Children with Periorbital Cellulitis

Author/s: D. Shah & V. Datta Author/s title: ST7 Paediatrics & Consultant Paediatrician
Approved by: CGAP Date approved: 22/12/2015 Review date: 22/12/2018
Available via Trust Docs Version: 3 Trust Docs ID:1279 Page 5 of 4