Preseptal and Orbital Cellulitis Pathway Background and Objectives Orbital cellulitis is a relatively uncommon condition but carries significant morbidity, including orbital abscess, vision loss, cavernous sinus thrombophlebitis, and intracranial abscess. Orbital abscess is a surgical emergency. Though they have distinctly different pathogenesis, differentiating orbital cellulitis from preseptal (periorbital) cellulitis is often difficult, especially in younger children. Preseptal cellulitis is more common than orbital cellulitis and has less risk of serious complications. Preseptal cellulitis arises from a superficial infection of the skin and soft tissues in the periorbital region anterior to the orbital plate. The most common organisms implicated in preseptal cellulitis are Staph aureus, Strep pneumoniae, other Strep species, and anaerobes. In comparison, orbital cellulitis arises from sinusitis, most commonly from the ethmoid sinuses, with spread of infection and inflammation through the thin layers of the lamina papyracea. The most common causative agents of orbital cellulitis are Staph and Strep species, and less commonly anaerobes. Both orbital and preseptal cellulitis can cause periorbital edema, erythema, eye pain, and fever, and therefore can sometimes be difficult to distinguish clinically. Patients with orbital cellulitis are more likely to have pain with extra-ocular movements, restricted extra-ocular movements, diplopia, proptosis, and an absolute neutrophil counts (ANC) >10,000. If there is concern for orbital cellulitis, an urgent CT scan with IV contrast to evaluate for orbital abscess is necessary. If orbital cellulitis/abscess is suspected and/or identified, care coordination between multiple services including, Pediatric Hospital Medicine, ENT, and Ophthalmology is required. The objectives of this pathway are to: Quickly identify patients with orbital cellulitis who may require surgery Identify those patients who require a CT Scan Improve coordination of the multiple subspecialists often involved in care of this group of patients Standardize antibiotics for these infections Algorithm Download Preseptal and Orbital Cellulitis Pathway Algorithm – Updated March 4, 2022 Quality Metrics Percentage of patients with pathway order set usage Percentage of patients with ophthalmology consult Percentage of patients who have a CT scan Percentage of patients who have a CT scan with documented sxs of orbital cellulitis Percentage of patients who require surgery Percentage of patients with appropriate antibiotic choice per pathway recommendation Percentage of patients with appropriate antibiotic duration per pathway recommendation ED average length of stay (minutes) Inpatient average length of stay (days) Number of returns to ED within 48 hours Number of readmission within 48 hours Educational Module Download Preseptal and Orbital Cellulitis Educational Module – Updated March 4, 2022 Key References Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010 Apr;125(4):e719-726. 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 Mar;72(3):377-83. Nageswaran S, Woods CR, Benjamin DK Jr, Givner LB, Shetty AK. Orbital cellulitis in children. Pediatr Infect Dis J. 2006 Aug;25(8):695-9. Pathway Contacts Majida Gaffar, MD Eric Hoppa, MD Ebla Abd Alrahman, MD Scott Schoem, MD Disclaimer The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case. View all Clinical Pathways >
