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Should a child with preseptal periorbital cellulitis be treated with intravenous or oral antibiotics?
  1. Shafic Al-Nammari, Junior Clinical Research Fellow,
  2. Benjamin Roberton,
  3. Craig Ferguson
  1. Moorfields Eye Hospital & St George’s Hospital

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    Report by Shafic Al-Nammari, Junior Clinical Research FellowSearch checked by Benjamin Roberton/Craig FergusonMoorfields Eye Hospital & St George’s Hospital

    A short cut review was carried out to establish whether there was any evidence to show whether children with preseptal periorbital cellulitis should be treated with intravenous or oral antibiotics. 395 papers were found using the reported searches of which none presented any evidence to answer the clinical question. It is concluded that 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.

    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.

    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]?

    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].

    Outcome

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

    Comments

    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 (ie 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 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.

    Report by Shafic Al-Nammari, Junior Clinical Research FellowSearch checked by Benjamin Roberton/Craig FergusonMoorfields Eye Hospital & St George’s Hospital

    References

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