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Periorbital and orbital cellulitis in children: a survey of emergency physicians and analysis of clinical practice guidelines across the PERUKI network
  1. Meriel Tolhurst-Cleaver1,
  2. Jordan Evans2,
  3. Thomas Waterfield3,
  4. Jonathan Adamson4,
  5. Robin Marlow5,
  6. Mark D Lyttle6,
  7. Damian Roland7,8
  1. 1 Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
  2. 2 Emergency Department, University Hospital of Wales Healthcare NHS Trust, Cardiff, Cardiff, UK
  3. 3 Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
  4. 4 Emergency Department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  5. 5 Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  6. 6 Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
  7. 7 Health Sciences, University of Leicester, Leicester, UK
  8. 8 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to Dr Meriel Tolhurst-Cleaver, Emergency Department, Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK; meriel.tolhurst-cleaver{at}


Background Due to limited evidence to guide management of periorbital cellulitis (POC), we surveyed current practice and assessed quality and consistency of local clinical practice guidelines (CPGs) to highlight future research priorities.

Methods A web-based survey was sent to a designated emergency physician (who clinically assesses children) at Paediatric Emergency Research United Kingdom and Ireland (PERUKI) sites between 23 November 2018 to 22 January 2019. A nominated site lead offered one response as a department-wide perspective on admission, severity assessment, treatment, disposition and specialty consultation request. Sites shared their CPG. These were compared using a standardised data collection tool, and quality assessed using Standardised Reporting Practice Guidelines in Healthcare (RIGHT) criteria. Survey responses were also compared against CPG recommendations.

Results 83% (49/59) institutions invited submitted an individual survey response. 67% of responding sites had a CPG and 63% (31/49) submitted these. CPG quality was poor (mean 6.7/35 RIGHT criteria). 21 different severity markers were identified across CPGs. Most CPGS recommend investigations for severe disease, yet 23% (7/31) advise blood culture universally. 90% of CPGs advise discharge with oral antibiotics for milder cases, yet 86% of respondents reported departmental admission of all patients with POC. Nearly all respondents included proptosis, systemically unwell and visual disturbance as indications for admission but differed regarding importance of other signs.

Conclusions We demonstrated variation in practice across the PERUKI network in assessment of severity and management of POC. CPGs vary in recommendations, and clinical practice appears to differ from CPGs. Guidelines were generally of poor quality when compared against RIGHT standards.

  • ophthalmology
  • pediatric emergency medicine
  • guideline

Data availability statement

Data are available on reasonable request. Any further data required may be made available via request to the corresponding author.

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Data availability statement

Data are available on reasonable request. Any further data required may be made available via request to the corresponding author.

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  • Handling editor Shammi L Ramlakhan

  • Twitter @merieltc, @adamsonjon, @mdlyttle, @damian_roland

  • Contributors Conceptualised and led study: MT-C. Contributed to the design of the study: all authors. Developed the survey: MT-C, JE. Analysed the survey data: MT-C. Analysed the clinical practice guidelines: MT-C, JE, TW. Drafted the manuscript: MT-C, JE, TW, RM, JA. Critically reviewed the manuscript and contributed to its revision: DR, MDL. Supervised all aspects of the work: TW, DR, MDL. All authors approved the final manuscript and share accountability for the study as a whole.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.