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Orbital Cellulitis Organism-Specific Therapy 

  • Author: Ama Sadaka, MD; Chief Editor: Thomas E Herchline, MD  more...
Updated: Jul 12, 2016

Specific Organisms and Therapeutic Regimens

Orbital cellulitis is a serious condition with potentially devastating visual and life-threatening complications. It can result from the following:[1, 2, 3]

  • Following extension of an infection from the periorbital structures, most commonly from the paranasal sinuses
  • Direct inoculation of the orbit due to trauma or surgery
  • Hematogenous spread from bacteremia

The bacteria that typically cause orbital complications, such as Staphylococcus aureus, Haemophilus influenzae, Streptococcus species, and anaerobic species including Fusobacterium and Bacteroides, tend to mirror those that cause acute sinusitis.[4, 5] Understanding the prevalence and antibiotic resistance patterns of pathogens in the community is necessary for adequate treatment. Prompt recognition and early aggressive treatment are crucial in controlling the spread.[6]

Organism-specific therapeutic regimens for orbital cellulitis are discussed below.

Methicillin-sensitive Staphylococcus aureus (MSSA)

MSSA orbital cellulitis may be treated with the following regimens:

  • Nafcillin 2 g IV q4h or
  • Oxacillin 2 g IV q4h or
  • Ampicillin-sulbactam 1.5-3 g IV q6h or
  • Cefuroxime 1.5 g IV q8h or
  • Ceftriaxone 1-2 g/day IV or
  • Clindamycin 600 mg IV q8h

Methicillin-resistant S aureus (MRSA)

MRSA orbital cellulitis may be treated with the following regimens:

  • Vancomycin 1 g (15 mg/kg) IV q12h or
  • Daptomycin 6 mg/kg IV q24h56

Streptococcus pneumoniae

S pneumoniae orbital cellulitis may be treated with the following regimens:

  • Amoxicillin-clavulanate 875 mg/125 mg (20-40 mg/kg) PO q12h or
  • Cefpodoxime 200-400 mg (5 mg/kg) PO q12h or
  • Cefdinir 600 mg/day (14 mg/kg/day) PO

Streptococcus pyogenes

S pyogenes orbital cellulitis may be treated with the following regimens:

  • Ampicillin-sulbactam 1.5-3 g IV q6h or
  • Ceftriaxone 1 g/day IV or
  • Clindamycin 600 mg IV q8h

Zygomycetes or Aspergillus

Zygomycetes or Aspergillus orbital cellulitis may be treated with the following regimens:

  • Voriconazole 6 mg/kg IV q12h for 2 doses, then 4 mg/kg IV q12h or
  • Voriconazole 200-300 mg PO q12h or
  • Amphotericin B deoxycholate 1 mg/kg IV q24h or
  • Liposomal amphotericin 3-5 mg/kg q24h

Special considerations

Patients with orbital cellulitis frequently complain of fever and malaise and report a history of recent sinusitis or upper respiratory tract infection. Orbital signs include periorbital cellulitis, limitation in ocular movements, pain with ocular movements, and proptosis.

Imaging studies are crucial in defining the extent and nature of orbital involvement and determining management. CT scanning of the sinus and orbit with and without contrast is recommended.

Consider surgical drainage if the response to appropriate antibiotic therapy is poor within 48-72 hours or if CT scans show the sinuses to be completely opacified.

If the presence of a drainable fluid collection is evident on CT scan, surgical drainage should be considered.

Consider orbital surgery, with or without sinusotomy, in every case of subperiosteal or intraorbital abscess formation, leaving the drains in place for several days.

In cases of fungal infection, surgical debridement of the orbit is indicated and may necessitate exenteration of the orbit and the sinuses.

Canthotomy and cantholysis should be performed on an emergent basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease.

Contributor Information and Disclosures

Ama Sadaka, MD Resident Physician, Department of Ophthalmology, University of Cincinnati Hospital

Ama Sadaka, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.


Andrew G Lee, MD Chair, Department of Ophthalmology, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, The University of Texas Medical Branch; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine

Andrew G Lee, MD is a member of the following medical societies: American Academy of Ophthalmology, Association of University Professors of Ophthalmology, American Geriatrics Society, Houston Neurological Society, Houston Ophthalmological Society, International Council of Ophthalmology, North American Neuro-Ophthalmology Society, Pan-American Association of Ophthalmology, Texas Ophthalmological Association

Disclosure: Received ownership interest from Credential Protection for other.

Specialty Editor Board

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

  1. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J. 2006 Aug. 25(8):695-9. [Medline].

  2. Uzcátegui N, Warman R, Smith A, et al. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus. 1998 Mar-Apr. 35(2):73-9; quiz 110-1. [Medline].

  3. Murphy C, Livingstone I, Foot B, Murgatroyd H, MacEwen CJ. Orbital cellulitis in Scotland: current incidence, aetiology, management and outcomes. Br J Ophthalmol. 2014 Nov. 98(11):1575-8. [Medline].

  4. Bedwell J, Bauman NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011. 19(6):467-73.

  5. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007. 144(4):497-501.

  6. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012. 54(8):e72-e112.

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