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Orbital Infections Medication

  • Author: Keith A Lafferty, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
Updated: Jul 02, 2014

Medication Summary

Drug therapy consists of antibiotics, antifungals, anticoagulants, and nasal decongestants.



Class Summary

Therapy must cover all likely pathogens in this clinical setting.

Nafcillin (Unipen)


DOC; treats infections caused by penicillinase-producing staphylococci. Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Do not use in treatment of penicillin G–susceptible staphylococcal infections.

Use parenteral therapy initially in severe infections. Change to PO therapy as condition warrants. Because of thrombophlebitis, particularly in elderly patients, administer parenterally only for short-term period (1-2 d); change to PO route as clinically indicated.

Oxacillin (Bactocill, Prostaphlin)


Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.

Ampicillin and sulbactam (Unasyn)


Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Cefuroxime (Kefurox, Zinacef)


Second-generation cephalosporin; maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and Moraxella catarrhalis.

Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

Cefoxitin (Mefoxin)


Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond.

Cefotetan (Cefotan)


Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Dosage and route of administration depend on condition of patient, severity of infection, and susceptibility of causative organism.

Meropenem (Merrem)


Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Vancomycin (Vancocin)


Potent antibiotic directed against gram positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who can not receive, or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.


Nasal decongestants

Class Summary

Used to reduce intranasal congestion.

Phenylephrine nasal (Neo-Synephrine)


Strong postsynaptic alpha-receptor stimulant with little beta-adrenergic activity that produces vasoconstriction of arterioles in the body. Increases peripheral venous return.

Oxymetazoline (Afrin, 4-Way Long Acting Nasal Spray)


Applied directly to mucous membranes, where stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.



Class Summary

Imidazole derivatives that exert a fungicidal effect by altering the permeability of fungal cell membranes.

Amphotericin B (Fungizone)


Produced by a strain of Streptomyces nodosus. Can be fungistatic or fungicidal. Binds to sterols (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death.



Class Summary

Heparin can be used in cavernous sinus thrombosis.



Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse thrombus but able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis. Various dosing nomograms available.


Low Molecular Weight Heparin

Class Summary

Enoxaparin can be used in the acute stages of septic cavernous sinus thrombosis.

Enoxaparin (Lovenox)


Produced by partial chemical or enzymatic depolymerization of unfractionated heparin (UFH). Binds to antithrombin III, enhancing its therapeutic effect. The heparin-antithrombin III complex binds to and inactivates activated factor X (Xa) and factor II (thrombin).

Does not actively lyse but is able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis.

Advantages include intermittent dosing and decreased requirement for monitoring. Heparin anti–factor Xa levels may be obtained if needed to establish adequate dosing.

LMWH differs from UFH by having a higher ratio of antifactor Xa to antifactor IIa compared to UFH.

No utility in checking aPTT (drug has wide therapeutic window and aPTT does not correlate with anticoagulant effect).

Contributor Information and Disclosures

Keith A Lafferty, MD Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine; Medical Student Director, Department of Emergency Medicine, Gulf Coast Medical Center

Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society

Disclosure: Nothing to disclose.


Keisha Bonhomme, MD Resident Physician, Department of Internal Medicine, St Vincent’s Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.


Robert G Hendrickson, MD Associate Professor of Emergency Medicine, Oregon Health and Science University School of Medicine; Attending Physician, Medical Director, Emergency Management Program, Department of Emergency Medicine, Oregon Health and Science University Hospital and Health Systems; Associate Medical Director, Director, Fellowship in Medical Toxicology, Disaster Preparedness Coordinator, Oregon Poison Center; Clinical Toxicologist, Alaska Poison Center and Guam Poison Center

Robert G Hendrickson, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

  1. Mathew A, Craig E, Al-Mahmoud R, Batty R, Raghavan A, Mordekar S, et al. Paediatric Post-septal and Pre-septal Cellulitis: 10-year Experience at a Tertiary-level Children's Hospital. Br J Radiol. 2013 Nov 28. [Medline].

  2. Nemet AY, Ferencz JR, Segal O, Meshi A. Orbital cellulitis following silicone-sponge scleral buckles. Clin Ophthalmol. 2013. 7:2147-52. [Medline]. [Full Text].

  3. Hightower S, Chin EJ, Heiner JD. Detection of increased intracranial pressure by ultrasound. J Spec Oper Med. 2012. 12(3):19-22. [Medline].

  4. Wayman D, Carmody KA. Optic Neuritis Diagnosed by Bedside Emergency Physician-Performed Ultrasound: A Case Report. J Emerg Med. 2014 Mar 15. [Medline].

  5. Ahmad R, Salman R, Islam S, Rehman A. Cavernous Sinus Thrombosis As A Complication Of Sphenoid Sinusitis: A Case Report And Review Of Literature. Internet J Otorhinolaryngol. 12(1):[Full Text].

  6. Ben Abdallah Chabchoub R, Kmiha S, Turki F, Trabelsi L, Maalej B, Ben Salah M, et al. [Septic cavernous sinus thrombosis following ethmoiditis: A case report.]. Arch Pediatr. 2013 Nov 26. [Medline].

  7. Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. 2002 Sep. 116(9):667-76. [Medline].

  8. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005 Apr 28. 352(17):1791-8. [Medline].

  9. 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. [Medline].

  10. Ambati BK, Ambati J, Azar N. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000 Aug. 107(8):1450-3. [Medline].

  11. DeMuri GP, Wald ER. Clinical practice. Acute bacterial sinusitis in children. N Engl J Med. 2012 Sep 20. 367(12):1128-34. [Medline].

  12. Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar. 127(3):e566-72. [Medline].

  13. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP, Margolis TP. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. 2007 Aug. 144(2):313-5. [Medline].

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

  15. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006. 104:322-45. [Medline]. [Full Text].

  16. Mills DM, Tsai S, Meyer DR, Belden C. Pediatric ophthalmic computed tomographic scanning and associated cancer risk. Am J Ophthalmol. 2006 Dec. 142(6):1046-53. [Medline].

  17. Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002 Feb. 112(2):224-9. [Medline].

  18. Parmar H, Gandhi D, Mukherji, SK, Trobe JD. Restricted Diffusion in the Superior Ophthalmic Vein and Cavernous Sinus in a Case of Cavernous Sinus Thrombosis. J Neuro-Ophthalmol. 2009. 29;1:16-20. [Medline].

  19. Sepahdari AR, Aakalu VK, Kapur R, Michals EA, Saran N, French A, et al. MRI of orbital cellulitis and orbital abscess: the role of diffusion-weighted imaging. AJR Am J Roentgenol. 2009 Sep. 193(3):W244-50. [Medline].

  20. Hennemann S, Crawford P, Nguyen L, Smith PC. Clinical inquiries. What is the best initial treatment for orbital cellulitis in children?. J Fam Pract. 2007 Aug. 56(8):662-4. [Medline].

  21. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. 1998 Oct. 105(10):1902-5; discussion 1905-6. [Medline].

  22. Farnath D. Ocular infections. Infectious Disease in Emergency Medicine. 2nd ed. 1998. 843-58.

  23. Ghezzi K, Renner GS. Ophthalmologic disorders. Emergency Medicine. Concepts and Clinical Practice. 1992. 2427-59.

  24. Gordon LK. Diagnostic dilemmas in orbital inflammatory disease. Ocul Immunol Inflamm. 2003 Mar. 11(1):3-15. [Medline].

  25. Hendrickson RG, Olshaker J, Duckett O. Rhinocerebral mucormycosis: a case of a rare, but deadly disease. J Emerg Med. 1999 Jul-Aug. 17(4):641-5. [Medline].

  26. Kraus DJ, Bullock JD. Orbital infections. Pepose JS, Holland G, Wilheimus K, eds. Ocular Infection and Immunity. Mosby-Year Book; 1996. 1321-40.

  27. Mahalingam-Dhingra A, Lander L, Preciado DA, Taylormoore J, Shah RK. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg. 2011 Aug. 137(8):769-73. [Medline].

  28. Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emergency department. Emerg Med Clin North Am. 2008 Feb. 26(1):181-98, vii. [Medline].

  29. Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int Ophthalmol Clin. 1996 Summer. 36(3):207-21. [Medline].

  30. Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. 2007 Jun. 21(2):393-408, vi. [Medline].

  31. Westfall CT, Shore JW, Baker AS. Orbital infections. Infectious Diseases. 2nd ed. 1373-7.

  32. Yohai RA, Bullock JD, Aziz AA, Markert RJ. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol. 1994 Jul-Aug. 39(1):3-22. [Medline].

Complications of orbital infections. Brain abscess in a young man secondary to an orbital infection from Mucor species.
Orbital infections. Orbital abscess with significant proptosis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Frontal sinusitis.
Orbital infections. Orbital abscess with significant proptosis.
Cavernous sinus and its cranial nerves.
Orbital cellulitis; chemosis.
Lamina papyracea.
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