eMedicine Specialties > Emergency Medicine > Ophthalmology
Periorbital Infections: Treatment & Medication
Updated: Nov 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Periorbital cellulitis
- In adult patients who are nontoxic and can be assured of appropriate follow-up, treatment can be with oral antibiotics on an outpatient basis.
- Most pediatric patients require admission. Intravenous antibiotics should be started. Once clinical improvement is noted, the patient should be switched to oral antibiotics.
- Patients who undergo outpatient treatment should be seen daily to ensure clinical improvement.
- Nasal decongestants may be used for the short term to reduce mucosal edema.40
- A Clinical Severity Index has been established for periorbital cellulitis in children. It uses systemic features of interaction and fever and local features of location, erythema, extent, and pain and tenderness.43
- Blepharitis
- The treatment of blepharitis, regardless of etiology, begins with eyelid hygiene. The patient should be instructed to wash the lids with a nonirritating baby shampoo or a commercially prepared lid scrubbing solution and to use warm compresses for 15 minutes at a time, 3 or 4 times a day.
- For blepharitis suspected to be infectious in nature, a topical antibiotic, such as bacitracin or erythromycin, should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process.44 Usually, it is applied 2-4 times a day for 2 weeks.
- Posterior blepharitis may be treated with an oral tetracycline, which decreases lipase production in staphylococci preventing plugging of Meibomian glands. This therapy is limited to patients older than8 years due to the risk of tooth enamel discoloration.44 Alternative treatment with the macrolide, erythromycin, is safe for use in children younger than 8 years.45
- Topical cyclosporine has shown benefit in treatment of posterior blepharitis in a small study of 30 patients compared to treatment with tobramycin/dexamethasone.
- A brief course of preservative-free topical steroids has been shown to decrease ocular surface inflammation.
- If blepharitis is caused by Demodex infestation, treatment with weekly lid scrubs with 50% tea tree oil and daily scrubs with tea tree shampoo for a minimum of 6 weeks has been shown to decrease mite load and improve inflammatory responses.
- Phthiriasis palpebrarum is treated with twice-daily application of petrolatum for 7-10 days. Alternatively, removal of the nits and lice can be accomplished with forceps.
- Dacryoadenitis
- Treatment of acute dacryoadenitis is largely supportive as the disease is usually self-limiting. Use warm compresses and nonsteroidal anti-inflammatory drugs.
- If the etiology is bacterial, antibiotic treatment with a first-generation cephalosporin should be started.
- If the etiology is EBV, steroids have been shown to improve the clinical course.
- For chronic dacryoadenitis, treat the underlying condition.
- Dacryocystitis
- Treat with oral antibiotics such as amoxicillin-clavulanic acid or dicloxacillin.
- In pediatric patients, the obstruction usually resolves by age 9-12 months. Many pediatric ophthalmologists will wait until after this age to probe the ducts to free the obstruction.
- Dacryocystorhinostomy is the surgical procedure of choice. This procedure allows for the bypassing of the lacrimal duct apparatus as long as the canalicular apparatus is intact.
- Punctal dilation and nasolacrimal irrigation is contraindicated in the acute stage due to the increased risk of periorbital cellulitis.
- Canaliculitis
- Remove concretions with gentle pressure using a cotton swab.
- Warm compresses
- Irrigation with penicillin solution to be performed by an ophthalmologist
- Systemic antibiotics, usually penicillin or amoxicillin for 1-2 weeks
- Topical antibiotics - Bacitracin or erythromycin: This rarely achieves complete resolution due to inability of antibiotics to penetrate concretions.
- Canaliculotomy with curettage is the definitive treatment.
Consultations
- Consider consultation with an ophthalmologist for any patient who may have orbital involvement.
- Most cases of lacrimal system infections can be managed conservatively. Consultation with an ophthalmologist is indicated if the condition is not resolved within 24-48 hours.
Medication
The goals of pharmacotherapy are to eradicate the infection, prevent complications, and reduce morbidity.
Antibiotics, systemic
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococci or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.
Used orally when outpatient management is indicated.
Has a half-life of 50-80 min. Only 10% is protein bound and greater than 90% recovered unchanged in urine.
Adult
250 mg PO qid or 500 mg PO bid for 7-10 d
Pediatric
20 mg/kg/d PO divided q8h for 7-10 d; in more serious infections, may increase dose to 40 mg/kg/d; not to exceed 1 g/d
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Provides useful coverage for most organisms associated with dacryocystitis.
Adult
1.5 g (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin; dosage reduced with renal failure
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). As an alternative to sulfonamides, clindamycin may be beneficial when used with pyrimethamine in acute treatment of CNS toxoplasmosis in patients with AIDS.
Adult
600 mg PO/IV q6-8h
Pediatric
20 mg/kg/d PO/IV divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Doxycycline (Bio-Tab, Doryx, Doxy, Periostat, Vibramycin, Vibra-Tabs)
Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
100-200 mg PO qd; some sources recommend using one half of initial dose during second month
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Vancomycin (Lyphocin, Vancocin, Vancoled)
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 cannot receive, or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
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.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
Adult
500 mg to 2 g/d IV divided tid/qid 7-10 d
1 mg/0.1 mL for intravitreal injection
25 mg/0.5 mL for subconjunctival injection, or
25 mg/mL 1 gtt q5min for 1-7 doses depending on severity, repeat q1h
Pediatric
Administer as in adults
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Cefuroxime (Ceftin)
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have and 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.
Adult
750-1500 mg IV q8h
Adjust dose based on creatinine clearance in renally impaired patients:
CrCl >20: No change
CrCl 10-20: 750 mg q12
CrCl <10: 750 mg q24h
Drug is dialyzable; administer dose after dialysis
Switch to PO dosage form as clinical situation warrants
250-500 mg PO bid
Pediatric
25-50 mg/kg IV q8h; switch to PO dosage form as clinical situation warrants
Oral susp not bioequivalent to tab form
Oral susp: 30 mg/kg/d PO divided bid; not to exceed 1000 mg/d
Tab: 125-250 mg PO q12h
Disulfiramlike reactions may occur when alcohol is consumed within 72 h of ingestion; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bioavailability increases when taken after food; fungal and microorganism overgrowth may occur with prolonged therapy; dosage adjustment for geriatric patients is not necessary; methicillin-resistant staphylococci are resistant to cefuroxime; use with caution in patients with a history of colitis; oral susp contains phenylalanine (do not give in patients with phenylketonuria)
Nafcillin (Nallpen, Unipen)
Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to PO therapy as condition warrants.
Because of thrombophlebitis, particularly in the elderly persons, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.
Adult
500-2000 mg IV q4-6h; switch to PO dosage form as clinical situation warrants
250-500 mg PO q4-6h, up to 1 g q4-6h for severe infections
Pediatric
Not approved for pediatric use; off-label dosing administered as follows:
100 mg/kg/d IV divided q6h
Severe infections: May increase to 200 mg/kg/d IV divided q6h; not to exceed 6-12 g/d; switch to PO dosage form as clinical situation warrants
50-100 mg/kg/d PO divided q6h
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; decrease dose in hepatic dysfunction
Amoxicillin and clavulanic acid (Augmentin)
Treats bacteria resistant to beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs more than 40 kg.
Adult
500-875 mg PO bid
Pediatric
In neonates and infants <3 months: 30 mg/kg/d divided PO q12h
In infants >3 months: 45 mg/kg/d PO divided q12h or 40 mg/kg/d divided q8h
Children >40 kg: Administer as in adults
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer for minimum of 10 d to eliminate organism; some formulations of Augmentin contain phenylalanine (do not give to phenylketonurics); caution in breastfeeding mothers
Cefaclor (Ceclor)
Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.
Adult
750-1500 mg/d PO divided bid/tid
Pediatric
<1 month: Not established
>1 month: 20-40 mg/kg/d PO divided q8-12h; not to exceed 1 g/d
Alcoholic beverages consumed <72 h after ingestion may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Risk of toxic reactions may be greater in patients with impaired renal function; administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s).
Adult
250 mg PO q6h; alternatively, 500 mg PO q12h
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided q6h; not to exceed 3 g/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last one half of pregnancy through age 8 y) can cause permanent tooth discoloration; Fanconilike syndrome may occur with outdated tetracyclines
Bacitracin (AK-Tracin)
Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.
Adult
Apply 0.25- to 0.5-inch ribbon q3-4h for 7-10 d into conjunctival sac(s)
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; vaccinia, varicella, epithelial herpes simplex keratitis, mycobacterial infections, fungal diseases of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic medications; prolonged use may result in overgrowth of nonsusceptible organisms
Erythromycin (E-Mycin)
Macrolide antibiotic that binds to 50S ribosomal subunit blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Does not affect nucleic acid synthesis.
Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.
Adult
Apply 0.5-inch (1.25 cm) ribbon 2-8 times/d depending on severity of infection
Pediatric
Apply as in adults
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
More on Periorbital Infections |
| Overview: Periorbital Infections |
| Differential Diagnoses & Workup: Periorbital Infections |
 Treatment & Medication: Periorbital Infections |
| Follow-up: Periorbital Infections |
| References |
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Further Reading
Keywords
periorbital infection, periorbital cellulitis, preseptal cellulitis, blepharitis, eyelid inflammation, lacrimal gland inflammation, hordeolum, stye, dacryoadenitis, dacryocystitis, canaliculitis
