Medication Summary
Drug therapy consists of antibiotics, antifungals, anticoagulants, corticosteroids, and nasal decongestants.
Antibiotics
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.
Antifungals
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.
Anticoagulants
Class Summary
Heparin can be used in cavernous sinus thrombosis.
Heparin
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).
Corticosteroids
Dexamethasone (Baycadron, Decadron DSC, Dexamethasone Intensol)
Has been studied at 0.3 mg/kg/d q6hr for 3 days
Methylprednisolone (A-Methapred, DepoMedrol, Medrol)
Prednisolone (FloPred, Millipred, Millipred DP)
Has been studied at 1 mg/kg/d for 7 days
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Complications of orbital infections. Brain abscess in a young man secondary to an orbital infection from Mucor species.
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Orbital infections. Orbital abscess with significant proptosis.
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Orbital infections. Subperiosteal abscess with contiguous sinusitis.
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Orbital infections. Subperiosteal abscess with contiguous sinusitis.
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Orbital infections. Frontal sinusitis.
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Orbital infections. Orbital abscess with significant proptosis.
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Cavernous sinus and its cranial nerves.
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Orbital cellulitis; chemosis.
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Lamina papyracea.
