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WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. GUIDELINE FOR MANAGEMENT OF PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION The management of preseptal and orbital cellulitis depends on accurate diagnosis and prompt treatment to minimise potentially life-threatening complications. This guideline covers all paediatric patients admitted to any Children’s ward within the Worcestershire Acute Hospitals NHS Trust THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : This guideline is for use by paediatric medical staff. Lead Clinician(s) Dr D Castling Consultant Paediatrician Approved for 3 month extension on: Extension approved by Trust Management Committee on: This guideline should not be used after end of: 08th June 2015 22nd July 2015 08th September 2016 Key amendments to this guideline Date 14/07/2008 July 2010 06.07.2012 21.09.2012 30/01/2015 08/06/2015 11/09/2015 Amendment Approved by Clinical Director on behalf of paediatric clinical improvement group No further amendment made Extended 3 months to allow for review Minor changes to the wording in the audit section only Document extended for 3 month period whilst being transferred into treatment pathway format Document extended for 3 months whilst being transferred into treatment pathway format Document extended for 12 months as per TMC paper approved on 22nd July 2015 Approved by: D Castling D Castling/A Short D Castling/A Short Dr Gallagher Dr Gallagher TMC Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 1 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. GUIDELINE FOR MANAGEMENT OF PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN INTRODUCTION N.B. Please see flow chart on page 4 of this guideline The orbital septum is a nearly impervious barrier to spread of infection from the preseptal to orbital area. Infection and inflammation confined to the eyelids and structures anterior to the orbital septum is referred to as preseptal (or periorbital) cellulitis. Whereas, infection of the orbital soft tissue posterior to the orbital septum is known as orbital cellulitis and most commonly occurs as a complication of sinusitis. Orbital cellulitis is potentially life threatening as there is a risk of direct extension to the brain. Other complications associated with orbital cellulitis include orbital abscess, subperiosteal abscess, brain abscess, meningitis, optic neuritis, cavernous sinus thrombosis and blindness. The most likely organisms include Strep pyogenes, Strep pneumoniae & Staph aureus. Over 5 years of age Staph aureus is most common. Anaerobes are unusual. Haemophilus influenza type b is a very uncommon cause of orbital cellulites since HiB immunisation. PRESEPTAL CELLULITIS More common in younger children. Usually caused by Strep pyogenes, Strep pneumoniae or Staph aureus. Secondary to: Infection affecting the skin or adjacent structure e.g. hordoelum (stye) or conjunctivitis, trauma, insect bite or upper respiratory tract infection (may lead to bacteraemic periorbital cellulitis). Associated findings: Swelling, erythema, oedema, warmth, and tenderness. (Globe unaffected therefore no other ocular signs or symptoms.) ORBITAL CELLULITIS Is an OCULAR EMERGENCY and more common in older children. It can be caused by Streptococcus spp (including Strep Milleri, pneumococcus and group A beta haemolytic streptococcus), Staph aureus and more rarely Haemophilus influenzae, anaerobes or Neisseria meningitidis. Secondary to: Spread of infection from surrounding structures –sinusitis (particularly ethmoid sinus), trauma, surgery and blood-borne spread Associated findings: Pain, conjunctival oedema, erythema, warm lid, flu-like symptoms, pyrexia, meningism, proptosis, restricted ocular motility, reduced visual acuity, and abnormal pupil reflexes. Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 2 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. INDICATIONS FOR ADMISSION Most patients with periorbital swelling will require admission. The only safe patient to send home is one with minimal upper lid oedema, a normal eye examination and none of the features below. Proptosis Diplopia Restricted ocular motility Reduced visual acuity Abnormal pupil reflexes Full eye examination not possible Toxic or systemically unwell Central nervous system signs or symptoms (drowsiness, vomiting, headache, seizure or cranial nerve lesion). CT scanning should be used as an adjunct to clinical findings. Indications for CT: Central signs Unable to accurately assess vision Proptosis Restricted ocular motility Deteriorating visual acuity Bilateral oedema No improvement/deterioration at 24 hours Swinging pyrexia not resolving at 36 hours Lumbar puncture should be considered in some high risk cases (see flow chart). Not if focal neurology present. Lumbar puncture should be deferred until after the CT scan. Consider particularly in children <12 months old as often difficult to appreciate meningeal signs. Antibiotics – see flow chart for protocol. (Doses as per latest BNF for Children.) For preseptal cellulitis, if penicillin allergy, use oral clarithromycin. For orbital cellulitis, or IV therapy for preseptal cellulitis and penicillin allergy, discuss with Microbiologist. IV Ceftriaxone could be used as an alternative to IV Cefotaxime to allow once daily treatment, or for home IV therapy if considered appropriate. Any patient with meningeal involvement will need an extended course of IV antibiotic and should be discussed with microbiology. Surgical drainage is recommended if: CT shows evidence of an abscess. Visual acuity worse than 20/60 on initial evaluation. Severe orbital complications e.g. blindness or afferent papillary defect. Progression of orbital signs and symptoms despite therapy. Lack of improvement within 48 hours despite medical therapy. Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 3 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. FLOWCHART FOR MANAGEMENT OF PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN Patient presents with eyelid swelling Painful eye movements +/- chemosis +/- proptosis +/- restricted eye movements +/- visual loss No chemosis No proptosis No ophthalmoplegia No visual loss PRESEPTAL Oral co-amoxiclav if only mild swelling (registrar review) Complete 7 days Abx Home with open access Eye swab for MC+S Nasal swab for MC+S (if discharge) FBC, CRP, U&E Blood cultures Consider LP (after CT, particularly in high risk group –after excluded ICP) No improvement or deterioration after 24 hrs IV Cefotaxime Add in IV Metronidazole if no improvement in 12-18 hours Abx FULL/HIGH dose Analgesia ENT & Ophthalmology opinion IV Abx until joint decision fit for home – complete 10 days of Abx. Abx will depend on culture and sensitivities, d/w microbiology High risk cases of orbital cellulitis <2 years Meningeal or focal neurological symptoms Eye malformation or operation in the vicinity Clinically toxic child Visual loss or limitation of eye movements ORBITAL IV Cefotaxime Add in IV Metronidazole if no improvement in 12-18 hours Abx FULL/HIGH dose – (see BNF) depending on culture and sensitivities Analgesia Nasal decongestant (ephedrine 0.5% nose drops TDS) Immediate referral to ENT & Ophthalmology CT scan – coronal & axial views of orbits & sinuses (to visualise optic nerve) Check visual acuity, pupil response, eye motility, daily. If clinical deterioration check more frequently IV antibiotics for 24-48 hours, followed by oral antibiotics for 7-14 days if satisfactory response Consider repeat CT scan or immediate operation if: o Failure of medical management o Decrease in visual acuity Abscess Severe ophthalmoplegia Visual acuity Endoscopic or open surgical drainage (send material for M, C+S) Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 4 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. MONITORING TOOL How will monitoring be carried out? Clinical Audit/Round Table discussion Who will monitor compliance with the guideline? Paediatric Clinical Governance Group STANDARDS Audit all cases of preseptal/orbital cellulitis that proceed to surgery For all cases that result in loss of sight, report incident on Datix and hold a round table discussions % 100% CLINICAL EXCEPTIONS 100% REFERENCES Dudin A & Othman A. Acute periorbital swelling: Evaluation of management protocol. Paediatric Emergency Care. 1996:12, 16-20 Goldberg F, Berne A & Oski F. Differentiation of Orbital Cellulitis From Preseptal Cellulitis by Computerised Tomography. Paediatrics. 1978:62, 1000-1005 Rhys-Williams S & Carruth J. Orbital infection secondary to sinusitis in children: diagnosis and management. Clinical Otolaryngol. 1992:17, 550-557 Howe L & Jones N. Guidelines for the management of periorbital cellulitis/abscess. Clinical Otolaryngol. 2004:29, 725-728 Schwartz G & Wright S. Changing Bacteriology of Periorbital Cellulitis. Annals of Emergency Medicine. 1996:28(6), 617-620 Laurence B & Givner M. Periorbital versus Orbital Cellulitis. Concise Reviews of Paediatric Infectious Diseases. 2002 (Dec), 1157-1158 Ellen R & Wald M. Periorbital and Orbital Infections. Paediatrics in Review. 2004: 25(9), 312319 Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 5 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. CONTRIBUTION LIST Key individuals involved in developing the document Name Dr D Castling Dr K Furneaux Dr J Brent Designation Consultant Paediatrician Senior House Officer ST2 Trainee in Paediatrics Circulated to the following individuals for comments Name Designation Mr M Porter Consultant ENT Surgeon Miss G Thurairajan Consultant Ophthalmologist Dr N Ahmad Consultant Paediatrician Dr M Ahmed Consultant Paediatrician Dr T Bindal Consultant Paediatrician Dr D Castling Consultant Paediatrician Dr T C Dawson Consultant Paediatrician Dr T El-Azzabi Consultant Paediatrician Dr G Frost Consultant Paediatrician Dr A Gallagher Consultant Paediatrician Dr M Hanlon Consultant Paediatrician Dr L Harry Consultant Paediatrician Dr B Kamalarajan Consultant Paediatrician Dr K Nathavitharana Consultant Paediatrician Dr C Onyon Consultant Paediatrician Dr J E Scanlon Consultant Paediatrician Dr A Short Clinical Director/Consultant Paediatrician Dr V Weckemann Consultant Paediatrician Dr F Childs Consultant Paediatrician - Community Dr J Crane Consultant Paediatrician - Community Dr D Lewis Consultant Paediatrician - Community Dr A Mills Consultant Paediatrician - Community A Borg Directorate Manager D Picken Matron, Paediatrics N Pegg Ward Manager, Riverbank L Greenway Ward Manager, Ward 1 S Courts Orchard Services Manager M Chippendale Advanced Nurse Practitioner Matt Kaye/Sarah Scott Lead Pharmacist for Paediatrics and Neonatal Circulated to the following CD’s/Heads of dept for comments from their directorates / departments Name Directorate / Department V Bullock Manager, Neonatal Unit Dr C Catchpole Consultant Microbiologist Circulated to the chair of the following committee’s / groups for comments Name A Smith Committee / group Medical Safety Committee Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 6 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. Supporting Document 1 – Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed. A completed checklist will need to be returned with the document before it can be published on the intranet. For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included. 1 Type of document Clinical guideline 2 Title of document Guideline for Management of Preseptal or Orbital Cellulitis in Children 3 Is this a new document? Yes No If no, what is the reference number WAHT-PAE069 4 For existing documents, have you included and completed the key amendments box? Yes No 5 Owning department Paediatrics 6 Clinical lead/s Dr Douglas Castling 7 Pharmacist name (required if medication is involved) Sarah Scott/Matt Kaye 8 Has all mandatory content been included (see relevant document template) Yes No 9 If this is a new document have properly completed Equality Impact and Financial Assessments been included? Yes No 10 Please describe the consultation that has been carried out for this document Reviewed by clinical lead and agreed for extension by Clinical Director. Extension to be documented at Paediatric Clinical Governance meeting on 26.10.12 11 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this document relates to. Management of preseptal or orbital cellulitis in children N/A Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval. Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 7 of 8 WAHT-PAE-069 It is the responsibility of every individual to check that this is the latest version/copy of this document. Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented Action Person responsible Timescale No change to practice. Members of the Paediatric Dr A Short October 2012 Clinical Governance Committee to be informed of extension of guideline at meeting on 26.10.12 Plan for dissemination Disseminated to Members of the Paediatric Clinical Governance Committee to be informed of the extension of this guideline. 1 Step 1 To be completed by Clinical Governance Department Is the document in the correct format? Has all mandatory content been included? 2 3 4 Yes No Yes No Date 26 October 2012 Date form returned 21/09/2012 Name of the approving body Paediatric Clinical Governance Committee (person or committee/s) Step 2 To be completed by Committee Chair/ Accountable Director Approved by (Name of Chair/ Dr Andrew Short Accountable Director): Approval date 21 September 2012 - extension to be confirmed and documented at the meeting on 26 October 2012 Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided (or approval email from accountable director in the case of minor amendments). Office use only Reference Number WAHT-PAE-069 Date form received 21/09/2012 Date document published 24/09/2012 Version No. 2.2 Guideline for Management of Preseptal and Orbital Cellulitis in Children WAHT-PAE-069 Version 2.5 Page 8 of 8
