Patient review, and modification and duration of intravenous therapy for periorbital cellulitis

For patients with periorbital cellulitis who are treated with intravenous therapy, clinical review within 24 hours is essential to ensure the patient is improving. If symptoms and signs have not improved at 24 hours or have worsened at any point, or if orbital signs develop (eg proptosis; diplopia; painful, tender or restricted eye movements) manage as for orbital cellulitis and seek expert advice from an ophthalmologist.

Note: Clinical review within 24 hours is essential to ensure the patient is improving.

Modify therapy based on the results of culture and susceptibility testing, if possible.

Switch to oral therapy when the patient has improved clinically – see Guidance for intravenous to oral switch. For intravenous to oral switch:

for patients at increased risk of MRSA infection, use trimethoprim+sulfamethoxazole or clindamycin
for patients without penicillin hypersensitivity, use dicloxacillin or flucloxacillin
for patients with nonsevere (immediate or delayed) penicillin hypersensitivity, or severe immediate¹ penicillin hypersensitivity who tolerated cefazolin, use cefalexin unless the patient has had a severe immediate¹ hypersensitivity reaction to amoxicillin or ampicillin
for patients with severe immediate¹ hypersensitivity to amoxicillin or ampicillin or severe delayed² hypersensitivity to any penicillin, use trimethoprim+sulfamethoxazole or clindamycin.

The usual total duration of antibiotic therapy (intravenous + oral) for patients with periorbital cellulitis is 7 days. Extend therapy if the infection has not resolved completely by the end of the treatment course. It is common for patients to have residual signs of inflammation at the end of treatment.

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return