Intravenous therapy for orbital (postseptal) cellulitis
The regimens below are only suitable for patients 1 month or older, but may be used for initial dosing for preterm and term neonates with orbital (postseptal) cellulitis, while awaiting expert advice.
For empirical intravenous therapy for patients with orbital cellulitis, while awaiting the results of culture and susceptibility testing and ophthalmology advice, use:
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily; for patients with septic shock or requiring intensive care support, use ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, 12-hourly12. See advice on modification and duration of therapy ceftriaxone ceftriaxone ceftriaxone
PLUS
flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly; for patients with septic shock or requiring intensive care support use flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice on modification and duration of therapy flucloxacillin flucloxacillin flucloxacillin
OR as a single drug
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly; for patents with septic shock or requiring intensive care support, use 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. See advice on modification and duration of therapy. cefotaxime cefotaxime cefotaxime
Patients at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection require treatment with vancomycin. In the ceftriaxone-based regimen, replace flucloxacillin with vancomycin. If using cefotaxime, add vancomycin. Use initially:
vancomycin intravenously; see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children for initial dosing. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use cefotaxime alone or ceftriaxone plus vancomycin (see dosages above).
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin, cefotaxime alone or ceftriaxone plus vancomycin (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin in whom cefotaxime alone or ceftriaxone plus vancomycin cannot be used, or for patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, use:
vancomycin intravenously; see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children for initial dosing. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy vancomycin vancomycin vancomycin
PLUS
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 12-hourly. For patients with septic shock or requiring intensive care support, use ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly5. See advice on modification and duration of therapy. ciprofloxacin ciprofloxacin ciprofloxacin
If activity against anaerobic bacteria is required (eg for patients with concurrent sinusitis), add to all of the above regimens:
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 8-hourly. See advice on modification and duration of therapy. metronidazole metronidazole metronidazole