Preseptal cellulitis

The oral route of drug administration may be indicated for some conditions in pediatric patients, such as in dacryocystitis and orbital or preseptal cellulitis. Young patients are able to swallow liquid suspensions and solutions more easily than oral solids (e.g., tablets or capsules). Oral medications are the most reliable form of dosing and delivery and continue to be the mainstay in pediatric drug therapy. 

Staphylococcus auretAs Skin abscesses, impetigo, cellulitis, pneumonia, septic arthritis, osteomyelitis, toxic-shock syndrome, enterotoxin food poisoning, surgical infections Blepharitis, hordeolum, conjunctivitis, dacryocystitis, corneal ulcer, preseptal and orbital cellulitis, endophthalmitis... 

Cefeclor is nsed to treat bacterial infections of the middle ear, limg, and urinary tract. Oral cefeclor can also be used to treat mild preseptal celluUtis. Parenteral administration of cefuroxime along with ampicillin/snlbactam is a recommended treatment for severe or imresponsive preseptal cellulitis (see Table 11-1). However, with the increase of penicillin-resistant isolates of Streptococcus pneumoniae, the effectiveness of empirically treating this condition with p-lactam dmgs needs to be carefully considered. 

Methicillin-resistant strains of Staphylococcus aureus and S. epidermidis and penicillin-resistant Streptococcus pneumoniae have been isolated from ocular infections. Therefore treatment of ocular infections caused by these organisms might require use of vancomycin for resolution. Vancomycin is also recommended for empiric intra-vitreal and topical therapy in bacterial endophthalmitis and for parenteral therapy in moderate to severe preseptal cellulitis (see Table 11-1). 

Al-Nammari S, Robertson B, Ferguson C. Towards evidence based emergency medicine best BETs from the Manchester Royal Infirmary. Should a child with preseptal periorbital cellulitis be treated with intravenous or oral antibiotics Emerg Med J 2007 24 128-129. 

Preseptal or periorbital cellulitis is an infectious process involving lid structures anterior to the orbital septum. The condition generally occurs due to one of three clinical scenarios (1) secondary to a localized infection or an inflammation of the eyelids or adjacent structures (i.e., sinusitis, conjunctivitis, blepharitis, and/or internal hordeolum), (2) secondary to eyelid or fecial trauma, and (3) after an upper respiratory tract infection. 

In patients withont evidence of local infection or trauma, preseptal cellulitis is often secondary to a respiratory tract... 

Before the introduction of the H. influenzae type B vaccine in 1985, nearly aU chUdren under 6 years of age with preseptal cellulitis were foimd to have H. influenzae type B or a A pneumoniae infection. This condition was of great concern due to the mortality from secondary meningitis. Becanse H. influenza is no longer of primary concern in chUdren, the most common causative bacteria are the group A streptococci. An important component in the history of young chUdren with ceUulitis shonld be to confirm or exclude H. influenzae type B vaccination. 

Modified from Jones DB, SteinkuUer PG. Microbial preseptal and orbital cellulitis. In Tasman W, Jaeger EA, eds. Duane s clinical ophthalmology, vol. 4. Philadelphia JB Lippincott, 1993 1-24 and Holdeman NR. Preseptal ceUulitis/orbital ceUulitis. In Onofrey BE, Skorin Jr L, Holdeman NR, eds. Ocular therapeutics handbook a clinical manual, ed. 2. Philadelphia Lippincott WiUiams and Wilkins, 2005 189-193 )... 

Sabouraud s agar plates. Although cultures of draining woimds may be useful in cases of preseptal cellulitis related to trauma or local infection, cultures of the conjunctiva, eyelids, and nasal mucosa are generally misleading. 

As previously stated,//, influenzae is no longer a major cause of cellulitis in children. However, when present, the condition is characterized by significant fever, leukocytosis, and unilateral hyperemia and edema of the eyelids. There is a sharply demarcated dark purple discoloration of the eyelid skin and adnexal area. Mild conjunctival hyperemia and chemosis may also occur. Unless the patient has received antibiotics, blood cultures are the most effective means of establishing the diagnosis. If meningeal signs are present, a lumbar puncture should be performed, because 12% to 25% of patients with Haemophilus preseptal or orbital cellulitis have concomitant meningitis. 

Figure 23-14 Preseptal cellulitis of the upper eyelid secondary to an internal hordeolum. Note the shallow skin fissure (arrotv) secondary to the significant sweUing. (Courtesy Dr. Anastas Pass, University of Houston, College of Optometry.)...

Figure 23-15 Sudden onset of preseptal cellulitis of left eye in a 3-year-old child secondary to an insect bite.

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