Management of Periorbital Cellulitis in Children Developed in response to: Type: Clinical Guideline Register No: 16019 Status: Public on ratification Update and improve practice Contributes to CQC Regulation: 9 Consulted With Post/Committee/Group Date Melanie Chambers Lead Nurse Children and young people March 2016 Mel Hodge Ward Sisters March 2016 Dr A Rao/ A. Cuthbertson Clinical Director March 2016 Dr Agrawal Paediatric Consultant March 2016 Dr Babu Paediatric Consultant March 2016 Dr Cyriac Paediatric Consultant March 2016 Dr Datta Paediatric Consultant March 2016 Dr Hassan Paediatric Consultant March 2016 Dr Lim Paediatric Consultant March 2016 Dr Nambiar Paediatric Consultant March 2016 Dr Ottayil Paediatric Consultant March 2016 Victoria Machell Clinical Governance Facilitator March 2016 Dr Teare Consultant microbiologist March 2016 Claire Fitzgerald Paediatric Pharmacist March 2016 Professionally Approved By Dr Datta Clinical Lead Paediatrics March 2016 Version Number 1.0 Issuing Directorate Women s and children s Ratified by: DRAG Chairmans Action Ratified on: 24 th May 2016 Executive Management Board Sign Off Date June 2016 Implementation Date 31 st May 2016 Next Review Date April 2019 Contact for Information Melanie Chambers Policy to be followed by (target staff) Nursing & Medical Staff Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) 04071 Standard Infection Prevention 04072 Hand Hygiene 11046 Child and Young Person Observation Policy 08038 Aseptic ANTT 06045 Antibiotic Prescribing Policy Document Review History Version Number Authored/Reviewed by Active Date 1.0 Victoria Machell 31 st May 2016 1
Index 1.0 Purpose 2.0 Scope 3.0 Background 4.0 Staging of infection 5.0 Indications for admission 6.0 Treatment 7.0 Indications for CT scan 8.0 Discharge criteria 9.0 Staff training 10.0 Infection Control 11.0 Equality and Diversity 12.0 Audit and Monitoring 13.0 Communication 14.0 References 2
1.0 Purpose 1.1 This guideline provides evidence based practice on the management of periorbital cellulitis to assist the treatment of patients in secondary care. 1.2 It includes criteria for admission and discharge, referral and indications for further investigations including CT scans. 2.0 Scope 2.1 This guideline is to be used by all nursing and medical staff caring for children under the age of 16. 3.0 Background 3.1 Periorbital cellulitis is a soft tissue infection which occurs in and around the orbit of the eye. It usually affects children under 5 years old but older children can be affected and often experience more complications. 3.2 Periorbital cellulitis can be very dangerous if it progresses into an abscess or further into cavernous sinus thrombosis. 3.3 Periorbital cellulitis often occurs as a result of sinusitis and is usually preceded by an upper respiratory infection or illness. 3.4 Periorbital cellulitis can also be caused by infections starting in eye itself, such as conjunctivitis, eye lid infections or trauma. 3.5 The bacterial infections are usually responsible for periorbital cellulitis, primarily streptococci, staphylococci and haemophilus. 4.0 Staging of infection 4.1 Stage 1: Pre Septal inflammation (infection of the tissues lying to the anterior of the orbital septum outside the orbit). This usually presents with lid erythema/oedema but child should be able to open their eye and can be treated with systemic antibiotics. 4.2 Stage 2: Orbital Cellulitis (infection of the tissues lying to the posterior of the orbital septum within the orbit). This usually involves more severe symptoms of stage 1 causing the eye to be closed and can be treated with systemic antibiotics. 4.3 Stage 3: Subperiosteal Abscess (abscess forms to the posterior of the orbit). This usually involves severe symptoms of the previous stage alongside proptosis, opthalmoplegia and visual impairment. Treatment for this will normally involve investigation with a CT scan, systemic antibiotics and surgery. 4.4 Stage 4: Orbital Abscess (abscess forms within the orbit). Symptoms will occur as in stages above and should be identified with a CT scan. Treatment will involve systemic antibiotics and surgery. 4.5 Stage 5: Cavernous sinus thrombosis (abscess spreads into the cavernous sinuses behind the orbit). Symptoms as in previous stages will be shown bilaterally and will 3
lead to central nervous system changes and signs. Identification will involve a CT scan with further imaging as needed, systemic antibiotics and surgery. 5.0 Indications for admission 5.1 Criteria/indicating factors for admission include all of the following; Presence of diplopia Presence of ophthalmoplegia Presence of proptosis Reduced visual acuity Reduced light reflexes or swinging light test Patients where it is not possible to examine the eye CNS signs or symptoms Patients who are systemically unwell or septic 5.2 Always consider that the majority of paediatric patients presenting with periorbital swelling will require admission to hospital 6.0 Treatment for patient not meeting discharge criteria 6.1 Investigations: Intravenous access with a minimum of blood cultures, FBC and CRP Bacterial eye swab sent for M,C&S Refer to ENT for assessment and daily review Refer to ophthalmology for assessment and daily review 6.2 Intravenous Antibiotic Treatment: First Line treatment: IV Co-Amoxiclav see BNFC for dose In cases with penicillin allergy: IV Clindamycin see BNFC for dose In cases with evidence of intracranial extension: IV ceftriaxone see BNFC for dose (dependant on severity) And IV metronidazole see BNFC for dose In cases with evidence of intracranial extension and penicillin allergy: Discuss with microbiologist 4
7.0 Indications for CT scan 7.1 The following criteria should be used to determine the need for a CT scan: CNS symptoms or signs such as drowsiness, seizure, headaches, vomiting Diplopia Opthalmoplegia Deteriorating acuity of vision or colour vision Abnormal pupil reaction Proptosis Inability to evaluate quality of vision Patient unable to open eye Bilateral periorbital oedema 7.2 CT scan should also be considered if there is no improvement following 24-36 hours of intravenous antibiotics or if swinging pyrexia is not resolving within 36 hours 8.0 Discharge Criteria 8.1 The only patients suitable for discharge are those with minimal eyelid swelling, a normal eye examination and no indicators for admission 8.2 Discharge, Oral antibiotics: First line antibiotics: PO Co Amoxiclav see BNFC for dose In penicillin allergy: PO Clindamycin see BNFC for dose 9.0 Staff Training 9.1 All medical and nursing staff must ensure that their knowledge, competencies and skills are up-to-date in order to complete their portfolio for appraisal. 9.2 During induction process junior medical staff will receive instruction on current polices and guidelines. 9.3 Reflective learning through review of difficult and complex cases of periorbital cellulitis will be encouraged by serious case review and case presentation in junior doctors and nursing teaching 10.0 Infection Prevention 10.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands before and after each procedure. 5
10.2 All staff should ensure that they follow Trust guidelines on infection prevention, using Aseptic Non-Touch Technique (ANTT) when carrying out procedures 11.0 Equality and Diversity 11.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 12.0 Audit and Monitoring 12.1 Where a child s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that requires updating. 12.2 As an integral part of the knowledge skills framework staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site. 13.0 Communication 13.1 Approved guidelines are published monthly in the Trust s Focus Magazine that is sent via email to all staff. 13.2 Approved guidelines will be disseminated to appropriate staff via email after ratification of guideline. 13.3 Regular memos are posted on the guideline notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders. 14.0 References NICE Advice KTT9 Antibiotic prescribing especially broad spectrum antibiotics January 2015 6