Cellulitis, Orbital

Background
The orbital septum is a layer of fascia extending vertically from the periosteum of the orbital rim to the levator aponeurosis in the upper eyelid and to the inferior border of the tarsal plate in the lower eyelid. Orbital cellulitis and preseptal cellulitis are the major infections of the ocular adnexal and orbital tissues. Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum, differentiating it from preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum. Orbital cellulitis has various causes and may be associated with serious complications. Up to 11% of cases of orbital cellulitis result in visual loss. Prompt diagnosis and proper management are essential for curing the patient with orbital cellulitis.

Pathophysiology
Orbital cellulitis occurs in the following 3 situations: (1) extension of an infection from the periorbital structures, most commonly from the paranasal sinuses, but also from the face, the globe, and the lacrimal sac; (2) direct inoculation of the orbit from trauma or surgery; and (3) hematogenous spread from bacteremia. The medial orbital wall is thin and perforated not only by numerous blood valveless vessels and nerves but also by numerous other defects (Zuckerkandl dehiscences). This combination of thin bone, foramina for neurovascular passage, and naturally occurring defects in the bone allows for easy communication of infectious material between the ethmoidal air cells and the subperiorbital space in the medial aspect of the orbit. The most common location of a subperiorbital abscess is along the medial orbital wall. The periorbita is adherent relatively loosely to the bone of the medial orbital wall, which allows abscess material to easily move laterally, superiorly, and inferiorly within the subperiorbital space. In addition, the lateral extensions of the sheaths of the extraocular muscles, the intermuscular septa, extend from one rectus muscle to the next and from the insertions of the muscles to their origins at the annulus of Zinn posteriorly. Posteriorly in the orbit, the fascia between the rectus muscles is thin and often incomplete allowing easy extension between the extraconal and intraconal orbital spaces. Venous drainage from the middle third of the face, including the paranasal sinuses, is mainly via the orbital veins, which are without valves, allowing the passage of infection both anterograde and retrograde. Infectious material may be introduced into the orbit directly from accidental or surgical trauma.

Ethmoid sinusitis is the most common cause of orbital cellulitis in all age groups and aerobic non-sporeforming bacteria are the organisms most frequently responsible.

Frequency
An increased incidence of orbital cellulitis occurs in the winter, both nationally and internationally, because of the increased incidence of sinusitis in cold weather.

United States
There is a noted increase in the frequency of orbital cellulitis due to community-acquired methicillin-resistant Staphylococcus aureus infections involved in orbital cellulitis.

Mortality/Morbidity
Prior to the availability of antibiotics, patients with orbital cellulitis had a mortality rate of 17%, and 20% of survivors were blind in the affected eye. However, with prompt diagnosis and appropriate use of antibiotics, this rate has been reduced significantly; blindness occurs in up to 11% of cases. Orbital cellulitis due to methicillin-resistant S aureus can lead to blindness despite antibiotic treatment.

Race
No racial predilection exists for orbital cellulitis.

Sex
No frequency difference exists between the sexes in adults, except for cases of methicillin-resistant S aureus, which are more common in females than in males by a ratio of 4:1. However, in children, orbital cellulitis has been reported as twice as common in males than in females.

Age
Orbital cellulitis, in general, is more common in children than in adults. Median age of children hospitalized with orbital cellulitis is 7-12 years.

Clinical
History
A thorough history and physical examination are critical in establishing a diagnosis of orbital cellulitis. Patients with orbital cellulitis frequently complain of fever, malaise, and a history of recent sinusitis or upper respiratory tract infection. Questioning the patient about any recent facial trauma or surgery, dental work, or infection elsewhere in the body is important.

Other common but variable accompanying signs include the following: o Conjunctival chemosis o Decreased vision o Elevated intraocular pressure o Pain on eye movement The above signs may be accompanied by the following: o Fever o Headache o Lid edema o Rhinorrhea o Increasing malaise

Physical
Proptosis and ophthalmoplegia are the cardinal signs and symptoms of orbital cellulitis. The symptoms advance rapidly at an alarming rate and eventually lead to prostration.

Proptosis and ophthalmoplegia may be accompanied by the following: o Conjunctival chemosis o Decreased vision o Elevated intraocular pressure o Pain on eye movement o Orbital pain and tenderness are present early. o Vision may be normal early, but it may become difficult to evaluate in very ill children with marked edema. o Dark red discoloration of the eyelids, chemosis, hyperemia of the conjunctiva, and resistance to retropulsion of the globe may be present. o Purulent nasal discharge may be present.

Causes
Orbital cellulitis is caused by infection of the orbital soft tissues by extension of infection from periorbital structures, direct inoculation from accidental trauma or surgery, or hematogenous spread of infection.

Orbital cellulitis is caused most commonly by ethmoid sinusitis, accounting for more than 90% of all cases. The process involves edema of the sinus mucosa, which leads to narrowing of the ostia and subsequent reduction or cessation of normal sinus drainage. Microflora indigenous to the sinuses and upper respiratory tract proliferate and invade the edematous mucosa, resulting in suppuration. It is enhanced by the reduced oxygen tension within the obstructed sinus cavity. The organisms gain access to the orbit through thin bones of the orbital walls, venous channels, foramina, and dehiscences. Then, subperiorbital and intraorbital abscesses may occur. The resulting elevation of intraorbital pressure results in the typical signs of proptosis, ophthalmoplegia, and chemosis.

Orbital cellulitis can be caused by direct extension of infection from the globe, eyelids, ocular adnexum, and other periocular tissues, as well as the sinuses. Orbital cellulitis may follow dacryocystitis, osteomyelitis of the orbital bones, phlebitis of the facial veins, and dental infections. Orbital cellulitis may be caused by any injury perforating the orbital septum. Orbital inflammation may be noted within 48-72 hours after injury, or, in the case of a retained orbital foreign body, it may be delayed for several months. Orbital fractures may result in orbital cellulitis. Surgical procedures, including orbital decompression, dacryocystorhinostomy, eyelid surgery, strabismus surgery, retinal surgery, and intraocular surgery, have been reported as the precipitating cause of orbital cellulitis. Postoperative endophthalmitis can extend to the orbital soft tissues. Bacterial causes of orbital cellulitis are most commonly Streptococcus species, S aureus, and Haemophilus influenzae type B. Pseudomonas, Klebsiella, Eikenella, and Enterococcus are less common culprits. Polymicrobial infections with aerobic and anaerobic bacteria are more common in patients aged 16 years or older. Fungal causes of orbital cellulitis are most commonly Mucor and Aspergillus species. Orbital cellulitis due to fungal infections carries a high mortality rate in patients who are immunosuppressed. Fungi can enter the orbit, most commonly Mucor and Aspergillus species. Mucormycosis is widespread in distribution, while aspergillosis more commonly is seen in warm humid climates. Mucormycosis has a rapid onset (1-7 days), while aspergillosis is much slower (months to years). Aspergillosis initially gives chronic proptosis and decreased visions, while mucormycosis gives the orbital apex syndrome (involving cranial nerves II, III, IV, V-1, and VI, and orbital sympathetics), and, more commonly, it presents with pain, lid edema, proptosis, and visual loss. While both may result in nasal and palatal necrosis, mucormycosis also may give thrombosing arteritis and ischemic necrosis, while aspergillosis gives chronic fibrosis and a nonnecrotizing granulomatous process.

Differential Diagnoses
Exophthalmos Mucormycosis Retinoblastoma Sarcoidosis Spider Bites Thyroid Ophthalmopathy

Other Problems to Be Considered

Infection (cavernous sinus thrombosis) Endocrine dysfunction (dysthyroid exophthalmos) Idiopathic inflammation (orbital myositis, orbital pseudotumor, Wegener granulomatosis) Neoplasm with inflammation (Burkitt lymphoma, histiocytosis X [Letterer-Siwe], leukemia, metastatic carcinoma, retinoblastoma, rhabdomyosarcoma, sarcoidosis)

Workup
Laboratory Studies

Laboratory evaluation should include the following: o A complete blood cell (CBC) count: Leukocytosis greater than 15,000 with a shift to the left commonly is seen. o Obtain blood cultures prior to the administration of any antibiotics, although they are unlikely to reveal the responsible organism. o Collect purulent material from the nose with a cotton or calcium alginate swab, smear for Gram stain, and culture on both aerobic and anaerobic media. Assess any material obtained from the sinuses or directly from an orbital abscess in the same manner. o Needle aspiration of the orbit is contraindicated.

Imaging Studies

High-resolution CT scan with contrast infusion, including axial and coronal views, is essential. o Axial views should include low narrow cuts of the frontal lobes to rule out peridural and parenchymal brain abscess formation. o Coronal views are helpful in determining the presence and extent of any subperiorbital abscesses. However, coronal views, which require hyperflexion or hyperextension of the neck, may be difficult in uncooperative children and in patients who are acutely ill. MRI may be helpful in defining orbital abscesses and in evaluating the possibility of cavernous sinus disease.

Other Tests

Lumbar puncture is advisable if cerebral or meningeal signs develop.

Treatment
Medical Care
The patient with orbital cellulitis should be promptly hospitalized for treatment. Hospitalization should be continued until the patient is afebrile and is clearly improved clinically. Historically, the presence of subperiosteal or intraorbital abscess was an indication for surgical drainage in addition to antibiotic therapy; however, medical management alone is successful in many cases. Medical care of orbital cellulitis consists of the proper use of the appropriate antibiotics. Intravenous broad-spectrum antibiotics should be started immediately until the choice of antibiotics can be tailored for specifically identified pathogens identified on cultures. Typically, intravenous antibiotic

therapy should be continued for 1-2 weeks and then followed by oral antibiotics for an additional 2-3 weeks. Fungal infection requires intravenous antifungal therapy along with surgical debridement.

Surgical Care
Consider surgical drainage if the response to appropriate antibiotic therapy is poor within 48-72 hours or if the CT scan shows the sinuses to be completely opacified. If the presence of a drainable fluid collection is evident on CT scan, surgical drainage should be considered in patients older than 16 years. Consider orbital surgery, with or without sinusotomy, in every case of subperiosteal or intraorbital abscess formation, leaving the drains in place for several days. In cases of fungal infection, surgical debridement of the orbit is indicated and may require exenteration of the orbit and the sinuses. Canthotomy and cantholysis should be performed on an emergency basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease. Surgical drainage of an orbital abscess is indicated if any of the following occurs:

A decrease in vision occurs. An afferent pupillary defect develops. Proptosis progresses despite appropriate antibiotic therapy. The size of the abscess does not reduce on CT scan within 48-72 hours after appropriate antibiotics have been administered. If brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.

Consultations
Consult other specialties as indicated.

Generally, obtain consultation with a pediatrician, an internist, or a family physician, as well as an infectious disease specialist, in any case of orbital cellulitis. Ear, nose, and throat (ENT) consultation is appropriate for cases of orbital cellulitis arising from sinus disease. Neurosurgical consultation is indicated if brain abscesses appear.

Diet
No special diet requirements are indicated other than adequate hydration of the patient.

Activity
Hospitalization with intravenous antibiotic therapy is indicated.

Medication
Prompt administration of appropriate antibiotics is key to successful treatment of orbital cellulitis. Most cases of orbital cellulitis result from ethmoid sinusitis; in such cases, the initial antibiotics are chosen based on the most likely sinus pathogens, primarily Streptococcus pneumoniae and other streptococci, S aureus, H influenzae, and nonsporeforming anaerobes. Orbital cellulitis resulting from infection of the maxillary sinus secondary to dental infections can be caused by microorganisms indigenous to the mouth, including anaerobes, commonly Bacteroides species. Those cases stemming from dacryocystitis most commonly are caused by S aureus, S pneumoniae, Streptococcus pyogenes, and nontypeable H influenzae. Those spreading from infections of the soft tissues of the eyelids and face are due most commonly to staphylococci and S pyogenes. The initial antibiotic regimen can be modified if the response is inadequate or if the cultures dictate otherwise. The occurrence of methicillin-resistant S aureus in orbital cellulitis is increasing, and empiric antimicrobial therapy should be directed against these organisms if they are prevalent in the community. Infection due to methicillin-resistant S aureus is best treated with vancomycin, cefotaxime, and clindamycin. Fungal orbital cellulitis also occurs and is primarily due to Mucor and Aspergillus species. Fungal infection requires antifungals, such as amphotericin. Corticosteroids may be helpful, but they should not be started until after any surgery is performed and until the patient has been on appropriate antibiotics for 2-3 days. If secondary glaucoma develops secondary to orbital cellulitis, ocular antihypertensives should be instigated promptly. In cases of posttraumatic orbital cellulitis, tetanus prophylaxis should be given according to standard protocol.

Antibiotics
Appropriate antibiotics may include nafcillin (for Staphylococcus or Streptococcus species), cefotaxime (for gram-negative organisms, nontypeable H influenzae, Moraxella, and resistant pneumococci), and metronidazole (for anaerobes). Ticarcillin-clavulanate would cover most gram-positive and gram-negative organisms and most anaerobes. Nafcillin in combination with ceftazidime is also appropriate, although chloramphenicol may be substituted for ceftazidime. Cefazolin can be used in place of nafcillin in cases of mild allergy to penicillin and vancomycin in cases of severe allergy to penicillin. Vancomycin, cefotaxime, clindamycin, and trimethoprim/sulfamethoxazole doublestrength would be appropriate for methicillin-resistant S aureus.

Vancomycin (Vancocin)
Tricyclic glycopeptide antibiotic for intravenous administration. Indicated for the treatment of susceptible strains of methicillin-resistant (beta-lactam resistant) staphylococci in penicillin-allergic patients.

Dosing Interactions Contraindications Precautions

Adult
2 g/d IV divided q6h or 1 g q12h administered over 1 h; give slowly at rate <10 mg/min at concentration <5 mg/mL

Pediatric
Infants and neonates: 15 mg/kg IV as initial dose, followed by 10 mg/kg q12h for neonates in first week of life and q8h thereafter up to age of 1 month Children: 10 mg/kg/dose IV q6h over 1h Administer every dose over a period of 1 h

Dosing Interactions Contraindications Precautions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Prolonged use may result in the overgrowth of nonsusceptible organisms; reversible neutropenia has been reported in patients receiving vancomycin (monitor leukocyte count); reduce dose in impaired renal function; caution in renal failure, neutropenia; Red Man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given as 2-h administration or as PO or IP administration; Red Man syndrome is not an allergic reaction

Clindamycin (Cleocin)
Inhibits bacterial protein synthesis at the bacterial ribosomal lever, binding with preference to the 50S ribosomal subunit and affects the peptide chain initiation process.

Dosing Interactions Contraindications Precautions

Adult
1200-2700 mg/d IV/IM divided q6h; not to exceed 4.8 g/d

Pediatric
Neonates (<1 mo): 15-20 mg/kg/d IV/IM divided q6-8h 1 month to 16 years: 20-40 mg/kg/d IV/IM divided q6-8h; not to exceed 4.8 g/d

Dosing Interactions Contraindications Precautions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Dosing Interactions

Contraindications Precautions

Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis

Dosing Interactions Contraindications Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Cefotaxime (Claforan)
Semisynthetic broad-spectrum antibiotic for parenteral use. Effective against grampositive aerobes, such as S aureus, including penicillinase and non-penicillinase producing strains, and S pyogenes, gram-negative aerobes, such as H influenzae, and anaerobes, such as Bacteroides species.

Dosing Interactions Contraindications Precautions

Adult
Intermittent IV administration of a solution containing 1-2 g in 10 mL of sterile water for injection, over a period of 3-5 min q4h; should not be administered over <3 min

Pediatric
0-1 week: 50 mg/kg IV q12h 1-4 week: 50 mg/kg IV q8h 1 month to 12 years:

<50 kg: 50-180 mg/kg/d IV in 4-6 equally divided doses >50 kg: Administer as in adults

Dosing Interactions Contraindications Precautions

Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Caution in history of gastrointestinal disease, particularly colitis; give half usual dose in patients with impaired renal function (especially estimated creatinine clearances <20 mL/min/1.73 m2)

Nafcillin (Unipen)
Semisynthetic penicillin effective against a wide gram-positive spectrum, including Staphylococcus, pneumococci, and group A beta-hemolytic streptococci.

Dosing Interactions Contraindications Precautions

Adult
500 mg to 1 g IV/IM q4-6h

Pediatric
0-4 kg (neonates): 10 mg/kg IM bid 4-40 kg: 25 mg/kg IM bid Alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses

Dosing Interactions Contraindications Precautions

Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and to prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated

Ceftazidime (Fortaz, Ceptaz)

Semisynthetic, broad-spectrum, beta-lactam antibiotic for parenteral injection. Has broad spectrum of effectiveness against gram-negative aerobes, such as H influenzae, grampositive aerobes, such as S aureus (including penicillinase and non-penicillinase producing strains) and S pyogenes, and anaerobes, including Bacteroides species.

Dosing Interactions Contraindications Precautions

Adult
1-2 g IV q8h

Pediatric
Neonates (0-4 wk): 30 mg/kg IV Infants and children: (1 mo to 12 y): 30-50 mg/kg IV; not to exceed 6 g/d >12 years: Administer as in adults

Dosing Interactions Contraindications Precautions

Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels; chloramphenicol has been shown to be antagonistic to beta-lactam antibiotics, including ceftazidime

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Reduce total daily dose in patients with renal insufficiency due to high and prolonged serum concentrations, which can occur in doses usually given for orbital cellulitis, although ceftazidime has not been shown to be nephrotoxic; prolonged use can result in overgrowth of nonsusceptible organisms; cephalosporins may be associated with a fall in prothrombin activity; administration of ceftazidime may result in false-positive reaction when testing for serum glucose with Clinitest, Benedict solution, or Fehling solution; caution in breastfeeding

Chloramphenicol (Chloromycetin)
Exerts bacteriostatic effect on a wide range of gram-negative and gram-positive bacteria and is particularly effective against H influenzae.

Dosing Interactions Contraindications Precautions

Adult
50 mg/kg/d PO/IV divided q6h; change to PO as soon as possible

Pediatric
<2 weeks: 25 mg/kg/d PO/IV divided q6h >2 weeks: 50 mg/kg/d PO/IV divided q6h Infants and pediatric patients in whom immature metabolic functions suspected: 25 mg/kg/d PO/IV divided q6h

Dosing Interactions Contraindications Precautions

Concurrently with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol

levels may be increased or decreased; chloramphenicol has been shown to be antagonistic to beta-lactam antibiotics

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Administer only when less potentially hazardous therapeutic agents are ineffective; most serious adverse effect of chloramphenicol is bone marrow depression resulting in serious and fatal blood dyscrasias (aplastic anemia that may be irreversible, thrombocytopenia, and granulocytopenia with high rate of mortality); perform baseline blood studies q2d during therapy; discontinue drug if reticulocytopenia, leukopenia, thrombocytopenia, or anemia occur; avoid repeated courses of drug if at all possible; avoid concurrent therapy with other drugs that may cause bone marrow depression; excessive blood levels may result from administration of recommended dose to patients with impaired liver or kidney function, including that due to immature metabolic processes in the infant (adjust dosage in such patients); readily crosses placental barrier (caution in pregnancy); caution in premature and full-term neonates to avoid gray syndrome toxicity; prolonged use of chloramphenicol may result in overgrowth of nonsusceptible organisms, including fungi

Ticarcillin (Ticar)
Semisynthetic injectable penicillin that is bactericidal against both gram-positive and gram-negative organisms, including H influenzae, S aureus (non-penicillinase producing), beta-hemolytic streptococci (group A), S pneumoniae, and anaerobic organisms, including Bacteroides and Clostridium species.

Dosing

Interactions Contraindications Precautions

Adult
200-300 mg/kg/d IV divided q4-6h; administer piggyback as slowly as possible to avoid vein irritation

Pediatric
<2000 g body weight: <7 days: 75 mg/kg/12h; 150 mg/kg/d IV >7 days: 75 mg/kg/8h; 225 mg/kg/d IV >2000 g body weight: <7 days: 75 mg/kg/8h; 225 mg/kg/d IV >7 days: 100 mg/kg/8h; 300 mg/kg/d IV Children: Administer as in adults

Dosing Interactions Contraindications Precautions

Tetracyclines decrease ticarcillin effects; decreases effect of oral contraceptives; large IV doses can increase risk of bleeding in patients receiving anticoagulants; ticarcillin increases duration of neuromuscular blockers; probenecid increases ticarcillin levels

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; if renal impairment is known or suspected, adjust dose and monitor blood levels

Cefazolin (Ancef, Kefzol, Zolicef)

Semisynthetic cephalosporin for IM or IV administration. Has bactericidal effect against S aureus (including penicillinase-producing strains), group A beta-hemolytic streptococci, and H influenzae.

Dosing Interactions Contraindications Precautions

Adult
500 mg to 1.5 g IV q6h

Pediatric
25-50 mg/kg/d IV/IM divided tid/qid

Dosing Interactions Contraindications Precautions

Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides, may increase renal toxicity; may yield false-positive urine-dip test for glucose

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions

Contraindications Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Prolonged use may result in overgrowth of nonsusceptible organisms; reduce dose in impaired renal function; pseudomembranous colitis may occur

Antifungals
Fungal orbital cellulitis is a potentially lethal condition, and the principal organisms involved, Mucor and Aspergillus, require the use of antifungals.

Amphotericin B (AmBisome)
Antifungal of choice in treatment of fungal orbital cellulitis. Administered IV and may be appropriately administered before laboratory confirmation of fungal infection in cases of severe infection.

Dosing Interactions Contraindications Precautions

Adult
5 mg/kg given IV as single infusion at rate of 2.5 mg/kg/h; contents of infusion should be shaken q2h

Pediatric
Administer as in adults

Dosing Interactions Contraindications Precautions

Coadministration with antineoplastic agents may enhance potential for renal toxicity, bronchospasm, and hypotension; corticosteroids and corticotropin (ACTH); concurrent administration with amphotericin B may potentiate hypokalemia, which could predispose patient to cardiac dysfunction (monitor cardiac function and serum electrolytes); administration of amphotericin B and cyclosporin A within several days of bone marrow ablation may be associated with increased nephrotoxicity; concurrent use with digitalis glycosides may potentiate digitalis toxicity (closely monitor serum potassium levels); concurrent use of flucytosine may increase toxicity of flucytosine; antagonism between amphotericin B and imidazoles may inhibit ergosterol synthesis; acute pulmonary toxicity has been reported in patients receiving IV amphotericin B and leukocyte transfusions (do not give concurrently); concurrent administration with other nephrotoxic medications, such as aminoglycosides and pentamidine, may enhance the potential for drug-induced renal toxicity (intensive monitoring of renal function is recommended in patients requiring any combination of nephrotoxic medications); amphotericin Binduced hypokalemia may enhance the curariform effect of skeletal muscle relaxants (closely monitor serum potassium levels when given concomitantly with skeletal muscle relaxants such as tubocurarine); if zidovudine is administered concomitantly, closely monitor renal hematologic function

Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Dosing Interactions Contraindications Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Should be administered under close clinical observation of medically trained personnel at initial dosage; acute reactions, such as fever and chills, may occur 1-2 h after starting IV infusion, although these symptoms usually decrease with repeat dosage; anaphylaxis, hypotension, bronchospasm, arrhythmias, and shock rarely may be seen; closely monitor serum creatinine during therapy

Nasal decongestants
Nasal decongestants may help open the sinus ostia and aid with drainage in cases of orbital cellulitis secondary to sinusitis.

Phenylephrine (Neo-Synephrine)
Beneficial in the treatment of nasal congestion that may cause blockage of ostia of sinus, interfering with sinus drainage.

Dosing Interactions Contraindications Precautions

Adult
1-2 sprays per nostril q3-4h

Pediatric
Administer as in adults

Dosing Interactions Contraindications Precautions

Bretylium may potentiate action of vasopressors on adrenergic receptors, possibly resulting in arrhythmias; MAOIs may significantly enhance adrenergic effects of phenylephrine, and pressor response may be increased 2- to 3-fold; guanethidine may increase pressor response of direct-acting vasopressors, possibly resulting in severe hypertension

Dosing Interactions Contraindications Precautions

Documented hypersensitivity; severe hypertension or ventricular tachycardia, glaucoma, cardiac disease, hyperthyroidism

Dosing Interactions

Contraindications Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Caution in elderly patients, hyperthyroidism, myocardial disease, bradycardia, partial heart block or severe arteriosclerosis; in hypovolemia, use is not a substitute for replacement of blood, fluids and electrolytes, and plasma (restore these promptly when loss has occurred)

Oxymetazoline (Afrin, Sinarest, Allerest)

Applied directly to mucous membranes where stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Dosing Interactions Contraindications Precautions

Adult
2-3 sprays or 2-3 gtt of 0.05% solution in each nostril bid am and hs or q10-12h

Pediatric
<6 years: 2-3 gtt of 0.025% solution in each nostril bid am and hs >6 years: Administer as in adults

Dosing Interactions Contraindications Precautions

Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in an increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents, such as ephedrine, may be increased; guanethidine potentiates effects of

epinephrine and inhibits effects of ephedrine; phenothiazines may reverse action of nasal decongestants, such as oxymetazoline; TCAs potentiate vasopressor response and may result in dysrhythmias

Dosing Interactions Contraindications Precautions

Documented hypersensitivity; MAOIs

Dosing Interactions Contraindications Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions
Caution in hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, hypertensive patients may experience change in blood pressure; do not use topical decongestants for longer than 3-5 d

Diuretics
These agents reduce IOP.

Acetazolamide (Diamox)
Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery desired to lower IOP.

Dosing Interactions Contraindications Precautions

Adult
250-500 mg IV, repeat in 2-4h prn; not to exceed 1 g/d Short-term therapy: 250 mg PO/IV q4h or 250 mg PO/IV bid

Pediatric
5 mg/kg/d or 150 mg/m2 qd PO/IV/IM 5-10 mg/kg/dose IV/IM q6h 10-15 mg/kg/d PO divided q6-8h