Suspected orbital or periorbital infection
Adult or child with eyelid swelling, redness or pain around the eye. Often follows sinusitis, a skin wound or insect bite, or dental infection.
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OphthalmologyEmergency
Orbital Cellulitis Management
Orbital Cellulitis Management: Suspected orbital or periorbital infection → Emergency signs: act now, do not wait for imaging → Signs of orbital (postse...
Pathway Overview
22 steps
Algorithm Steps
22 total
01Start 02Warning Emergency signs: act now, do not wait for imaging
Check before anything else. Sepsis, vision loss or mucormycosis needs action in minutes to hours.
- Septic or unwell (child or adult): treat as sepsis now; start IV antibiotics without delay
- Falling vision, RAPD, tense orbit or IOP >40 mmHg: orbital compartment syndrome; lateral canthotomy and cantholysis now (aim within 2 h)
- Diabetes (esp. DKA) or immunosuppressed, with black eschar on nose, palate or skin: suspect mucormycosis; urgent ENT debridement, IV liposomal amphotericin B, ID
03Decision Signs of orbital (postseptal) involvement?
Yes if any: proptosis; painful or restricted eye movement; diplopia; reduced visual acuity or colour vision; RAPD; severe or persistent headache or other intracranial signs.
- If Yes
- Orbital signs
04Action Orbital cellulitis: emergency admission
Orbital signs present. Admit. Urgent ophthalmology and ENT review. Keep fasted until the need for surgery is clear.
- Bloods: FBC, CRP, blood cultures (swab any pus or nasal discharge)
- Eye and neuro observations at least 4-hourly: acuity, colour vision, pupils, eye movements, proptosis, conscious state
- Do not do a lumbar puncture: risk from raised intracranial pressure if infection has spread
- Child: involve the paediatric team; consider transfer to a paediatric centre
05Action Orbital: start IV antibiotics now
Give before imaging. Severe penicillin allergy: no flucloxacillin or amoxicillin-clavulanate; see the allergy lines and ask ID. Neonate (28 days or less): use cefotaxime, not ceftriaxone.
- Adult: ceftriaxone 2 g IV daily PLUS flucloxacillin 2 g IV 6-hourly. Intracranial spread: ceftriaxone 2 g IV 12-hourly
- Child: cefotaxime 50 mg/kg (max 2 g) IV 6-hourly OR ceftriaxone 100 mg/kg (max 4 g) IV daily (also the dose for intracranial spread)
- MRSA risk (known carriage, prior MRSA, high local rates): add vancomycin; dose by weight, renal function and levels (pharmacy)
- Dental source, intracranial spread or gas in an abscess: add metronidazole (adult 500 mg IV 12-hourly; child: dose per pharmacy); ask ID
- Severe penicillin allergy, adult: clindamycin 600 mg IV 8-hourly PLUS ciprofloxacin 400 mg IV 12-hourly; ask ID or microbiology
- Severe penicillin allergy, child: ask ID before giving a cephalosporin
- Sinusitis: nasal decongestant and nasal steroid, as advised by ENT
06Action Orbital: urgent contrast-enhanced CT orbits, sinuses and brain
For all patients with orbital signs. Do not delay antibiotics for the scan.
- Look for subperiosteal or orbital abscess, sinus disease and intracranial spread
- Suspected cavernous sinus thrombosis or intracranial spread: add MRI (or CT venography); involve neurosurgery
- Contrast allergy or severe renal impairment: discuss the best study with radiology
07Action Orbital: stage with CT (Chandler)
Stage guides the need for drainage.
- I: preseptal cellulitis
- II: orbital cellulitis, no abscess
- III: subperiosteal abscess
- IV: orbital abscess
- V: cavernous sinus thrombosis
08Warning Orbital: watch for spread at every review
These complications threaten sight and life. Escalate at once.
- Cavernous sinus thrombosis: signs in both eyes, new cranial nerve palsies, drowsiness: urgent MRI or CT venography, neurosurgery, ID
- Meningitis, subdural empyema or brain abscess: severe headache, seizures, focal signs: neurosurgery; no lumbar puncture before imaging
- Optic neuropathy: falling acuity or colour vision, new RAPD: emergency drainage
09Decision Orbital: urgent drainage needed now?
Yes if any: orbital abscess; reduced vision or RAPD; intracranial spread; gas in an abscess; subperiosteal abscess not suitable for an antibiotic trial (see drainage step).
- If Yes
- Drainage needed
10Action Orbital: urgent ENT and ophthalmology drainage
For an abscess that needs drainage, vision threat, intracranial spread, or no improvement after 24-48 h of IV antibiotics.
- Orbital abscess: drain
- Subperiosteal abscess: drain if age 9 years or older, large or not medial, frontal sinus or dental source, vision loss or RAPD, or it recurs
- Drain the involved sinuses as needed; send pus for culture
- Intracranial spread: neurosurgery and ID now; adult ceftriaxone 2 g IV 12-hourly plus metronidazole; child doses as in the antibiotic step
11Outcome Orbital: drainage done
Continue IV antibiotics after surgery and change them to match culture results. When improving, switch to oral amoxicillin-clavulanate (doses in the 'Orbital, improving' step).
If No- Antibiotic trial
12Decision Orbital, no surgery yet: improving after 24-48 h of IV antibiotics?
Assess vision, colour vision, pupils, eye movements, proptosis, lid swelling and fever. Worse at any time: repeat CT and urgent surgical review.
- If Yes
- Improving
13Action Orbital, improving: continue IV, then switch to oral
Switch when clearly improving and afebrile. Children usually need at least 3-4 days of IV antibiotics first. Severe penicillin allergy: no amoxicillin-clavulanate; oral choice (for example clindamycin) as advised by ID.
- Adult: amoxicillin-clavulanate 875/125 mg oral 12-hourly
- Child: amoxicillin-clavulanate 22.5 mg/kg (amoxicillin part; max 875 mg) oral 12-hourly
- Total course usually 10-14 days; longer after an abscess or bone involvement (specialist advice)
- ENT follow-up for the underlying sinus disease
14Outcome Orbital: infection resolving
Complete the oral course. Arrange ENT and eye follow-up. Return at once if vision, eye movement or headache gets worse.
If No- Not improving or worse
15Action Orbital, not improving or worse: repeat CT, surgical review
No improvement after 24-48 h of IV antibiotics, or any worsening. Repeat contrast-enhanced CT. Urgent ENT and ophthalmology review for drainage.
- Path rejoins step 10Shared downstream outcome
If No- No orbital signs
16Warning No orbital signs: periorbital (preseptal) cellulitis; check these first
Infection of the eyelid and skin in front of the orbital septum. Re-check for orbital signs at every review.
- Both eyes, painless or non-tender swelling, patient well: consider an allergic reaction
- Neonate: consider gonococcal or chlamydial infection; send PCR swabs; neonatal team. Do not give ceftriaxone to a neonate with jaundice or on IV calcium
- Severe penicillin allergy: avoid flucloxacillin and amoxicillin-clavulanate; use clindamycin
17Decision Periorbital: needs IV antibiotics?
Yes if any: systemically unwell or febrile; significant swelling or the eye cannot be examined; age under 3 months; Hib immunisation not complete; immunocompromised; no better after 36-48 h of oral antibiotics; follow-up not assured.
- If Yes
- IV needed
18Action Periorbital, moderate or severe: admit for IV antibiotics
Severe (eye cannot be examined, significant swelling, age under 3 months, Hib not complete): manage as orbital cellulitis, with contrast CT, ENT and ophthalmology review and orbital doses (child: cefotaxime 50 mg/kg (max 2 g) IV 6-hourly OR ceftriaxone 100 mg/kg (max 4 g) IV daily).
- Adult: ceftriaxone 2 g IV daily PLUS flucloxacillin 2 g IV 6-hourly
- Child, moderate: cefazolin 50 mg/kg (max 2 g) IV 8-hourly OR ceftriaxone 50 mg/kg (max 2 g) IV daily (hospital in the home)
- Child, moderate, suspected MRSA: clindamycin 15 mg/kg (max 600 mg) IV 8-hourly
- Adult, severe penicillin allergy: clindamycin 600 mg IV 8-hourly
- Blood cultures if febrile and unwell
- Improving: switch to oral as for mild; total 7-10 days
19Decision Periorbital: improving at 24-48 h review?
Check for new orbital signs, fever and spread of swelling.
- If Yes
- Improving
20Outcome Periorbital, improving: complete the course
Finish 7-10 days in total (IV then oral, or oral only). Return at once if eye pain, swelling, double vision or reduced vision develops.
If No- Not improving
21Action Periorbital, not improving or worse: escalate
Re-examine for orbital signs.
- Orbital signs now present: manage as orbital cellulitis (orbital steps above)
- On oral antibiotics: admit for IV antibiotics as for moderate
- On IV antibiotics: manage as severe; contrast CT; ENT and ophthalmology
- Path rejoins step 04Shared downstream outcome
If No- Mild
22Action Periorbital, mild: oral antibiotics and review in 24-48 h
Well, minimal swelling, eye opens and can be examined, follow-up assured.
- Adult: amoxicillin-clavulanate 875/125 mg oral 12-hourly
- Adult, severe penicillin allergy: clindamycin 450 mg oral 8-hourly
- Child: cefalexin 20 mg/kg (max 750 mg) oral 8-hourly
- Child, suspected MRSA: clindamycin 15 mg/kg (max 600 mg) oral 8-hourly
- Usually 7-10 days in total
- Path rejoins step 19Shared downstream outcome
Guideline Source
RCH Melbourne Clinical Practice Guideline: Periorbital and orbital cellulitis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult antibiotics follow Australian practice (ceftriaxone plus flucloxacillin, Therapeutic Guidelines: Antibiotic); check the current eTG and local MRSA rates.
- Immunocompromised patients may have fungal infection (mucormycosis); discuss all with ID and ENT.
- Children's doses are from RCH Melbourne (2021); neonates need neonatal team advice.
- Orbital apex syndrome and infection after orbital trauma or surgery are not covered in detail.
Contraindicated Populations
Neonates (28 days or less): neonatal team managementSuspected invasive fungal sinus-orbital infection (mucormycosis): ENT and ID management
Applicable Regions
AUUSEUGlobal
AU: Children: RCH Melbourne CPG Periorbital and orbital cellulitis (Dec 2021). Adults: Therapeutic Guidelines: Antibiotic (orbital cellulitis section revised March 2025). Use state retrieval services for transfer.
US: Flucloxacillin is not available. Use a local anti-staphylococcal agent (for example cefazolin, nafcillin or oxacillin) per local guideline.
Global: Adjust antibiotics to local resistance (MRSA) and local guidelines. ENT UK (2017) uses IV piperacillin-tazobactam for adults and IV co-amoxiclav for children.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Orbital Cellulitis Management?
The Orbital Cellulitis Management is a emergency clinical algorithm for Ophthalmology. It provides a structured decision tree to guide clinical decision-making, based on RCH Melbourne Clinical Practice Guideline: Periorbital and orbital cellulitis.
What guideline is the Orbital Cellulitis Management based on?
This algorithm is based on RCH Melbourne Clinical Practice Guideline: Periorbital and orbital cellulitis (DOI: N/A).
What are the limitations of the Orbital Cellulitis Management?
Known limitations include: Adult antibiotics follow Australian practice (ceftriaxone plus flucloxacillin, Therapeutic Guidelines: Antibiotic); check the current eTG and local MRSA rates.; Immunocompromised patients may have fungal infection (mucormycosis); discuss all with ID and ENT.; Children's doses are from RCH Melbourne (2021); neonates need neonatal team advice.; Orbital apex syndrome and infection after orbital trauma or surgery are not covered in detail.. Individual patient factors may require deviation from these recommendations.
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