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Which bacteria are suspected in a human or animal bite wound?

  • Staphylococcus aureus (correct)
  • Escherichia coli
  • Streptococcus pneumoniae
  • Bacteroides (correct)

    • What symptom is NOT typically associated with eyelid infections?

  • Tenderness
  • Mild fever
  • Eyelid warmth
  • Decreased visual acuity (correct)

    • Which condition is indicated by unilateral eyelid erythema and absence of proptosis?

  • Chalazion
  • Orbital cellulitis
  • Hordeolum (correct)
  • Allergic eyelid swelling

    • What indicates a potential chalazion rather than an internal hordeolum?

    <p>Non-tender lipid bump or cyst</p> Signup and view all the answers

    Which of the following is a differential diagnosis for orbital cellulitis?

    <p>Cavernous sinus thrombosis</p> Signup and view all the answers

    Which of the following symptoms is associated with allergic eyelid swelling?

    <p>Prominent itching</p> Signup and view all the answers

    In the case of a red-purplish coloration of the eyelid in children, what should be suspected?

    <p>Infection with Strep pneumoniae</p> Signup and view all the answers

    What is the primary approach in the work-up of an eyelid infection?

    <p>Ruling out orbital cellulitis</p> Signup and view all the answers

    Which condition would contraindicate the use of an MRI?

    <p>Metallic foreign bodies</p> Signup and view all the answers

    What is the recommended duration for intravenous antibiotics in the treatment of severe infection in orbital cellulitis?

    <p>2-3 weeks</p> Signup and view all the answers

    What is the maximum daily dose of Vancomycin for adults suspected of having MRSA with intracranial extension?

    <p>2 g IV every 12 hours</p> Signup and view all the answers

    What is an appropriate additional treatment consideration if anaerobic infection is suspected in a patient with chronic orbital cellulitis?

    <p>Add Metronidazole</p> Signup and view all the answers

    In the management of orbital cellulitis, when is it reasonable to switch from intravenous to oral antibiotics?

    <p>When the patient becomes afebrile and shows substantial improvement</p> Signup and view all the answers

    What is indicated for children who are afebrile and have mild conditions?

    <p>Amoxicillin/Clavulanate 20-40 mg/kg/day</p> Signup and view all the answers

    Which of the following antibiotics is NOT considered the treatment of choice for conditions requiring macrolides?

    <p>Ciprofloxacin</p> Signup and view all the answers

    Which test is ordered if systemic infection is suspected?

    <p>CBC and blood cultures</p> Signup and view all the answers

    What is the maximum daily dose of Augmentin for children?

    <p>1 g</p> Signup and view all the answers

    Which antibiotic should be used if a patient is allergic to both penicillin and sulfa drugs?

    <p>Erythromycin</p> Signup and view all the answers

    In the case of human or animal bites, which type of bacteria should be suspected?

    <p>Anaerobes</p> Signup and view all the answers

    Which medication is commonly prescribed for adults with mild infections?

    <p>Augmentin 250-500 mg q 8hr</p> Signup and view all the answers

    What is the method for palpating in assessment of periorbital area?

    <p>Lymph node palpation</p> Signup and view all the answers

    If a patient demonstrates an allergic reaction to penicillin, which alternative should be administered?

    <p>Trimethoprim/Sulfamethoxazole</p> Signup and view all the answers

    What is the characteristic issue when the eye cannot be opened following trauma?

    <p>Opacification</p> Signup and view all the answers

    Which antibiotic is recommended for treating bite wounds suspected to be caused by anaerobic organisms?

    <p>Clindamycin</p> Signup and view all the answers

    In which situation is hospitalization for IV antibiotics required for a patient?

    <p>Patient appears toxic</p> Signup and view all the answers

    What is the primary pathogen associated with orbital cellulitis when it originates from local trauma?

    <p>Staphylococcus aureus</p> Signup and view all the answers

    What is a common precipitating factor for bacterial orbital cellulitis?

    <p>Severe lid infectious disease</p> Signup and view all the answers

    Which of the following antibiotics should be used with caution in patients with a previous reaction to penicillin?

    <p>Ceftriaxone</p> Signup and view all the answers

    What role do warm compresses play in the treatment of bite wounds?

    <p>They reduce swelling and provide comfort.</p> Signup and view all the answers

    What is the recommended dosage of Ceftriaxone for a child receiving IV antibiotics?

    <p>100 mg/kg/day</p> Signup and view all the answers

    Which of the following is NOT a common route for infection in bacterial orbital cellulitis?

    <p>Bloodstream infection</p> Signup and view all the answers

    What is a likely microbe causing infection from a sinus infection related to bacterial orbital cellulitis?

    <p>Streptococcus pneumoniae</p> Signup and view all the answers

    What is a common symptom of mucormycosis in patients?

    <p>Severe exophthalmos</p> Signup and view all the answers

    Which diagnostic test is essential in the evaluation of suspected mucormycosis?

    <p>CT scan of orbits and sinuses</p> Signup and view all the answers

    Which hydration-related benefit is significant in the recovery from infections?

    <p>Enhanced immune system support</p> Signup and view all the answers

    What symptom is specifically associated with necrotizing orbital infections like mucormycosis?

    <p>Marked diplopia</p> Signup and view all the answers

    What finding on a CT scan would suggest orbital cellulitis?

    <p>Orbital opacification</p> Signup and view all the answers

    Which clinical history detail is most relevant when suspecting mucormycosis?

    <p>History of diabetes or immunosuppression</p> Signup and view all the answers

    What is a distinguishing feature between preseptal cellulitis and orbital cellulitis?

    <p>Fever and malaise</p> Signup and view all the answers

    What ocular nerve involvement might indicate a more serious orbital condition?

    <p>CN III, IV, VI</p> Signup and view all the answers

    Which symptom is least likely to be associated with severe mucormycosis?

    <p>Painless eye redness</p> Signup and view all the answers

    Which condition might present with a positive Kerning test?

    <p>Meningitis</p> Signup and view all the answers

    Why is a complete ophthalmic evaluation critical in these cases?

    <p>To evaluate potential vision loss and ocular involvement</p> Signup and view all the answers

    Study Notes

    Preseptal Cellulitis

    • This is an infection of the eyelid and soft tissues in front of the orbital septum.
    • Common causes include:
      • Human or animal bites
      • Skin trauma (lacerations, insect bites)
      • Spread from nearby infections (acute hordeolum, dacryocystitis, sinusitis)
      • Hematogenous spread from a remote upper respiratory tract or middle ear infection.
    • Key Symptoms:
      • Unilateral eyelid erythema, edema, warmth, and tenderness.
      • No proptosis or restriction of eye movements.
      • May not be able to open the eye.
      • No vision loss, including color vision.
      • Red-purplish coloration in children signals the condition.
      • CT scan shows opacification anterior to the orbital septum.
    • Common organisms involved:
      • Staphylococcus aureus
      • Streptococcus pyogenes
      • Strep. pneumoniae
      • Haemophilus influenzae
    • Differential diagnoses:
      • Orbital cellulitis: proptosis, pain with eye movement, decreased visual acuity, fever, chemosis.
      • Chalazion: focal inflammation, palpable mass, pointing meibomian gland.
      • Allergic eyelid swelling: sudden onset, bright red, prominent itching, no tenderness or pain, history of allergies, new eye or skin medication use.
      • Viral conjunctivitis: all signs of conjunctivitis.
      • Cavernous sinus thrombosis: proptosis, paresis of cranial nerves III, IV, VI, typically bilateral, decreased sensation of the first and second division of cranial nerve V.
    • Treatment:
      • Mild Cases (older than 5 years, afebrile):
        • Children: Amoxicillin/Clavulanate (Augmentin) 20-40 mg/kg/day in 3 doses or Cefaclor (Ceclor) the same dose (max 1 g/day) for 10 days.
        • Adults: Augmentin 250-500 mg q 8hr for 7-10 days.
      • Other antibiotics:
        • Penicillins: Flucloxacillin, Dicloxacillin, Cloxacillin 250-500 mg BID-QID.
        • Cephalosporins: Cephalexin (Keflex), Cefadroxil, Cephradine 250-500 mg BID-QID.
        • Macrolides: Azithromycin (Zpack), Clarithromycin 500 mg BID.
        • Fluoroquinolones: Ciprofloxacin, Levofloxacin 500 mg BID-QID.
        • Sulfamethoxazole-trimethoprim (SMX-TMP): BID.
      • If allergic to penicillin:
        • Bactrim (Trimethoprim/Sulfamethoxazole): Peds: 8 mg/kg/day Trimethoprim and 40 mg/kg/day sulfamethoxazole PO in 2 divided doses. Adults: 160 mg Trimethoprim and 800 mg Sulfamethoxazole PO BID for 10 days.
        • Erythromycin: Children 30-50 mg/kg/day in 3-4 doses. Adults: 250-500 mg q 6 hr for 10 days.
      • If allergic to penicillin and sulfa drugs:
        • Ceftin, Cefopodoxime, Cefzil, Omincef: Possible to use with caution as they lack the same side chain as penicillin but avoid if possible.
      • Bite wounds (anaerobic mouth): Suspect streptococcus or pyogenes. Use Penicillin G IV, Ampicillin/Sulbactam, Cefoxitin, Metronidazole, and Clindamycin (TID) to cover anaerobes.
    • Pallowing management: Warm compresses, hydration, rest.
    • Hospitalization is required if:
      • Under 5 years old.
      • H. influenzae infection.
      • No response to oral treatment.
      • Non-compliance.
      • The patient appears toxic.
      • IV antibiotics are necessary.
    • IV antibiotics:
      • Ceftriaxone: Child: 100 mg/kg/day IV in 2 doses. Adult: 1-2 g IV q 12 hr.
      • Vancomycin (if MRSA is suspected): Child: 40 mg/kg/day IV 3-4 doses. Adults: 0.5 to 1 g IV q 12 hr.
      • Duration: 2 weeks initially, then transition to oral antibiotics once improvement is observed.

    Orbital Cellulitis

    • Group II
    • Definition: A life-threatening infection of the soft tissue behind the orbital septum.
    • Typical Precipitating factors:
      • Penetrating eyelid trauma.
      • Orbital medial wall blow-out fracture.
      • Severe eyelid infectious disease (dacryoadenitis, orbital tumors, severe internal hordeolum).
      • Bites from insects, humans, or animals.
      • Meningitis.
      • Sinus and dental infections.
      • Most common routes of infection: adjacent sinuses or teeth and direct inoculation through penetrating eyelid injury.
    • Common Organisms:
      • Staphylococcus aureus and Streptococcus pyogenes predominate in infections arising from local trauma.
      • Streptococcus pneumoniae is the most common pathogen associated with sinus infections.
      • Haemophilus influenzae type B (HIB), once common, is now less common due to wide vaccination (ask about vaccination history).
      • Mucormycosis (fungus) is uncommon and causes orbital cellulitis in diabetic or immunosuppressed patients.
    • Signs and Symptoms:
      • Prominent eyelid edema, redness, and distention.
      • Proptosis.
      • Significant pain upon palpation.
      • Diplopia from limited eye movements and pain.
      • Vision loss and APD may be present.
      • CT scan shows preseptal and orbital opacification.
    • Symptoms: pain, reduced vision, redness, diplopia, fever, and malaise.
      • Fever and malaise are not present in preseptal cellulitis as the inflammation involves the sinuses.
    • Work-up:
      • History: Trauma, ENT or systemic infection, stiff neck (meningitis - Kerning and Brudzinski test), mental status, diabetes, immunosuppressive illness (suspect Mucormycosis), lid lesions.
      • Complete ophthalmic evaluation: VA, diplopia work-up (CN 3, 4, 6), pupillary examination, ONH (papilledema), skin sensation around the orbit (test CN V).
      • Vital Signs, mental status, neck flexibility.
      • CT of orbits and sinuses (axial and coronal), without contrast, to rule out foreign bodies, orbital or periosteal abscess, and sinus disease. MRI is contraindicated in metallic foreign bodies.
      • CBC with differential, blood cultures, gram stain, and culture if a wound is present.
      • Lumbar puncture if meningitis is suspected.
    • Management:
      • True emergency, requires hospitalization.
      • Refer to the emergency room for immediate hospitalization and intravenous antibiotics.
      • Intravenous antibiotics for gram-positive, gram-negative, and anaerobic organisms for 2-3 weeks or until improvement.
        • Unasyn (Ampicillin-sulbactam) 1.5-3 g IV q6h.
      • For MRSA coverage (if suspected):
        • Vancomycin (glycopeptide):
          • Child: 40 to 60 mg/kg per day IV divided into 3 or 4 doses, maximum daily dose 4 g.
          • Adult: 2 g IV per day (2 g IV q 12 hours if an intracranial extension is suspected).
          • Monitor vancomycin levels after the 4th dose to prevent toxicity. (Vancomycin trough)
        • Plus one of the following: Ceftriaxone, Cefotaxime, Ampicillin-sulbactam, Piperacillin-tazobactam.
    • Additional management strategies:
      • If an anaerobic infection is suspected or the patient has chronic orbital cellulitis, consider adding Metronidazole 15 mg/kg IV load, then 7.5 mg/kg IV q 6 hr.
      • If allergic to penicillin/cephalosporins:
        • Use vancomycin in combination with:
          • Ciprofloxacin
          • Levofloxacin
      • For uncomplicated orbital cellulitis with good response to IV antibiotics, it is reasonable to switch to oral therapy.
      • If afebrile and eyelid and orbital findings have begun to resolve, switching to oral antibiotics is warranted.

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