Sinogenic orbital and subperiosteal abscesses: Microbiology and methicillin-resistant Staphylococcus aureus incidence

Ocular Manifestations of Pediatric Rhinosinusitis: A Comprehensive Review

Background: Rhinosinusitis is a common childhood illness that may result in a number of ocular problems. The goal of this thorough analysis is to compile the available data regarding the kinds, prevalence, and treatment of ocular problems related to juvenile rhinosinusitis. Methods: A comprehensive analysis of electronic databases, such as PubMed, Embase, and Cochrane Library, was carried out to pinpoint pertinent research articles written in English and published between the beginning and August of 2023. Included were studies that discuss ocular problems in young children suffering from rhinosinusitis. Study characteristics, ocular complication kinds, occurrence rates, and management approaches were the main topics of data extraction. Results: A significant number of pertinent research on ocular problems related to juvenile rhinosinusitis was found through the literature search. Preliminary searches indicated that orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, and optic neuritis are probably the most often reported ocular problems. It is expected that these problems will occur at a wide range of incidence rates, from somewhat unusual to more prevalent. Depending on the severity of the consequences, management techniques are expected to require a combination of surgical and medicinal procedures. Healthcare professionals will benefit from the findings since they will improve knowledge of the clinical presentation, diagnosis, and treatment of these potentially blinding consequences. The evaluation also assists in identifying knowledge gaps and guides future directions for this field of study, both of which are critical to enhancing patient outcomes. Conclusions: The wide range of topics included in this study will help to better understand the burden of ocular consequences related to juvenile rhinosinusitis and will make it easier to build preventative and treatment plans that work better.

Microbiology and Antibiotic Resistance Profiles of Orbital Subperiosteal Abscesses: A Comparison of Pediatric, Adolescent, and Adult Populations

PURPOSE

The purpose of this study was to compare the microbiology and antibiotic resistance profiles of orbital subperiosteal abscesses (SPA) among 3 age cohorts.

METHODS

A retrospective study was conducted at a tertiary care center through a medical record search to identify patients with orbital cellulitis and SPA on imaging from January 1, 2000 to September 10, 2022. Patients were categorized into pediatric (<9 years old), adolescent (9-18 years old), and adult (>18 years old) cohorts. Primary outcomes included culture and antibiotic susceptibility results. Secondary outcomes included antibiotic therapy and surgical intervention.

RESULTS

Of the 153 SPA patients included, 62 (40.5%) were in the pediatric cohort (4 months-8 years, mean 5.0 ± 2.7), 51 (33.3%) were adolescent (9-18 years, 12.7 ± 2.8), and 40 (26.1%) were adult (19-95, 51.8 ± 19.3). Viridians group Streptococci were the most frequent organisms isolated across groups. The anaerobic infection rate was higher in the adult compared to the pediatric group (23.0% vs, 4.0%, p = 0.017), while that of the adolescent did not differ significantly from either. Pediatric patients carried a lower rate of clindamycin resistance than adolescent and adult cohorts, who shared similar rates (0 vs. 27.0% and 28.0%, respectively; p = 0.016). There were progressive increases in duration of intravenous antibiotic therapy ( p < 0.195) and rate of surgical intervention ( p < 0.001) going from younger to older cohorts.

CONCLUSION

Organisms isolated from orbital SPA from the past 2 decades demonstrate a predominance of Streptococcal species. Older age may be associated with anaerobic infection, clindamycin resistance, and more aggressive management. Adolescent infections are more similar to adult rather than pediatric counterparts but may require less aggressive management than the former.

Bacterial orbital cellulitis - A review

Infections of orbit and periorbita are frequent, leading to significant morbidity. Orbital cellulitis is more common in children and young adults. At any age, infection from the neighboring ethmoid sinuses is a likely cause and is thought to result from anatomical characteristics like thin medial wall, lack of lymphatics, orbital foramina, and septic thrombophlebitis of the valveless veins between the two. Other causes are trauma, orbital foreign bodies, preexisting dental infections, dental procedures, maxillofacial surgeries, Open Reduction and Internal Fixation (ORIF), and retinal buckling procedures. The septum is a natural barrier to the passage of microorganisms. Orbital infections are caused by Gram-positive, Gram-negative organisms and anaerobes in adults and in children, usually by Staphylococcus aureus or Streptococcus species. Individuals older than 15 years of age are more likely to harbor polymicrobial infections. Signs include diffuse lid edema with or without erythema, chemosis, proptosis, and ophthalmoplegia. It is an ocular emergency requiring admission, intravenous antibiotics, and sometimes surgical intervention. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities to identify the extent, route of spread from adjacent structures, and poor response to intravenous antibiotics and to confirm the presence of complications. If orbital cellulitis is secondary to sinus infection, drainage of pus and establishment of ventilation to the sinus are imperative. Loss of vision can occur due to orbital abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, and exposure keratopathy, and possible systemic sequelae include meningitis, intracranial abscess, osteomyelitis, and death. The article was written by authors after a thorough literature search in the PubMed-indexed journals.

High risk and low prevalence diseases: Orbital cellulitis

INTRODUCTION

Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted.

CONCLUSION

An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.

Odontogenic Sinusitis is a Common Cause of Operative Extra-Sinus Infectious Complications

BACKGROUND

Orbital, intracranial, and osseous extra-sinus complications can arise from bacterial or fungal sinusitis. Odontogenic sinusitis (ODS) can cause extra-sinus complications, but its prevalence remains poorly characterized.

OBJECTIVE

To determine the frequency of ODS as a cause of operative extra-sinus infectious complications and describe clinical features of all complicated sinusitis cases.

METHODS

A multi-institutional retrospective review was performed on all operative sinusitis-related extra-sinus complications from 2011 to 2020. ODS was diagnosed by sinus computed tomography (CT) and dental evaluations when available. Demographics, complication types, sinusitis etiologies, and various clinical features were analyzed.

RESULTS

Forty-five patients were included (mean age 55.5 years, 56% male). Of the extra-sinus complications, 40% were orbital only, 22% intracranial only, 13% osseous only, and 25% involved combined complications. The 2 most common causes of extra-sinus complications were ODS (40%) and mucopyocele (27%). When invasive fungal etiologies were excluded, and only unilateral maxillary opacification on CT was considered, nearly 60% of extra-sinus complications were due to ODS. Unilateral maxillary sinus opacification on CT was present in 100% of complicated ODS compared to 44% of nonodontogenic cases, and oral anaerobes were only identified in ODS cases. No complicated ODS patients underwent dental interventions during hospitalization.

CONCLUSION

ODS was the most common cause of operative extra-sinus infectious complications. Clinicians should consider ODS high on the differential diagnosis of all patients presenting with complicated sinusitis, especially when sinusitis is unilateral and invasive fungal infection is not suspected.

Extrasinus Complications From Odontogenic Sinusitis: A Systematic Review

OBJECTIVE

Odontogenic sinusitis (ODS) can cause infectious orbital, intracranial, and osseous complications. Diagnosis and management of complicated ODS have not been discussed in recent sinusitis guidelines. The purpose of this systematic review was to describe epidemiological and clinical features, as well as management strategies of complicated ODS.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library.

REVIEW METHODS

A systematic review was performed to describe various features of complicated ODS. All complicated ODS studies were included in qualitative analysis, but studies were only included in quantitative analysis if they reported specific patient-level data.

RESULTS

Of 1126 studies identified, 75 studies with 110 complicated ODS cases were included in qualitative analysis, and 47 studies with 62 orbital and intracranial complications were included in quantitative analyses. About 70% of complicated ODS cases were orbital complications. Only 23% of complicated ODS studies were published in otolaryngology journals. Regarding ODS-related orbital and intracranial complications, about 80% occurred in adults, and 75% were male. Complicated ODS occurred most commonly from apical periodontitis of maxillary molars. There were no relationships between sinusitis extent and orbital or intracranial complications. High rates of anaerobic and α-hemolytic streptococcal bacteria were identified in complicated ODS. Management generally included systemic antibiotics covering aerobic and anaerobic bacteria, and surgical interventions were generally performed to address both the complications (orbital and/or intracranial) and possible infectious sources (dentition and sinuses).

CONCLUSION

ODS should be considered in all patients with infectious extrasinus complications. Multidisciplinary management between otolaryngologists, dental specialists, ophthalmologists, and neurosurgeons should be considered to optimize outcomes.

Microbiology of orbital cellulitis with subperiosteal abscess in children: Prevalence and characteristics of Streptococcus anginosus group infection

Purpose: To evaluate the predominant pathogens and clinical course in pediatric patients with orbital cellulitis (OC) complicated by subperiosteal abscess (SPA).Methods: This is a single-center retrospective chart review evaluating pediatric patients with OC complicated by SPA treated at a tertiary care center in the Pacific Northwest. Data were analyzed for characteristics, rates of infection, and antibiotic resistance of the predominant pathogens in pediatric patients.Results: Twenty-seven children were identified with OC complicated by SPA and bacterial cultures drawn. The average age (SD) of the patients was 9.2 years (4.8), median 9.6; 15 range 5 months to 17.2 years. Seventeen (63.0%) were male. Sinusitis was present in all patients. Streptococcus species were the most common pathogen accounting for 52% (17/33) of isolates. Streptococcus anginosus group (SAG) was the predominant species and were isolated in 10 out of 27 (37%) children in the study. Twenty-one (78%) patients required surgery for the treatment of SPA. Among surgically treated patients, females tended to be younger than males (p = .068). Pediatric patients with SAG infections required more surgery than children without this isolate, 100% and 65%, respectively (p = .030). Female patients tended to have SAG infections more often than males (p = .063).Conclusions: Orbital infections caused by SAG require surgical management more often than those caused by other pathogens. Our results suggest a difference in pathogenic organisms in male and female patients with SPA. SAG is one of the most common pathogens isolated in orbital cellulitis complicated by SPA in children.

The management of periorbital cellulitis secondary to sinonasal infection: a multicenter prospective study in the United Kingdom

BACKGROUND

Periorbital cellulitis is a potential sight-threatening complication of sinusitis. The majority of patients improve with medical management. Previous studies have suggested significant variations in practice and lack of evidence regarding the optimal management of this condition.

METHODS

A prospective study was conducted over a 12-month period at 8 centers in the United Kingdom assessing the management of patients requiring inpatient treatment for periorbital cellulitis secondary to sinonasal infections.

RESULTS

A total of 143 patients were recruited, of whom 40 were excluded. Of the remaining 103 patients, 5 (4.9%) were diagnosed with neurosurgical complications. This resulted in 98 patients admitted with periorbital cellulitis secondary to an upper respiratory tract infection/sinusitis. A total of 72 were children, of whom 12 (16.7%) required surgical intervention; and of 26 adults, 5 (19.2%) required surgery: the most common antimicrobial regimes administered were intravenous ceftriaxone (with or without metronidazole), and co-amoxiclav. The use of both ceftriaxone and metronidazole from admission was associated with the shortest duration of inpatient stay (3.8 days) in comparison to ceftriaxone alone (5.8 days) or co-amoxiclav (4.5 days) and a reduction in number of patients requiring surgical intervention. There was also an association between the early use of intranasal decongestants and steroids and reduction in requirement for surgical intervention.

CONCLUSION

For a condition where swab and blood cultures are often negative, this study supports the use of ceftriaxone in combination with metronidazole. The administration of intranasal decongestants and corticosteroids correlated with a smaller percentage of those progressing to surgery in those with and without periorbital abscesses.

Calculated parenteral initial treatment of bacterial infections: Infections in the ear, nose, throat and mouth and jaw area

This is the sixth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the antibacterial treatment of more severe infections of the ear, the nose, the throat and the maxillofacial region, including odontogenic and salivary gland infections.

Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis

OBJECTIVE

The objective of this study was to investigate the microbiological cultures and the management of acute ethmoiditis complicated by subperiosteal orbital abscess (SPOA) in a pediatric population.

METHODS

The medical records of children under 18 years old was performed in a tertiary referral pediatric center from January 2009 to April 2017. Clinical examination, computed tomography scans, medical and surgical treatments were reviewed and compared to other studies in literature.

RESULTS

One hundred and twenty-nine children were hospitalized for acute ethmoiditis. Among them, forty eight were complicated by SPOA. The mean age of these children were 7 years (range 10 months-16 years). Thirtyfour underwent surgical drainage; for the others the medical treatment was sufficient. Microbiological samples were obtained during the surgical intervention and were contributive in 91% of cases. Streptococcus spp was the most frequently encountered bacteria (60% of cases). We also found anaerobic bacteria (12%), and Staphylococcus aureus (12%). 94% of children received two intravenous antibiotics (a third-generation cephalosporin and metronidazole) for a mean duration of four days. Then the oral treatment was based on amoxicillin-clavulanate during about 8.5 days. All children were cured without sequelae.

CONCLUSIONS

For five years Streptococcus milleri, Staphylococcus spp and anaerobic bacteria are on the rise in acute ethmoiditis complicated by SPOA. That is why antibiotics must be adapted to these bacteria even in children under ten years old.

Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

BACKGROUND

The presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.

METHODS

Patients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj.

RESULTS

Two hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides.

CONCLUSION

Our study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.

Microbiology and choice of antimicrobial therapy for acute sinusitis complicated by subperiosteal abscess in children

OBJECTIVES

Review past studies of the microbiology of subperiosteal abscesses (SPOA) complicating sinusitis in children and their implications of the antimicrobials administered to treat the infection.

METHODS

Literature search was conducted of the Cochrane Library, EMBASE, TRIP, EMBASE, and MEDLINE databases from their inception.

RESULTS

The most common pathogens isolated from studies of SPOA complicating sinusitis are aerobic (Streptococcus pneumoniae, Streptococcus spp., Haemophilus spp., Eikenella corrodens), anaerobic (Peptostreptococcus, Fusobacterium, Prevotella, Porphyromonas, Bacteroides, and Veillonella spp.), and micoaerophilic streptococci (Streptococcus anginosus/Streptococcus milleri group), all members of the oropharyngeal flora. S. pneumoniae and S. aureus were more frequently recovered in children >7 years old, while polymicrobial aerobic-anaerobic flora were more often isolated from those >15 years. The introduction of pneumococcal vaccine reduced the rate of isolation of S. pneumoniae, and correlated with increase of recovery of S. aureus including methicillin resistant strains, as well as Streptococcus pyogenes and S. anginosus/milleri group.

CONCLUSIONS

The microbiology and consequently the treatment of respiratory infections including sinusitis and its complications has evolved over the past decades. Establishing the microbiology of SPOA by obtaining appropriate cultures for both aerobic and anaerobic bacteria are essential for proper antimicrobial selection.

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis

PURPOSE

Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.

METHODS

All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.

RESULTS

Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.

CONCLUSIONS

Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Subperiosteal abscess of the orbit: evolving pathogens and the therapeutic protocol

PURPOSE

Because of widespread antibiotic use, immunization against selective species, and the emergence of hypervirulent organisms, we sought to determine changes over time in the bacteriology of sinusitis-related subperiosteal abscess (SPA) of the orbit and their impact on patient outcomes under a uniform management protocol.

DESIGN

Comparative case series.

SUBJECTS

Patients≤18 years of age with sinusitis-related SPA treated from 2002 to 2012; comparable cohorts from earlier time frames.

METHODS

We analyzed culture results and outcomes in surgical cases, compared overall and age-specific results with those in a 1977 through 1992 patient series, and compared the proportion of patients<9 years old requiring surgery among 1988 through 1998, 1999 through 2008, and current cohorts.

MAIN OUTCOME MEASURES

Patients requiring surgery; prevalence of pathogens; criteria prompting surgery; visual and systemic outcomes.

RESULTS

Ninety-four patients met inclusion criteria: 53 (56%) recovered with medical therapy alone and 41 (44%) underwent surgical drainage. Compared with the 1977 through 1992 cohort, there was increased representation of Streptococcus anginosus group, S aureus, and group A β-streptococci. Methicillin-resistant S aureus (MRSA) accounted for 4 of 7 S aureus isolates. Of 94 patients, 74 (79%) were <9 years of age: 53 (72%) recovered without surgery and 21 (28%) underwent drainage. Comparable figures were 67.5% versus 32.5% and 85% versus 15% in 1988 through 1998 and 1999 through 2008 cohorts, respectively. Whereas patients≥9 years old in the 1977 through 1992 cohort had a higher proportion of positive cultures and more varied pathogens than younger patients, in the current series both groups had similar culture yields and aerobic constituencies. Anaerobes were isolated from only patients≥9 years old in both series. In cases positive for MRSA and other aggressive aerobes, initial findings prompted early drainage; outcomes were not compromised by adherence to the treatment protocol.

CONCLUSIONS

The proportion of children<9 years requiring surgery for sinusitis-related SPA has remained a minority (15%-32.5%), without a clear upward trend over 25 years. Anaerobes continue not to factor in the younger subgroup, but more aggressive aerobic pathogens, including MRSA, have emerged. In such cases, surgical criteria that supersede age are triggered under the current treatment algorithm, and modification is not recommended.

Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease

BACKGROUND

Patient characteristics, risk factors, and microbiology are important to consider in the management of complications of acute bacterial sinusitis (ABS) in pediatric patients. This study evaluates this subset of patients and compares them to patients that undergo surgery for chronic rhinosinusitis (CRS).

METHODS

This study is a retrospective review of all pediatric patients from 2002 to 2011, who underwent sinus surgery at a tertiary hospital. Patients who underwent surgery for ABS complication were compared to patients who underwent surgery for CRS. Statistical analysis was completed using chi-square test or Fisher's exact test with a statistical significance set at p<0.05.

RESULTS

Twenty-seven patients with a complication of ABS and 77 patients with CRS were analyzed. The groups did not differ demographically. Patients with a complication were statistically less likely to have seasonal allergies, prior sinusitis, prior nasal steroid use, or adenoidectomy (p<0.05). In addition, they had more frequent involvement of ethmoid and frontal sinuses (p<0.05). The most common cultures results were no growth (30.8%), Streptococcus milleri (30.8%), and normal flora (19.2%) in ABS for the with a complication group, and normal flora (41.5%), coagulase negative Staphylococcus (22%), and Propionobacterium (19.5%) for the CRS group. Most prevalent complications were preseptal cellulitis (55.5%), orbital subperiosteal abscess (29.6%), subgaleal abscess (22%), and epidural abscess (22%). Five patients had simultaneous orbital and intracranial complications.

CONCLUSIONS

Patients who present with complications of ABS vary significantly from the CRS patients. Location of most commonly affected sinuses and microbiology also differ and is crucial for understanding the management of this disease process.

Orbital fracture leading to severe multifascial space infection including the parapharyngeal space: a report of a case and review of the literature

Orbital trauma can result in periorbital and orbital infections. Orbital infections have been classified by Chandler et al in 1970 to their anatomic location and boundaries. This case report describes a patient who developed a severe orbital infection following orbital fractures. The infection progressed to the parapharyngeal space. The patient required multiple incision and drainage surgeries and tissue debridements to have clinical resolution. To our knowledge, there has not been a case described in the literature of an orbital infection progressing to the parapharyngeal space. A literature review of orbital trauma leading to infection discusses the pathogenesis of the infections. This case demonstrates that close clinical follow-up and appropriate medical management of comorbidities that put a patient at higher risk of developing an infection is of the utmost importance in the treatment of maxillofacial trauma patients.

Acute MRSA sinusitis with intracranial extension and marginal vancomycin susceptibility

Methicillin resistant Staphylococcus aureus (MRSA) is increasingly being described as a cause of acute sinusitis. We present a patient with acute MRSA sinusitis complicated by rapid intracranial extension, marginal vancomycin susceptibility (MIC = 2 mg/L), delayed drainage of intracranial abscess, and subsequent development of rifampin resistance. Given the relatively high risk of intracranial extension of severe acute bacterial sinusitis and high mortality associated with invasive MRSA infections, we suggest early surgical drainage of intracranial abscesses in these circumstances. We believe this is important given the limited intracranial penetration of currently available treatment options for MRSA, especially those with a vancomycin minimal inhibitory concentration (MIC) of ≥2 mg/L.

The correlation of microbiology growth between subperiosteal orbital abscess and affected sinuses in young children

BACKGROUND

Subperiosteal orbital abscess (SPOA) typically presents as a collection of pus in the space between the periorbit and the lamina papyracea adjacent to the infected paranasal sinuses. The aim of this study was to investigate the simultaneous microbiological growth from an SPOA and the paranasal sinuses in the same children.

METHODS

A retrospective study was performed on cultures obtained from involved sinuses and surgically drained abscesses in young children with SPOA from January 1992 to March 2009.

RESULTS

Twenty-two children with a mean age of 5.9 years were included. Results of the microbiological studies were available from the sinuses of 17 children (77.2%) and from the SPOA in 18 children (81.8%). High rates of staphylococci bacteria and Streptococcus viridans were observed compared with lower-than-expected upper respiratory tract infection pathogens. Both groups showed scarce anaerobic and polymicrobial growth. In 13 children (59%), both sinus and abscess culture results were available with correlation found in only 4 (30.7%) of these children.

CONCLUSION

In this study we report the results of bacteriological studies of nasal sinuses and SPOAs in young children, with a low rate of correlation between both sites and low rates of anaerobic growth, but high rates of staphylococcal growth in the SPOA cultures. These observations might be related to the trend toward conservative treatment in children.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years

OBJECTIVE

To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

METHODS

Analysis of the medical literature published since the last version of the guideline (2001).

RESULTS

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

CONCLUSIONS

Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Microbiological profile of orbital abscess

BACKGROUND

Knowledge of the culture and sensitivity pattern is necessary, for the institution of appropriate empirical antibiotic therapy in orbital abscess.

OBJECTIVE

The objective of this study is to describe culture and sensitivity patterns of specimens from the orbit and surrounding structures.

MATERIALS AND METHODS

Retrospectively the medical records of 56 cases of orbital abscess were reviewed.

RESULTS

Cultures were positive in 38/56 (68.8%) orbital specimens and the organisms included Staphylococcus aureus 18, Streptococci 7, Pseudomonas aeruginosa 3, 2 each of Enterobactersp, Escherichia coli, Proteus mirabilis, Acinetobacter sp. and 1 each of Actinomyces israelii, Diptheroids, Coagulase negative Staphylococcus, Citrobacter freundii, Methicillin-resistant S. aureus and Enterococcus faecalis. Four had polymicrobial infection. Culture of purulent nasal discharge, swabs taken from foci of infection on the face, and blood cultures were done in 26/56, and positive cultures were obtained in 16/26 (61.5%) specimens. In 12 patients, there was a concurrence in the organism cultured from the orbit and from cultures from other sites. Gram-negative organisms were associated with increased ocular morbidity.

CONCLUSION

Gram-positive cocci, especially S. aureus are the most common organisms isolated from orbital abscesses. Infections by Gram-negative organisms were associated with more complications. Empirical intravenous antibiotic therapy should have a broad spectrum of activity effective against a wide range of Staphylococcal organisms and Gram-negative bacilli.

Community-associated methicillin-resistant Staphylococcus aureus causing orbital cellulitis in Australian children

Community-associated methicillin-resistant Staphylococcus aureus has only emerged recently as a cause of serious ocular infections in several different countries. At a tertiary pediatric hospital in Brisbane, Australia, community-associated methicillin-resistant S. aureus orbital cellulitis was first noted in 2009. Since then, it has caused 4 of 9 such infections.