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Update on periocular infections Robert Kersten M.D., F.A.C.S. UCSF Ophthalmology

Preseptal cellulitis/abscess

Necrotizing fasciitis

Orbital cellulitis/abscess

Rhino-orbital-cerebral mucormycosis

No orbital ssx- Va, EOM’s, proptosis, IOP

Epidermal inclusion cysts, dacryocystitis, penetrating injury, chalazion, insect bite

Rarely underlying sinusitis

29 y.o.- cardboard box struck R.L.L. 4 d before

Progressive swelling, erythema- 2d Augmentin

Nl. Va, pupils

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Nl. E.O.M.

Enophthalmos

Afebrile

WBC-10.2 k

? Mgmnt

(6 P.M.)

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Culture-MRSA

I.V.-Vancomycin

Packing advanced

Home with PICC line, 2 wks Vanc.

Central eschar granulated

Dual life style

Colonizer, commensal, normal flora

Virulent pathogen

Tendency to relapse or recur

5-25% treatment failure rate

Antibiotic resistance

Penicillin resistance 90% of all strains

Methicillin resistance (beta-lactam class resistance) 50-75% of hospital strains, 25-50% of community strains

<5% in 1990’s- large majority HA-MRSA CA-MRSA first reported in 1990’s

41.9% soft tissue infections by 2005 Univ of Cincinnati

2000- no cases mrsa 2006- 60% preseptal soft tissue infections

2010- routine culture Olson et al 2011

Conjunctiva 12.1% MRSA Eyelid 15.3% MRSA

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HA-MRSA

Fewer toxins

Panton-Valentine leukocidin rare

Greater drug resistance

CA-MRSA Toxins more common

P.V. leukocidin common (cytotoxin causes tissue necrosis)

Bacteremia/pneumonia/orbit

*Vancomycin resistant relatively- may require debridement

Linezolid (oxazolidinines)

HA-MSRA

Older patients (68 y)

Hospitals, nursing homes

Dialysis

Indwelling percutaneous catheters

18% household contacts also culture + ‘ve

½ life colonization 40 mos.

CA-MSRA

Younger patients (23 y)

Smokers

Diabetics

Non-white

Lower household income

Dermatologic dz.

Children Day care

Anyone!

CA-MRSA Oxacillin 0%

Ciprofloxacin 79%

Clindamycin 83%

Erythromicin 44%

Gentamicin 94%

Rifampin 96%

Tetracycline 92%

Bactrim(Trimethoprin/Sulfamethoxazole) 95%

Vancomycin 100%

(new reports of VRSA- ? Micro-abscess role)

HA-MRSA 0%

16%

21%

9%

80%

94%

90%

100%

Trimethoprim/sulfamethoxasole 1 DS q 8-12 +/- rifampin 300 mg q 12

Ciprofloxacin 500 mg q 12 +/- rifampin 300 mg q 12

Doxycycline 100 mg g 12 +/- rifampin 300 mg q 12

Clindamycin (risk induced resistance) 150-300mg q 6 +/- rifampin 300 mg q 12

Linezolid 600 mg q 12 $120 per day

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Erythema, swelling L gum x 10 days

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No orbital ssx- Va, EOM’s, proptosis, IOP

Epidermal inclusion cysts, dacryocystitis, penetrating injury, insect bite

Rarely underlying sinusitis

Treat for MRSA!

72 y.o.- EtOH abuse Rapidly progressing R ptosis Periocular swelling and erythema I.V. cefazolin x3d

Skin necrosis, breakdown Tachycardia, fever, leukocytosis Transferred Va- 20/40 // 20/30 NoRAPD E.O.M.s full

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Cultures- Group A strep Klebsiella Responded to Debridement and I.V. Unacin/Clindamycin

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Subcutaneous infection sparing overlying skin

Rapid spread

Type 1- post-op, poly-microbial- anaerobes

Type 2- Group A strep, +/- MRSA

M-protien on strep cell membrane- prevents phagocytosis

Pyogenic exotoxins- “toxic-shock syndrome”, organ failure, circulatory collapse

Pain

Rapidly spreading erythema, cyanosis, blanching

Hypesthesia

Blisters, bullae, necrosis overlying skin

Crepitus (Type 1)

Tachycardia, fever, leukocytosis, malaise, myalgias

D.M.

Et-OH

I.V. drug use

Immunosuppression

+/- trauma

? NSAIDs

Increasing incidence 0.085/100,000 in 1990

0.4/100,000 by 1996

Necrotic fascia/sub-cutaneous tissue urgent debridement- often repeated over course

Medical treatment alone a/c near %100 mortality

Antibiotic tx- type 2

PCN and Clindamycin

Toxic shock- support, IVIG

Mortality: 14-24%

Toxic shock: 33-60% mortality

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56 y.o. – C.C.- R. eye pain, increasing

p 5 d.

Present to E.D.-“out of Percocet”

Type 2 D.M

Va- N.L.P.// 20/30

R. RAPD

I.O.P.- 50’s tonopen

E.O.M.s- Frozen globe

R. proptosis

Afebrile

W.B.C.- 18,000

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Drain subperiosteal roof abscess

FESS- frontal, sphenoid, post ethmoid

C & S- MRSA

D/C with PICC line, Vancomycin x 3 wks

Orbital signs

Proptosis

Limited EOMs

Optic neuropathy

Increased I.O.P.-

Delay in appropriate treatment may be blinding

Sinusitis gone bad >90%

Sinus: 90%

Direct innoculation

or cutaneous spread: 5%

Hematogenous: <5%

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Inferior orbital abscess: Maxillary sinusitis

Antibiotics and sinus surgery mainstays of treatment:

Younger age: acute sinusitis Single organism responds well to

IV AB’s x 4d 3wks p.o.

Harris et al: orbital abscess

90% avoid surgical intervention - 9 yr old or under

- small medial abscess

- isolated ethmoiditis

- no visual compromise

Orbital Cellulitis

Abscess in 50%

Usually sub-periosteal - adjacent to sinusitis

Orbital infection and sinusitis: Urgent ENT consult!

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Initial medical therapy IF: Less than 10 y.o. “not large” medial sub- periosteal abscess Isolated acute ethmoid sinusitis No optic neuropathy

3rd generation cephalosporin

Ampicillin- sulbactam

MRSA- Vancomycin

15 y.o.m.-

3 d c/o pain, swelling, erythema O.S. then diplopia, decreased vision O.S. PMHx.-2 mos. s/p floor fx

O.S.

Admitted ENT, ophth consulted

Va- 20/60 O.S., no RAPD

IOP- 36 mm tonopen

5 mm L. proptosis

EOM- global decrease O.S.

Fundus– “normal” optic nerve, arteries and veins

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ENT – planned urgent FESS Ophth. recommended anti- glaucoma gtts, observe for response I.V. ATBs Following a.m. NLP

Endoscopic drainage maxillary sinus

L. Inferior orbital exploration

no pus sub-periosteal space

intra-orbital abscess

Culture-Group A strep.

coag –’ve staph., few colonies

aeromonas

Increased I.O.P. reflects increased orbital pressure Not a glaucoma problem!!! Urgent drainage of sinusitis and abscess

Orbital “Compartment” Retrobulbar optic nerve ischemia >>retinal ischemia

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16 y.o.f.- “fell” and bumped head (repeatedly) on kitchen table “bruising , swelling L.U.L.” diplopia maximal 2 days post injury- stable despite 2 weeks of oral ampicillin Increasing pain, transferred to UCSF V.A.- 20/100, but no RAPD, motility globally limited, intact sensation V1 I.O.P.- 21/18 Hertel- 21/13mm

Image!

Culture Polymicrobial- gm +’ves, anaerobes

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Superior orbital abscess / frontal sinusitis special concerns: Intracranial complications Empyema/abscess

9yo girl, in usual healthy state

2d ago, dev HA and right eye pain

PCP did throat swab strep Rx Amox

Next day, felt worse with HA and swelling of eyelid Rx IM ceftriaxone

Cont to get worse (fever, pain), vomited, not making sense, not responsive

CT @ OSH showed intracranial dot of gas

Intubated for GCS 7-8

Transferred here

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R orbital roof fx with superior orbital abscess- Culture-“Mycoplasma hominis” Surgical evacuation, I.V. ATB, 4 week course p.o. Zithromycin

F/U neurosurg Released p 4 weeks F/U oculoplastics following day

Referred back to neurosurg.

Hematogenous H.Flu orbital cellulitis dramatically decreased following introduction of HIB vaccine

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Sinusitis gone bad >90%

Orbital abscess in >50%

Urgent surgery unless <10 y.o.

Increased IOP not glaucoma

Beware frontal sinusitis

46 y.o.- diet controlled type 2 diabetes Systemic steroids for 10 d Diplopia / eye pain/ ptosis

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Rhizopus oryzae spores ubiquitous

Inhaled naso or oropharynx and sinuses

Usually cleared by phagocytosis

Immunocpmpromised: germination, hyphae,

Vascular invasion, infarction, tissue necrosis

Insidious onset

Diabetic keto-acidosis

Neutropenia

Hematologic malignancy

Immunosuppresion

High index of suspicion

Examine oral, naso-pharynx for eschar

Diagnostic approaches: biopsy of necrotic tissue from the most accessible tissue

. Pathology: a large (30-50 micron) nonseptate,

branching hypha that stains with H+E (unlike other fungi), PAS, and GMS. The organisms have a tendency to invade the orbital blood vessels leading to necrosis.

Orbital mucormycosis High suspicion, early diagnosis

Correct underlying immunosuppression

Surgical debridement of infarcted tissue

Anti-fungal therapy

Amphoterecin B-Caspofungin combination therapy

Superior to Lipid amphotericin B monotherapy

Rhino-Orbital-Cerebral Mucormycosis

100% vs. 25% (p.01)

Hyperbaric Oxygen- ?

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> 46 y.o

Febrile

Frontal sinus involvement

Non-diabetic (4 x mortality)

Extent of disease (Rhino-cerebral 3x > rhino-orbital)

Anti-fungal treatment

Exenteration better survival Case-by-case: (patients w fever)

Treatment:

- Treat the underlying metabolic disorder or neutropenia.

- Antifungal: Amphotericin B (lipid formulation) alone or combined with echinocandins (e.g. caspofungin)

- Wide surgical debridement (excise until presence of freely bleeding tissue) and orbital exenteration done on case by case basis.

Reed C, Bryant R, Ibrahim AS, Edwards J Jr, Filler SG, Goldberg R, Spellberg B. Combination polyene-caspofungin treatment of rhino-orbital-cerebral mucormycosis. Clin Infect Dis. 2008;47(3):364.

Orbital mucormycosis

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Sinusitis gone bad >90%