Critical Care Medicine-Infections and Immunologic Disease>>>>>Head and Neck, Upper Airway Infections
Question 1#

A 19-year-old woman presents with 5 days of progressive swelling around her right eye. She reports a week of prior nasal pain. On examination, her right eyelid is swollen, the globe is proptotic, and eye movement is limited by pain. Visual acuity is intact. Vital signs are:

A CT scan demonstrates inflammation of extraocular muscles, fat stranding, and anterior displacement of the globe, with frontal sinusitis. There is no evidence on CT of intracranial inflammation, nor any vascular compromise. While awaiting the results of blood cultures, which of the following antibiotic regimens is MOST appropriate to administer at this time?

A. Levofloxacin
B. Vancomycin and metronidazole
C. Vancomycin and ceftriaxone
D. Piperacillin-tazobactam

Correct Answer is C


Correct Answer: C

This patient’s clinical presentation and CT findings are characteristic of orbital cellulitis, an infection involving the contents of the orbit. Orbital cellulitis may cause loss of vision and even loss of life. It is distinguished from preseptal cellulitis (a less severe infection of the anterior portion of the eyelid) by ophthalmoplegia, pain with eye movements, proptosis, and characteristic findings of infection on CT including inflammation of extraocular muscles, fat stranding, and anterior displacement of the globe. CT or MR venography should also be performed to rule out cavernous sinus thrombosis. Most patients with uncomplicated orbital cellulitis can be treated with antibiotics alone. A broad-spectrum regimen should be administered to target Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA]), Streptococcus pneumoniae, and other streptococci, as well as gram-negative bacilli. When intracranial extension is suspected, the regimen should also include coverage for anaerobes. Of the options provided for this patient, vancomycin and ceftriaxone would be the most appropriate coverage regimen. Levofloxacin or piperacillintazobactam alone or the combination of vancomycin and metronidazole would not be broad enough to cover likely pathogens. Moreover, since there is minimal concern for intracranial involvement, the anaerobic coverage of metronidazole is not needed.


  1. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127:e566.
  2. Amin N, Syed I, Osborne S. Assessment and management of orbital cellulitis. Br J Hosp Med (Lond). 2016;77:216-220.