Development of an Institutional Orbital Cellulitis Clinical Pathway

Abstract

Purpose : Preseptal/orbital cellulitis frequently presents to pediatric emergency and primary providers, with potentially vision or life-threatening complications. A high degree of variability exists in management, due to paucity of scientific evidence, lack of consensus, and differences in individual physician and surgeon practices, across and within institutions. We sought to develop a management pathway for preseptal/orbital cellulitis at a tertiary children’s hospital and primary care network, to standardize practice, maximize outcomes, and document the consensus building process required for pathway development.

Methods : With institutional support, we formed a multidisciplinary committee at Children’s Hospital of Philadelphia (CHOP) with representation from ophthalmology, oculoplastics, otorhinolaryngology, pediatric hospitalists, outpatient pediatrics, emergency medicine, infectious disease, neuroradiology, and antimicrobial stewardship. Over regular, full committee and subspecialty meetings, all aspects of preseptal/orbital cellulitis evaluation and management were sequentially reviewed. Consensus was built through review and debate of the literature and expert opinion, followed by divisional and hospital reviews and web-accessible posting for point of care use, with electronic order sets. Implementation will be periodically evaluated through pathway and antibiotic compliance, readmissions, length of stay, imaging and lab testing utilization, ICU care escalation, and clinical outcomes like vision loss and mortality.

Results : The team identified key areas of variability in practice and ultimately provided standardized recommendations for evaluation and treatment. Discussion points included standardizing non-ophthalmologist exams to identify “orbital signs” and navigate differential diagnosis; use of imaging studies, subspecialty consultations, and lab testing; empiric antibiotic regimens; need for direct attending-level discussions between surgeons; observation on oral antibiotics before discharge; and use of adjuvant therapies, like steroids or nasal saline rinses.

Conclusions : Our development of an orbital cellulitis clinical pathway provides guidance to reduce variability in practice both at CHOP and at other institutions, as it is freely available on the internet, and is a procedural model of interdisciplinary clinical pathway development.

This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.