DOI: 10.1097/IOP.0b013e318192a29b
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PMID: 19273945
Issn Print: 0740-9303
Publication Date: 2009/01/01
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Excerpt
MRSA has become a frequently reported cause of ophthalmic infectious disease including preseptal cellulitis, eyelid abscesses, orbital cellulitis, endophthalmitis, and keratitis.3 More worrisome is the prospect of a dangerous strain of community-acquired MRSA, the USA300 clone, which is becoming exceedingly common and responsible for a more severe and aggressive disease course than the more typical nosocomial MRSA variety.4 Pathologic examination in MRSA USA300 clone shows extensive tissue necrosis due to its Panton-Valetine leukocidin gene, which encodes a cytotoxin that has been shown in vitro to destroy neutrophils and macrophages.
Our recent experience with 11 cases of MRSA periorbital cellulitis all arising from a focal insult to the superficial periorbital tissue demonstrates that aggressive and early treatment is required to bring it under control. Most cases of periorbital cellulitis seen in the past 2 years have been MRSA positive. Our patients on average were 29 years old with a bimodal population. The younger, teenage cohort of patients had focal abscesses with surrounding cellulitis that were easily drained and treated with oral antibiotics on an outpatient basis. One infant in our series, however, did require a prolonged hospital course with 2 trips to the operating room to treat a superficial cellulitis that quickly became a large orbital abscess.
Six adult patients, aged 30 to 61 years, had more aggressive infections that spread along tissue planes with multiple microabscesses and a true tissue cellulitis. These more aggressive infections required hospitalization, intravenous antibiotics, and in some cases, multiple surgeries. Intravenous steroids were administered in 3 of 6 adult cases with severe infections and secondary inflammation. The steroids clearly helped these 3 patients in their recovery when surgery did not.
Fortunately, there are still multiple antibiotics that work against community-acquired MRSA, including sulfonamides (trimethoprim-sulfamethoxazole), quinolones, aminoglycosides (gentamicin), tetracyclines, clindamycin, and rifampin. All of our patients with MRSA preseptal or orbital cellulitis demonstrated a worsening clinical course early in the infection. The combination of a high index of suspicion with appropriate antibiotics, early and aggressive surgical drainage with debridement, and the occasional use of steroids allowed all of our patients with MRSA to recover with minimal to no long-term sequelae.
