Re: “Intravenous Steroids With Antibiotics on Admission for Children With Orbital Cellulitis”

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We read with interest the article by Chen et al.,1 a prospective trial of treatment of orbital cellulitis, and would like to share our concerns over the conclusions the authors have drawn from the results. The study included 43 pediatric patients presenting with orbital cellulitis, 28 of whom received intravenous (IV) antibiotics with a 3-day course of IV steroids initiated at the time of admission, and 15 of whom received IV antibiotics alone. The primary outcome measure was a significantly decreased hospital stay in the group treated with IV steroids, irrespective of whether they underwent surgery. A prior published report demonstrated that the treatment of pediatric orbital cellulitis with IV antibiotics and corticosteroids after the CRP fell below 4 was similarly associated with a shorter length of hospital stay.2
The current study does not consider, however, the potential catastrophic risks associated with corticosteroid immunosuppression in the presence of an unknown infectious orbital process. While rare, resistant, bacterial and invasive fungal infections may progress unchecked and undetected in the face of immunosuppression, resulting in irreversible vision loss, meningitis, and death. A study of this small size would not be able to measure this risk. While the case can be made for the more discretionary use of steroids in high-risk cases, the current study does not provide such guidance. The lack of randomization in the study may represent such a bias as it is unclear that the offer to treat with corticosteroids was presented to parents in a uniform manner and not influenced by the severity of the condition.
Ultimately, in both the current and prior study of corticosteroid use, the singular outcome advantage of the bimodality-treated group was shortened length of stay. If all other outcome measures are the same, perhaps a study of the criteria for discharge on oral medications is required. If taken on clinical appearance alone, the corticosteroid-treated group would be expected to appear less ill and more likely to be discharged earlier than those treated with antibiotics alone. Moreover, in another recent study of the duration of IV antibiotic treatment of children with sinusitis-related orbital cellulitis and subperiosteal abscess—none of whom received IV steroids—the mean and median interval for hospital discharge and the successful outcome was 4.0 days,3 similar to that of the authors’ corticosteroid-treated group.
Perhaps taken together, these studies most importantly justify earlier discharge based on criteria as yet to be established. However, we do not feel that early hospital discharge should be the sole impetus for a change in treatment protocol that jeopardizes the well-being of even a small subset of these patients. Given the shift in practice patterns that has already developed in both the fields of ophthalmology and otolaryngology, we would advocate for the use of extreme caution when applying the results of this study to routine clinical practice. While the case can be made for the therapeutic value of corticosteroid treatment in select cases including: orbital compartment syndrome, when emergent drainage of the offending abscess, the magnitude of the edema is vision threatening, and where reduction in sinonasal edema may improve postoperative sinus drainage. Certainly further investigations are required before the concomitant use of IV steroids with IV antibiotics becomes standard of care for the treatment of pediatric orbital cellulitis.
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