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

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We thank Campbell et al.1 for their interest in our article2 and their insightful comments. We wish to address some points raised in their manuscript. The potential for bias if steroids were offered to patients depending on disease severity was mitigated as steroids were offered to all consecutive children who presented with orbital cellulitis irrespective of severity of disease as outlined in the Methods section. Parental willingness to consent to steroid therapy was the only factor in their administration. Campbell et al. discuss the rare but important possibility of drug-resistant bacterial or fungal infection potentially worsened through immunosuppression with steroids. We agree that extreme care and caution be followed prior to initiation of steroids in children with orbital cellulitis and why exclusion criteria including presumed fungal infection and immunocompromised state were put in place for the study. Given the rarity of such orbital infections, it is possible that our cohort of 43 children did not have either of these worrisome pathogens, and clinicians should be vigilant of these possibilities when deciding on steroid initiation.
We also support the notion by Campbell et al. that a more uniform strategy and criteria be in place for patients with orbital cellulitis. However, as is the case with many diagnoses throughout medicine, discharge currently is based on the clinical intuition of treating physicians. We felt comfortable with discharge if the child continued to show clinical improvement after transitioning to oral antibiotics without fever for a period of at least 24 hours. Finally, we agree that our article should not be viewed as one attempting to change current standard of care. Rather it is sharing our experiences in treating children with orbital cellulitis to provoke thought and further studies to continue the ultimate goal of delivering optimal care to our patients.
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