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Community-associated Methicillin-resistant Staphylococcus aureus Causing Orbital Cellulitis in Australian Children

Vaska, Vikram L. FRACP, FRCPA*; Grimwood, Keith MD, FRACP; Gole, Glen A. MD, FRANZCO; Nimmo, Graeme R. MD, FRCPA§; Paterson, David L. PhD, FRACP, FRCPA*; Nissen, Michael D. FRACP, FRCPA

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The Pediatric Infectious Disease Journal: November 2011 - Volume 30 - Issue 11 - p 1003-1006
doi: 10.1097/INF.0b013e318224fda5


Most cases of orbital cellulitis result from spread of infection from an adjacent sinus, although they can occasionally follow penetrating trauma, nearby skin infection or bacteremia. Important etiologic pathogens are Staphylococcus aureus, nontypeable Haemophilus influenzae, Streptococcus (Str.) species, including Str. pneumoniae, and anaerobes in older children. Management involves intravenous (IV) antibiotics and often surgery for underlying sinus disease or orbital collections.

A notable recent development in S. aureus epidemiology is the global emergence of community-associated methicillin-resistant S. aureus (CA-MRSA) clones. They usually possess SCCmec allotypes IV or V and the virulence factor Panton–Valentine leukocidin (PVL) which can cause tissue necrosis. The appearance of CA-MRSA has been accompanied by increased rates of skin and soft-tissue infections and of severe, invasive disease. In Australia, CA-MRSA was first described in the 1980s in remote areas of Western Australia. In the late 1990s in Queensland, infections in persons of Polynesian ethnicity were shown to be from sequence type (ST) 30-MRSA-IV, the South-West Pacific clone reported previously in New Zealand. Subsequently, a new “Queensland” clone ST93-MRSA-IV was recognized as the predominant Australian clone.1 A 2008 Queensland survey found 15% of S. aureus clinical isolates to be CA-MRSA.2

Following our observation of 4 cases of CA-MRSA orbital cellulitis, we examined their medical records, reviewed the microbiology of treated cases of orbital cellulitis in the previous 10 years and searched the literature for CA-MRSA as a cause of serious ocular infections in children.



The Royal Children's Hospital (RCH), Brisbane is 1 of 2 tertiary pediatric hospitals in the state of Queensland, Australia. The Queensland Children's Health Services District Ethics Committee approved the study.

CA-MRSA Orbital Cellulitis Cases.

Data were collected on those cases (January 2009–June 2010) on which the RCH Infectious Diseases Unit had consulted.

Orbital Cellulitis Cases.

All cases treated at RCH between July 2000 and June 2010 were identified by International Classification of Diseases-10 Australian Modification (ICD-10 AM) code (H05.0) search. Case demographic, clinical and microbiologic data were retrieved.


Blood cultures, operative and pus specimens collected as part of usual clinical care were analyzed by the Pathology Queensland Central Laboratory using routine bacteriologic methods. CA-MRSA isolate genotyping was performed by single nucleotide polymorphism and binary gene typing.3


Fisher exact test was applied to CA-MRSA case numbers.

Literature Review.

OVID Medline (1948 onward; MeSH and keyword search) and Embase (1966 onward; “extensive search”) databases were searched (April 2011) for “orbital cellulitis” or “orbital diseases” or “eye infections, bacterial” and “methicillin.” Articles with clear cases of pediatric (≤18 years) CA-MRSA ocular infections were then identified. Bibliographies of included articles were also examined. Cases were not included where ocular involvement was either uncertain, not the primary, or presenting infection or involved preterm neonates.


CA-MRSA Cases.

Case 1.

A 13-year-old boy presented with 24 hours of right periorbital swelling, pain, and fever after 3 days of coryza and headache. Orbital computerized tomography (CT) showed right-sided opacification of sinuses, proptosis, and edema of the preseptal soft tissues and of the intraorbital fat (mainly in the roof of the orbit) with displacement of the superior rectus muscle, but no subperiosteal collection. Flucloxacillin and ceftriaxone therapy was commenced. On the third hospital day MRSA was identified in blood cultures. The antibiotics were changed to IV vancomycin and lincomycin and within 2 days he was much improved. The IV antibiotics were continued for 7 days, followed by 14 days of oral clindamycin with good effect. The S. aureus blood culture isolate was resistant to beta-lactam antibiotics and erythromycin, but there was no inducible clindamycin resistance. Genotype was clonal complex (CC) 30-MRSA; PVL positive (ie, ST30-MRSA-IV, the South West Pacific Clone).

Case 2.

A 4-year-old girl presented with 24 hours of bilateral periorbital swelling and fever following coryzal symptoms. A sibling had experienced repeated episodes of pyoderma. CT scans showed pansinusitis and a subperiosteal collection in the medial right orbit with rarefaction of the right lamina papyracea. Initial treatment with flucloxacillin and ceftriaxone was changed to vancomycin for 5 days, then lincomycin for 6 weeks, followed by 2 months of oral clindamycin. She underwent 2 drainage procedures of the maxillary sinus and subperiosteal collections. Follow-up indicated a good outcome. Blood and operative specimens grew MRSA (beta-lactam resistant only; unavailable for genotyping).

Case 3.

An 11-year-old Polynesian boy presented with fever and left periorbital swelling within 48 hours of developing a pustule on the eyelid. He and family members had a history of skin infections. Initial CT scans showed indurated periorbital tissue and minor inflammatory phlegmon in the lateral postseptal extraconal position. After failing to improve with flucloxacillin and cefotaxime by day 4, lincomycin was added. Repeat imaging found extensive periorbital soft-tissue swelling and an orbital abscess, with no evidence of sinus disease. At surgery, he had signs of necrotizing fasciitis involving periorbital tissue, which was debrided and the orbital abscess drained. Following culture results lincomycin became the sole agent for the next 8 days, followed by oral clindamycin for another 3 weeks. He also received IV immunoglobulin 1 g/kg immediately after surgery. Although blood cultures were negative, operative samples grew an MRSA (beta-lactam resistant only; genotype CC30-MRSA PVL+). He underwent successful surgical correction of left-sided ptosis 3 months later.

Case 4.

A 14-day-old female child, born at term after an uneventful pregnancy and delivery, presented with fever and lethargy, followed by right periorbital swelling and purulent ocular discharge. CT scans showed multiple locules of low density fluid with irregular enhancing margins in the right orbit, while the ethmoid air cells were replaced with soft-tissue density signal. She underwent drainage of the orbital collection and the initial antibiotics (flucloxacillin and ceftriaxone) were changed to IV lincomycin for 21 days following culture results. She also received dexamethasone 0.1 mg/kg 8 hourly (weaned over 10 days). At the age of 6 months, her ocular examination was normal. Although blood cultures were sterile, operative specimens grew MRSA (beta-lactam resistant only; genotype ST93-MRSA-IV; PVL+).

Orbital Cellulitis Cases and Microbiology.

Forty-three patients (of which 25 were males) aged 14 days to 17 years (median 8.3-years) were treated for orbital cellulitis between July 2000 and June 2010. Of the 24 (56%) cases with positive cultures, 7 grew Str. milleri group organisms alone; 5, methicillin-susceptible S. aureus; 4, MRSA (current cases); 1 each of H. influenzae, Str. pyogenes, Str. pneumoniae, Str. milleri + methicillin-susceptible S. aureus, and Str. milleri + mixed anaerobes; and 3, mixed upper airway commensal flora. The only positive blood cultures were in 2 patients with MRSA. Furthermore, although no MRSA orbital cellulitis was noted before 2009, CA-MRSA strains caused 4/9 (44%) cases of orbital cellulitis treated in the 18-month period, January 2009 to June 2010; Fisher exact test P = 0.001.

Literature Review.

All CA-MRSA ocular infection case reports and series in the literature that included pediatric cases4–17 are shown in the Table, Supplemental Digital Content 1,


CA-MRSA appears to have been first reported as a cause of pediatric ocular infections in 2005.17 Most reports originated from the United States.4–8,10,12–16 However, there are few epidemiologic data for CA-MRSA eye infections. In 2 recent case-series (including adolescents and adults8 and infants14), CA-MRSA was the most common cause of periorbital or orbital infection. In a Texan pediatric series,12 8/11 (73%) S. aureus isolates from 38 cases of orbital cellulitis were MRSA, however, in a Colorado series4 only 1/8 S. aureus isolates were MRSA. Our data from a single institution are consistent with the recent emergence of CA-MRSA as a significant cause of orbital cellulitis.

In Australia, cavernous sinus thrombosis and meningitis in an adult (CA-MRSA; ST93; PVL+),18 and a rare case of Pott's puffy tumor with bilateral orbital abscesses in a preterm neonate caused by (hospital-associated) nonmultidrug resistant MRSA (genotype not determined)19 have both been reported from Brisbane.

Many of the reported CA-MRSA infections are described as severe with periorbital infection spreading through tissue planes, causing necrosis, and requiring repeated surgical intervention.8 Case 3 in our series had evidence of such tissue effects. Systemic complications such as bacteremia, pneumonia, brain, and lung abscesses are also reported,5,7,9–11,13,14,17 all of which can be features of severe PVL + CA-MRSA infections. Two of our 4 cases had bacteremia, but no complications at other sites were observed.

Vancomycin remains the recommended treatment for serious CA-MRSA infections,20 although lincosamides, for example, lincomycin and clindamycin (for susceptible isolates), or linezolid can be used if the patient is stable and clears the bacteremia rapidly. Combination therapy for vancomycin with agents (clindamycin, rifampin, or linezolid) that suppress PVL synthesis in vitro is unproven and is best individualized in those with serious disease. Surgical drainage is often required for intraorbital collections, which if untreated can lead to intracranial spread of infection, thromboses, and blindness. Despite the potentially serious adverse outcomes from CA-MRSA orbital infections, most studies5,7–11,13,16,17 report a good response to treatment.

Given the documented increase in CA-MRSA infections globally and recent reports (including this one in Australian children) of it causing serious ocular disease, it is apparent that CA-MRSA is emerging as an important ocular pathogen. In regions where CA-MRSA is prevalent, this fact should be taken into account during the initial empiric treatment for severe ocular infections.


1.Nimmo GR, Coombs GW. Community-associated methicillin-resistant Staphylococcus aureus (MRSA) in Australia. Int J Antimicrob Agents. 2008;31:401–410.
2.Nimmo GR, Schooneveldt JM, Sutherland JL, et al. Epidemiology of non-multiresistant methicillin-resistant Staphylococcus aureus infection in Queensland, Australia: associations with indigenous populations and Panton-Valentine leukocidin. Eur J Clin Microbiol Infect Dis. 2010;29:1253–1259.
3.Huygens F, Inman-Bamber J, Nimmo GR, et al. Staphylococcus aureus genotyping using novel real-time PCR formats. J Clin Microbiol. 2006;44:3712–3719.
4.Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127:e566–e572.
5.Kobayashi D, Givner LB, Yeatts RP, et al. Infantile orbital cellulitis secondary to community-associated methicillin-resistant Staphylococcus aureus. J AAPOS. 2011;15:208–210.
6.Liao S, Durand ML, Cunningham MJ. Sinogenic orbital and subperiosteal abscesses: microbiology and methicillin-resistant Staphylococcus aureus incidence. Otolaryngol Head Neck Surg. 2010;143:392–396.
7.Rutar T. Vertically acquired community methicillin-resistant Staphylococcus aureus dacryocystitis in a neonate. J AAPOS. 2009;13:79–81.
8.Goldstein SM, Shelsta HN. Community-acquired methicillin-resistant Staphylococcus aureus periorbital cellulitis: a problem here to stay. Ophthal Plast Reconstr Surg. 2009;25:77.
9.Bukhari EE, Al-Otaibi FE. Severe community-acquired infection caused by methicillin-resistant Staphylococcus aureus in Saudi Arabian children. Saudi Med J. 2009;30:1595–1600.
10.Vazan DF, Kodsi SR. Community-acquired methicillin-resistant Staphylococcus aureus orbital cellulitis in a non-immunocompromised child. J AAPOS. 2008;12:205–206.
11.Kadhiravan T, Piramanayagam P, Banga A, et al. Lemierre's syndrome due to community-acquired methicillin-resistant Staphylococcus aureus infection and presenting with orbital cellulitis: a case report. J Med Case Rep. 2008;2:374.
12.McKinley SH, Yen MT, Miller AM, et al. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007;144:497–501.
13.Rogers GA, Naseri I, Sobol SE. Methicillin-resistant Staphylococcus aureus orbital abscess in a neonate. Int J Pediatr Otorhinolaryngol Extra. 2007;2:99–101.
14.Miller AM, Yen KG, Yen MT, et al. Infantile orbital cellulitis: rising incidence of methicillin-resistant Staphylococcus Aureus (MRSA) infections. J AAPOS. 2006;10:77.
15.Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006;104:322–345.
16.Kodsi S. Community-acquired methicillin-resistant Staphylococcus aureus in association with chronic dacryocystitis secondary to congenital nasolacrimal duct obstruction. J AAPOS. 2006;10:583–584.
17.Huang SF, Lee TJ, Lin KL. Concomitant bilateral orbital and brain abscesses—unusual complications of pediatric rhinosinusitis. Chang Gung Med J. 2005;28:51–55.
18.Munckhof WJ, Krishnan A, Kruger P, et al. Cavernous sinus thrombosis and meningitis from community-acquired methicillin-resistant Staphylococcus aureus infection. Intern Med J. 2008;38:283–287.
19.Cheng S, Vu P. Pott's puffy tumor in a premature neonate: the new youngest case reported in the post-antibiotic era. Orbit. 2009;28:412–414.
20.Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18–e55.

methicillin-resistant Staphylococcus aureus; eye infections; orbital cellulitis; child

Supplemental Digital Content

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