Orbital Cellulitis/Abscess

Patient Population: Pediatric

Need for drainage/source control of head and neck infections should be evaluated carefully in consultation with Pediatric Otolaryngology, Head and Neck Surgery. If initial non-operative management is chosen, a narrow spectrum regimen (i.e. without vancomycin), is encouraged to facilitate transition to oral therapy. 

ID consultation is recommended for head and neck infections occcurring in immunocompromised patients, and for those with atypical features, chronic course, or lack of response to first line therapy. 

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments
Orbital cellulitis/abscess 


Staphylococcus aureus 

Haemophilus influenzae 


Ampicillin-sulbactam (Unasyn) 50 mg ampicillin/kg/dose (max 2000 mg ampicillin/dose) IV q6h  

If there is a large abscess (>10mm), anticipated to undergo surgical drainage, toxic appearance, rapidly progressive proptosis or ophthalmoplegia, or patient with history of documented MRSA infection or carriage within the last 6 months: 

ADD Vancomycin  

(follow link for dosing and monitoring)  

Penicillin or cephalosporin allergy with higher risk for allergic reaction:  

Consult ID/ASP 

Urgent OHNS and Ophthalmology consults recommended to evaluate need for source control   

ID consult recommended (see details above) 

For intracranial extension, refer to Intracranial Abscess section for empiric therapy 

Therapy may be tailored based on cultures from I&D. If Vancomycin was started but MRSA not recovered, Vancomycin should be discontinued.  

Duration: Uncomplicated orbital cellulitis/abscess is typically treated first with IV therapy then converted to enteral therapy within days based on clinical improvement, with a total duration of 14-21 days (combined IV and enteral).  

A longer duration may be indicated if there is significant bone destruction or a large abscess that is not drained. 


Seltz LB, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics 2011;127:e566-e572. 

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.