Acute orbital cellulitis
In the second retrospective analysis, a group led by pediatrician Maria Anna Leszczynska, MD, of Johns Hopkins All Children’s Hospital in Baltimore, analyzed a retrospective PHIS cohort of 5,645 children younger than 18 years with a primary diagnosis of orbital cellulitis treated at 51 hospitals from January 2007 to December 2018.
Of these, 1,347 (24%) received steroids, but, contrary to earlier reports, the data showed no reduction in length of stay associated with these drugs after adjustment for age, meningitis, abscess, or vision issues (ebeta, 1.01; 95% CI, 0.97-1.06). Corticosteroid exposure was, however, associated with operative episodes after 2 days’ hospitalization (OR, 2.05; 95% CI, 1.29-3.27) and 30-day readmission (OR, 2.40; 95% CI, 1.52-3.78).
“Among children hospitalized for orbital cellulitis, we did not observe the reduction in LOS [length of stay] for patients prescribed systemic corticosteroids as described previously in the literature,” the authors wrote.
In terms of surgical procedures, 52.0% of corticosteroid recipients versus 14.0% of nonrecipients underwent surgery (P < .001), and more were hospitalized in the pediatric ICU (4.4% vs 2.6%; P < .001).
According to the editorialists: “Both observations suggest that children who received steroids may have been a sicker group of patients.”
Dr. Wald and Dr. Eickhoff pointed out that the effect of steroids is ultimately unclear because of the retrospective study’s inherent potential for bias because of unobserved confounders. Were steroids prescribed more often when children were perceived to be sicker with more severe disease, or did these medications cause worse outcomes?
The authors agreed that the study could not determine causality. “Although we used all available markers of disease severity, there does not exist a validated disease severity clinical score for pediatric orbital cellulitis,” they wrote.
Dr. Ricardo A. Quinonez
According to Ricardo A. Quinonez, MD, an associate professor of pediatrics and division and service chief of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston, “orbital cellulitis is a not very common thing in children so we don’t treat many patients with this. But having said that, there is usually some debate among providers about whether to use steroids.”
Some centers use them routinely for central nervous system and eye infections or extensions of sinusitis, he said, but there is variability in the prescribing of corticosteroids. “There’s ongoing discussion as to whether they‘re as helpful in orbital cellulitis as they are in similar conditions,” Dr. Quinonez said in an interview. “At our institution we don’t typically prescribe them – not never but not routinely. Children who are sicker tend to get steroids, as they do in other conditions.”
In the context of PPA as in the first study, he added, “I think the evidence favoring the use of steroids in infections that affect the airway is stronger, and their use is definitely more prevalent in those instances.”
While both PHIS analyses suggested some benefit from steroids, he continued, some children may not benefit and there may be harms. “The evidence is still mostly retrospective and observational with no multicenter randomized controlled data. Without those data the evidence is difficult to interpret and subject to all the biases that observational and retrospective data is subject to and the current evidence should not lead physicians to change their practice until controlled, randomized evidence is available.”
The editorialists concurred with the study authors and Dr. Quinonez that large, controlled, prospective clinical trials are needed to ascertain the effect of steroids and to standardize the approach to diagnosis and management. “Use of administrative databases are not optimal to answer questions related to outcome,” they wrote.
The study by Dr. Goenka and associates received no external funding; the study by Dr. Leszczynska and associates also received no external funding. None of the authors declared potential competing interests. Dr. Quinonez had no competing interests to declare. Dr. Wald and Dr. Eickhoff disclosed no competing interests with regard to their editorial.