Open Journal of Ophthalmology, 2012, 2, 89-92
http://dx.doi.org/10.4236/ojoph.2012.23019 Published Online August 2012 (http://www.SciRP.org/journal/ojoph)
89
Late-Onset Orbital Cellulitis with Abscess Formation
Caused by Klebsiella Pneumoniae*
Jing Li, Jianmin Ma#, Xin Ge
Beijing Tongren Eye Center, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing Tongren Hospital, Capital Medical
University, Beijing, China.
Received June 27th, 2012; revised July 30th, 2012; accepted August 15th, 2012
ABSTRACT
Klebsiella pneumoniae is a facultative anaerobic gram-negative, non-motile, capsulated, gas-producing rod found wi-
dely in nature and often associated with urinary and respiratory infections in humans. Orbital cellulitis with abscess
formation caused by K. pneumoniae is rare. Here, we present a case of K. pneumonia-inducing orbital cellulitis with
abscess formation in a patient who had undergone an orbital wall fracture prosthesis with hydroxyapatite implantation
due to orbital trauma 9 years ago. The patient was treated successfully with antibiotics and surgery.
Keywords: Orbital Cellulitis; Abscess; Klebsiella Pneumoniae
1. Case Report
A 52-year-old man presented to our ophthalmology de-
partment with a 1 week history of eye pain, blephare-
dema, conjunctival congestion, and proptosis in the left
eye. 7 days prior, he had suddenly developed a fever of
39.0˚C after a continuous period of being overworked. A
tentative diagnosis of orbital cellulitis was made and the
patient was treated with intravenous cefoxitin sodium as
an inpatient. Most of the symptoms slightly improved.
Nine years before his presentation, the patient had been
admitted to our hospital for the first time with orbital
trauma following a traffic accident. He had received an
orbital wall fracture prosthesis with hydroxyapatite im-
plantation. He denied recent facial trauma or dental work.
Visual acuity was 20/20 in both eyes. The adduction of
the left eye was severely restricted. Due to his orbital
trauma and surgical history, we advised him to undergo
an orbital computed tomography. To our surprise, a huge
abscess formation was seen adjacent to the implant of the
medial wall of the left orbit (Figure 1). The laboratory
findings showed a high level of leukocytes, erythrocyte
sedimentation rate, and C-reactive protein. Under general
anesthesia, incision and drainage of the orbital abscess
was performed. The purulent material was collected and
cultured immediately. The isolate was found to be gram-
negative. Using the Vitek II automated system (bioMérieux,
Marcyl’Etoile, France), the isolate was confirmed as ex-
tended-spectrum β-lactamase-producing Klebsiella pneu-
moniae, with a 96% confidence level. Antimicrobial sus-
ceptibility test was performed using the Vitek II auto-
mated system which resulted in the MICs shown in Ta-
ble 1. The Kirby-Bauer agar diffusion method was used
as a confirmatory tool. The Clinical and Laboratory Stan-
dards Institute (CLSI) guidelines for susceptibility testing
of K. pneumoniae were followed. After surgery, the pa-
tient was managed with intravenous piperacillin/tazo-
bactam 4.5 mg/12 h for 7 days and imipenem/cilastatin
sodium 250 mg/12 h for 14 days. His symptoms subsided
completely and laboratory findings became normal with-
out recurrence for 6 months.
Figure 1. Computed tomogr aphy of the orbit show ing orbital
cellulitis with a huge abscess adjacent to the hydroxyapatite
implant of the medial wall of the left orbit and partial
pneumatization of the left ethmoidal sinus.
*Conflict of Interest: None of the authors has conflict of interest with
the submission. Financial support: No financial support was received
for this submission.
#Corresponding author.

Late-onset Orbital Cellulitis with Abscess Formation Caused by Klebsiella Pneumoniae
90
Table 1. Disk susceptibilities of the K. pneumoniae isolates.
Antibiotic MIC (μg/ml) Susceptibilityα
Ampicillin ≥32 R
Ampicillin/sulbactam 16 I
Piperacillin/tazobactam 8 S
Cefazolin ≤4 R
Cefotetan ≤4 S
Ceftazidime ≤1 S
Ceftriaxone ≤1 S
Cefepime ≤1 S
Aztreonam ≤1 S
Ertapenem 0.25 S
Imipenem ≤1 S
Amikacin ≤2 S
Gentamicin ≤1 S
Tobramycin ≤1 S
Ciproxacin 1 S
Levofloxacin 1 S
Nitrofurantoin 256 R
Trimethoprim/sulfanilamide 2/38 S
αR, resistant; I, intermediary; S, susceptible
2. Discussion
K. pneumoniae is a facultative anaerobic gram-negative,
non-motile, capsulated, gas-producing rod found com-
monly in nature and is often associated with urinary and
respiratory infections in humans. K. pneumoniae is the
most common and most important rod of the Klebsiella
species that are identified as pathogenic to humans and
include K. pneumoniae, R. oxytoca, K. ornithinolytica, K.
planticola, and K. terrigena. It is also a common oppor-
tunistic pathogen in humans; therefore, immunocompro-
mised and/or postoperative patients are prone to suffer
from infections with this pathogen. In addition, K. pneu-
moniae is one of the most important pathogen that can
product extended-spectrum beta-lactamases, leading to its
resistance to most antibiotics.
K. pneumoniae is associated with wound infections [1-
3], respiratory tract infections [4], arthritis [5-8], osteo-
myelitis [5,7], septicemia [5,9], meningitis [5,10-11],
genitourinary infection [7,12], and so on. Eyeball infec-
tions due to K. pneumoniae is not rare and can cause ker-
atitis [13], conjunctivitis [14] and endophthalmitis [15-
17]. However, to the best of our knowledge, orbital cel-
lulitis caused by K. pneumoniae has rarely been reported
in the literature [18-20].
Orbital cellulitis and abscess are medical emergencies.
Delayed or inadequate management may lead to perma-
nent loss of vision [21-23]. Therefore, history-taking, cli-
nical examination, and laboratory investigation including
proper orbital imaging is essential in determining the
source of infection [24]. There are various sources of
orbital cellulitis, including the sinuses, open fractures,
foreign bodies, periocular surgery, Munchausen’s syn-
drome, intraocular tumors, and so on [24,25]. The skin
and the sinuses are colonized by various microorganisms.
Orbital cellulitis following trauma is due to direct expo-
sure of the orbital contents to these microorganisms [24].
Open and closed periorbital fractures involving the si-
nuses or the nasal bone, may be a risk factor for orbital
infection [26,27]. The most common bacteria isolated
from pediatric and adult patients with community-ac-
quired acute purulent sinusitis are Streptococcus pneu-
moniae, Haemophilus influenzae, Moraxella catarrhalis,
and Streptococcus pyogenes. Staphylococcus aureus and
anaerobic bacteria (Prevotella and Porphyromonas, Fu-
sobacterium and Peptostreptococcus spp) are the main
isolates in chronic sinusitis [28]. Infection may present
within a few hours to several years after trauma [23,24].
After some surgeries involving the orbit, there is an
increased risk for infection, especially in the presence of
alloplastic foreign bodies. Cataract surgery [29,30], ble-
pharoplasty [31], strabismus surgery [32,33], and other

Late-onset Orbital Cellulitis with Abscess Formation Caused by Klebsiella Pneumoniae 91
procedures may all expose the orbit to infection [34,35].
Therefore, patients undergoing any interventional proce-
dures should be closely monitored for signs of infection
and should be treated aggressively if evidence of an in-
fection is found [24].
Because K. pneumoniae is almost extended-spectrum
β-lactamase-producing bacillus, it is resistant to most anti-
biotics. Susceptibility testing is necessary to help physi-
cians choose the appropriate antibiotics in clinic. In our
case, the results of the susceptibility testing showed that
piperacillin/tazobactam, cefazolin, cefotetan, ceftazidime,
ceftriaxone, cefepime, aztreonam, ertapenem, imipenem,
amikacin, gentamicin, tobramycin, ciproxacin, levoflox-
acin are all effective. However, the extended-spectrum
β-lactamase-producing bacteria, which show susceptible
to penicillins, cephalosporins and aztreonam often be-
come resistant to them. Therefore, β-lactamase inhibitors
and carbapenems are recommended in clinical practice.
Our patient was treated with intravenous piperacillin/
tazobactam for 7 days and oral imipenem for 14 days
after surgery without recurrence for 6 months.
3. Conclusion
To our knowledge, this is the first case of late-onset or-
bital cellulitis and abscess formation induced by K. pneu-
moniae after an orbital wall fracture prosthesis with hy-
droxyapatite implantation reported in the literature. Or-
bital cellulitis and abscess formation due to K. pneumo-
niae should be considered, whenever patients suffer the
orbital trauma and undergo surgery.
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