Clinical Characteristics and Differences in Pathogen Distribution of Orbital Cellulitis Between Children and Adults in Northern China

Clinical Characteristics and Differences in Pathogen Distribution of Orbital Cellulitis Between Children and Adults in Northern China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Characteristics and Differences in Pathogen Distribution of Orbital Cellulitis Between Children and Adults in Northern China Peipei Jia, Xiaolu Cao, Dan Zhang, Pengfei Han, Tao Li, Yu Duan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9297175/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: To investigate the differences in clinical features and pathogen distribution of orbital cellulitis between adults and children in northern China, and to provide evidence for precise clinical diagnosis and management. Methods: A retrospective analysis was conducted on the clinical data of 131 patients with orbital cellulitis admitted to Hebei Eye Hospital between 2014 and 2023, including 76 adults and 55 children. The two groups were compared in terms of etiologies, treatment modalities, length of hospital stay, and microbiological results. Results: No significant differences were observed between groups in sex, geographical distribution, or seasonal variation. However, adults showed significantly higher rates of surgical intervention (44.7% vs. 25.5%, P < 0.05) and a longer median hospital stay (11 days vs. 7 days, P < 0.001) compared with children. Regarding etiologies, pediatric cases were predominantly attributed to rhinogenic infections (58.2%), whereas adult cases showed more heterogeneous causes, including trauma (21.3%) and lacrimal apparatus diseases (18.7%). Microbiological analyses revealed that all pathogens isolated from children were Gram-positive bacteria (100%), whereas adults exhibited a more diverse pathogen spectrum, including Gram-positive bacteria (69.6%), Gram-negative bacteria (28.3%), and fungi (2.2%). The overall microbial composition differed significantly between the two groups (P < 0.05). Conclusions: Adults and children with orbital cellulitis differ substantially in etiologies, pathogen profiles, and clinical manifestations. Age-specific individualized management is therefore essential: pediatric patients should be treated with emphasis on rhinogenic sources and adequate coverage of Gram-positive bacteria, while adult patients require consideration of more diverse etiologies and may benefit from broader-spectrum empirical antimicrobial regimens to optimize clinical outcomes. orbital cellulitis eye infection antibiotic resistance pathogen distribution age group Figures Figure 1 Figure 2 Figure 3 Introduction Orbital cellulitis is an acute and potentially life-threatening infectious disorder involving the soft tissues of the orbit, characterized by a rapid onset and aggressive clinical course (1). If not promptly treated, the disease may lead to severe complications such as optic neuritis, cavernous sinus thrombophlebitis, and intracranial infection, and can even be fatal (2). Therefore, early and accurate diagnosis and intervention are crucial for improving patient outcomes. However, systematic clinical data on orbital cellulitis remain limited both in China and worldwide, and comparative studies across different age groups are particularly scarce. In this study, we retrospectively collected and analyzed hospitalized cases diagnosed with orbital cellulitis over the past decade at a single tertiary ophthalmic center in northern China. Patients were stratified into pediatric and adult groups based on age. A comprehensive comparison was conducted regarding sex, geographical distribution, seasonal patterns, treatment approaches, hospitalization characteristics, etiological factors, pathogen profiles, and antimicrobial susceptibility patterns. The aim was to provide evidence-based guidance for age-specific individualized management strategies and to enhance clinicians’ ability to recognize and manage this ophthalmic emergency. Materials and Methods 2.1 Study Population A retrospective review was conducted on the clinical records of 131 patients diagnosed with orbital cellulitis and treated at Hebei Eye Hospital between January 1, 2014, and December 31, 2023. The study protocol was approved by the Ethics Committee of Hebei Eye Hospital. 2.2 Clinical Data Collection Clinical information for all 131 hospitalized patients was extracted, including demographic characteristics (age, sex, residence region, and season of onset), etiological factors, treatment modalities, clinical manifestations, laboratory findings, and microbiological results. Patients were classified into two groups based on age: the adult group (≥18 years old) and the pediatric group (<18 years old). The adult group comprised 76 cases, with ages ranging from 19 to 86 years, and a median age of 51.5 years. The pediatric group included 55 cases, with ages ranging from 4 months to 17 years, and a median age of 4 years. 2.3 Inclusion criteria and exclusion criteria Inclusion criteria: 1) patients with a definite diagnosis of orbital cellulitis based on clinical symptoms (such as eyelid redness, pain, proptosis, and limited movement) and imaging examinations such as orbital CT/MRI; 2) patients who have been hospitalized for treatment and have met clinical cure criteria; 3) patients with complete clinical data that can meet the requirements for research data collection and analysis. Exclusion criteria: 1) patients diagnosed with non-infectious orbital inflammation; 2) patients who only received outpatient treatment and were not hospitalized; 3) patients who were discharged halfway and did not meet the clinical cure criteria; 4) patients with incomplete clinical data and who were unable to complete data collection and analysis. 2.4 Specimen Collection and Culture A single ophthalmologist collected appropriate amounts of secretions under sterile conditions for bacterial and fungal culture. Positive cultures were subjected to pathogen identification and antimicrobial susceptibility testing. 2.5 Reagents and Instruments Blood agar plates and MacConkey agar plates were purchased from Zhengzhou Antu Biological Engineering Co., Ltd. Bacterial identification and antimicrobial susceptibility testing were performed using the VITEK 2 Compact automated microbial identification and susceptibility analysis system (bioMérieux, France) together with its corresponding identification and susceptibility cards. Quality control strains included Staphylococcus aureus (ATCC 25923), Escherichia coli (ATCC 25922), and Pseudomonas aeruginosa (ATCC 27853), all obtained from the American Type Culture Collection (ATCC). 2.6 Pathogen Identification and Antimicrobial Susceptibility Testing Pathogen identification and antibiotic resistance analysis of isolated strains were conducted using the VITEK 2 Compact automated system, supplemented by manual antimicrobial susceptibility testing with the Kirby–Bauer disk diffusion method. Interpretation of antimicrobial susceptibility results strictly followed the breakpoints specified in the Clinical and Laboratory Standards Institute (CLSI) document “Performance Standards for Antimicrobial Susceptibility Testing” (M100-Ed32, 2023). 2.7 Statistical Analysis Data analysis was performed using WHONET 5.6 software and processed using SPSS 25.0. Count data were expressed as number of strains and percentages (%). Differences between groups in sex, region, season, and treatment modality were analyzed using the χ² test; length of hospital stay was analyzed using the Mann–Whitney U test; and pathogen detection was analyzed using Fisher’s exact test. A P value < 0.05 was considered statistically significant. Results 3.1 Clinical Characteristics Regarding sex distribution, data showed that the proportion of males was slightly higher than females in both the adult and pediatric groups, and the difference in sex composition between the two groups was not statistically significant (χ² = 0.702, p > 0.05). In terms of regional distribution, patients in both groups were predominantly from rural areas, and no significant difference was observed between adults and children (χ² = 0.351, p > 0.05). With respect to seasonal distribution, there was no significant difference in the seasonal pattern of disease onset between the two groups (χ² = 0.439, p > 0.05)(Table 1) . However, a significant difference was found in treatment modalities between adults and children (χ² = 5.11, p ＜ 0.05), with the proportion of adults receiving surgical treatment markedly higher than that of children. Comparison of length of hospital stay also revealed a significant difference between the two groups (Mann–Whitney U = 1396.5, r = 0.46, p < 0.001). Specifically, the median hospital stay for adult patients was significantly longer than the pediatric patients(Table 1) (Figure 1) . Table 1. Comparison of Clinical Characteristics Between Adult and Pediatric Patients With Orbital Cellulitis Clinical characteristics Adult group Pediatric group P value Sex Male 40（52.6%） 33（60.0%） 0.402 Female 36（47.1%） 22（40.0%） Region Rural 60（78.9%） 41（74.5%） 0.554 Urban 16（21.1%） 14（25.5%） Season Spring 17（22.4%） 15（27.3%） 0.932 Summer 20（26.3%） 14（25.5%） Autumn 19（25.0%） 13（23.6%） Winter 20（26.3%） 13（23.6%） Treatment modality Surgical treatment 34（44.7%） 14（25.5%） 0.024 Non-surgical treatment 42（55.3%） 41（74.5%） Median hospital stay 11 7 < 0.001 Figure 1. Comparison of treatment modalities between adult and pediatric patients with orbital cellulitis 3.2 Etiological Factors The results showed a highly significant difference in the distribution of etiological factors between the adult and pediatric groups with orbital cellulitis (χ² = 21.92, P < 0.001). The causes in children were predominantly rhinogenic (58.2%). In contrast, the etiological distribution in adults was more diverse, mainly including trauma (21.3%), lacrimal system diseases (18.7%), and rhinogenic factors (21.3%)(Figure 2) . Figure 2:Comparison of etiological factors between adult and pediatric patients with orbital cellulitis. 3.3 Microbiological Characteristics 3.3.1 Positive Culture Rate A total of 31 specimens were submitted from 55 pediatric patients; excluding duplicate isolates from the same individual, 25 pathogenic strains were isolated, yielding a positive rate of 80.6% (25/31). In the adult group, 57 specimens were submitted from 76 patients, and 46 pathogenic strains were isolated, with a positive rate of 80.7% (46/57). 3.3.2 Distribution of Isolated Pathogens The results showed a significant statistical difference in the distribution of pathogen types between the adult and pediatric groups (P < 0.05). All pathogens isolated from the pediatric group were Gram-positive bacteria, predominantly Staphylococcus aureus and Streptococcus pneumoniae, with no Gram-negative bacteria or fungi detected. Although Gram-positive bacteria also predominated in the adult group (69.6%), a considerable proportion of Gram-negative bacteria (28.3%) and a small number of fungal isolates (2.2%) were identified (Figure 3) . The spectrum of pathogens in adults was more complex, including opportunistic organisms such as Klebsiella pneumoniae and Pseudomonas aeruginosa(Table 2). Table 2 :Distribution of isolated pathogens in adult and pediatric patients with orbital cellulitis Bacterial species Pediatric group (strains) Adult group (strains) Gram-positive bacteria 25 32 Staphylococcus aureus 14 10 Streptococcus pneumoniae 3 0 Gram-positive bacilli 3 2 Staphylococcus capitis 2 1 Group A Streptococcus 2 4 Staphylococcus hominis 1 1 Staphylococcus epidermidis 0 14 Gram-negative bacteria 0 13 Klebsiella pneumoniae 0 5 Citrobacter koseri 0 1 Morganella morganii 0 1 Proteus mirabilis 0 1 Acinetobacter haemolyticus 0 1 Pseudomonas putida 0 1 Enterobacter cloacae 0 1 Stenotrophomonas maltophilia 0 1 Pseudomonas aeruginosa 0 1 Fungi 0 1 Total 25 46 Figure 3: Comparison of pathogen distribution between adult and pediatric patients with orbital cellulitis. 3.3.3 Antibiotic Resistance Analysis The results showed that the difference in MRSA detection rates between the adult and pediatric groups was not statistically significant (P > 0.05)(Table 3). Table 3 :Distribution of MRSA in adult and pediatric groups Bacterial species Pediatric group (strains) Adult group (strains) Staphylococcus aureus 14 10 Methicillin-resistant Staphylococcus aureus (MRSA) 5 5 MRSA detection rate 35.7% 50.0% Discussion Through a comparative analysis of the clinical and microbiological characteristics of orbital cellulitis in adults and children in northern China, this study revealed a series of significant differences in disease composition, treatment strategies, and pathogen profiles, which hold important implications for clinical practice. Although no significant sex difference was observed between adult and pediatric patients with orbital cellulitis, the proportion of males was higher than females in both groups, a trend also reported in multiple studies (3). Mukund et al. (4) found that male children accounted for up to 70% of pediatric orbital cellulitis cases. The higher susceptibility of males to orbital cellulitis may be associated with behavior-related factors (such as increased outdoor activities leading to a higher risk of trauma) and sex-related immunological differences (5,6). In addition, studies have shown that male patients are more likely to require surgical intervention than female patients (5,7). The incidence of orbital cellulitis was significantly higher in rural areas than in urban areas. This regional disparity may be attributed to multiple factors (8): limited medical resources in rural regions, insufficient diagnostic and treatment capabilities for periorbital infections at primary healthcare facilities, delayed healthcare-seeking behavior due to transportation barriers, economic constraints, or lower health awareness among rural residents, and higher occupational exposure risks in agricultural settings, such as plant-related injuries and animal contact, which increase the likelihood of infection. Seasonal factors are widely recognized as important environmental contributors to the onset of orbital cellulitis.Some studies have reported that the incidence of orbital cellulitis is higher in autumn and winter, which may be related to the increased prevalence of respiratory tract infections and sinusitis during colder seasons (9,10,11). In this study, however, no obvious seasonal pattern was observed. Both adult and pediatric cases were distributed relatively evenly throughout the year. This distribution pattern may reflect the diverse etiologies of orbital cellulitis, such as sinusitis, trauma, odontogenic infections, and lacrimal system diseases, each of which follows its own epidemiological pattern; these differences may neutralize one another, resulting in a relatively stable year-round incidence. The appropriate selection of therapeutic strategies represents a pivotal determinant of disease progression and clinical prognosis in orbital cellulitis. Notably, the proportion of patients undergoing surgical intervention was significantly higher in the adult cohort than in the pediatric cohort, a finding that is consistent with previous reports in the literature (12). The medical treatment of orbital cellulitis is a basic treatment, especially suitable for patients with mild conditions and no surgical indications. Its core goal is to rapidly control infection, reduce orbital edema and inflammation, and prevent progression to severe complications. The major measures include anti-infective treatment, anti-inflammatory detumescence, symptomatic support, and local adjuvant therapy. The purposes of surgical treatment for orbital cellulitis are: surgical drainage of the formed abscess to quickly eliminate the infection lesions and prevent further spread of inflammation; optic nerve decompression when the infection seriously threatens visual function; surgery as an active intervention for patients whose clinical conditions (such as fever, pain, proptosis, limited movement, etc.) remain unchanged or even worsen after adequate antibiotic treatment. Additionally, some surgeries are related to the etiology and aim to address the underlying cause of infection, such as removing traumatic foreign bodies, debridement and suturing, tumor resection, resection of infected lesions, or surgical treatment of primary diseases such as chronic dacryocystitis.Differences in treatment strategies mainly arise from two aspects: first, children usually respond well to antibiotic therapy, and considering the risks associated with anesthesia and the potential impact of surgery on craniofacial development, clinicians tend to prefer conservative treatment in pediatric cases (13); second, adults often have more complex etiologies (such as odontogenic infections or retained foreign bodies), making them more prone to abscess formation, which represents a clear indication for surgical intervention. Kaur (14) elucidated that among patients requiring surgical intervention, debridement is the most commonly performed surgical procedure, accounting for 61.5% of all surgical cases.In addition, previous studies have shown that early surgical management often leads to better clinical outcomes in adult patients (9), supporting the rationale for prioritizing surgical intervention in this population. Notably, Cohen et al. also reported that elevated C-reactive protein(CRP) levels may serve as an important predictor of surgical need in orbital cellulitis (15,16). This finding provides clinicians with an objective reference for assessing whether adult patients require surgical intervention and may help optimize clinical decision-making. Length of hospital stay is a key indicator for the comprehensive assessment of disease severity, clinical heterogeneity, and healthcare burden in patients with orbital cellulitis. In the present study, the mean duration of hospitalization was significantly longer in adult patients than in pediatric patients.This difference is primarily attributable to two factors: first, the proportion of adults requiring surgery was substantially higher, and the surgical procedure itself, along with the necessary postoperative monitoring and observation, directly prolonged the hospitalization period; second, compared with children, adult patients often have multiple chronic comorbidities, resulting in a higher risk of postoperative complications and slower physiological recovery, which inevitably leads to longer recovery and hospitalization times. Although immune maturity and immunosuppression have been implicated in previous studies, immune status was not specifically evaluated in our cohort. Alison Gibbons et al. further reported that higher levels of inflammatory markers absolute neutrophil count(ANC), white blood cell count(WBC), CRP, and neutrophil-to-lymphocyte ratio(NLR) were associated with longer hospital stays (15). The underlying etiology of orbital cellulitis plays a decisive role in the formulation of individualized treatment strategies. The present study demonstrates that there are fundamental differences in the etiological distribution of orbital cellulitis between adult and pediatric patients. In pediatric patients, causes were highly concentrated, with rhinogenic factors playing a predominant role, which is consistent with previous reports (10,17). The paranasal sinuses in children are not fully developed, with relatively wide ostia, and the bony wall separating the sinuses from the orbit is thinner and more permeable. These anatomical features facilitate the spread of sinus infection into the orbit through weak areas of the medial orbital wall or via venous communications. In addition, the immune system in children is still maturing and remains functionally inadequate (18), which further compromises host defense against infection. Together, these factors markedly increase the risk of orbital cellulitis in the pediatric population. In contrast, the etiological spectrum in adults is more heterogeneous. Besides rhinogenic factors, trauma and lacrimal system diseases are also major causes. Adults are more frequently engaged in high-risk activities, leading to an increased incidence of eyelid and periocular trauma. P. Lakshmi(19) pointed out that trauma is the most common cause of orbital cellulitis in adults.Moreover, with advancing age, the incidence of obstructive lacrimal diseases such as dacryocystitis gradually increases, and recurrent dacryocystitis and dacryolithiasis are important risk factors for dacryocystitis complicated by orbital cellulitis (20). Additionally, adult soft tissue spaces and fascial structures are more compact, a characteristic that may amplify the impact of traumatic injuries and local organic lesions (such as lacrimal outflow obstruction), thereby increasing the proportion of non-rhinogenic etiologies. Furthermore, previous studies have reported that patients with comorbidities, impaired immune function, or pre-existing ocular conditions have a significantly higher risk of developing orbital cellulitis (21), and that immunosuppression is closely associated with unfavorable outcomes, particularly vision loss (20). This fundamental etiological difference necessitates distinct diagnostic approaches in clinical practice: in pediatric patients, clinicians should first evaluate for sinus infection and design interventions that take into account sinus development and immune immaturity; in adult patients, a comprehensive assessment of medical history, history of trauma, and lacrimal system disease is essential, along with careful evaluation of lacrimal drainage function, to accurately identify the underlying cause and implement targeted treatment, ultimately improving patient prognosis. Differences in microbiological characteristics constitute the core rationale for implementing differentiated clinical management strategies in adult and pediatric patients with orbital cellulitis and directly inform the selection of empiric antimicrobial therapy. The results of this study showed that the pathogen spectrum of orbital cellulitis differed significantly between adults and children: all pathogens isolated from the pediatric group were Gram-positive bacteria, whereas the adult group exhibited a more diverse microbiological profile, including Gram-positive bacteria, Gram-negative bacteria, and even fungi. Yadalla D reported that pediatric cases are often caused by a single aerobic pathogen, whereas adults are more likely to present with polymicrobial infections (9). In terms of bacterial composition, the major pathogens isolated in this study were Streptococcus species and Staphylococcus aureus, which is consistent with previous findings (3). Staphylococcus epidermidis was detected in the adult group, but not in the pediatric group. This difference may be associated with the different etiological compositions of the two groups: Staphylococcus epidermidis infections in adults are mainly attributed to lacrimal causes (5 cases) and post-traumatic infections (5 cases), while the etiology in children is predominantly rhinogenic infections. H. influenzae was not detected in the pediatric group, which may be related to the difficulty in the culture of this fastidious bacterium, as well as the widespread vaccination of Hib vaccine in China(22,23).Based on these microbiological characteristics, empirical antimicrobial therapy should be tailored accordingly. For pediatric patients, antibiotics targeting Gram-positive bacteria should be prioritized; for adult patients—particularly those with severe disease or complex underlying conditions—broad-spectrum antibiotics covering both Gram-positive and Gram-negative pathogens are recommended, with additional antifungal coverage considered when risk factors are present. It is noteworthy that individuals with systemic comorbidities, impaired immune function, or prior ocular implants are more susceptible to infections caused by highly resistant or aggressive pathogens such as Pseudomonas aeruginosa, which may increase treatment difficulty and worsen prognosis (21). MRSA, as one of the important pathogens of orbital cellulitis, has drawn increasing clinical attention due to its infection characteristics and the challenges it poses for management. The incidence of MRSA-related ocular infections has shown a continuous upward trend across many regions worldwide (24). Compared with other pathogens, MRSA infections typically exhibit a more aggressive clinical course. Its antimicrobial resistance and high-virulence mechanisms—such as toxin production, adhesion factors, and immune evasion—collectively contribute to increased treatment complexity (25). MRSA-induced orbital cellulitis is often associated with a prolonged disease course and may cause severe complications across different age groups (25,26). The results of this study showed no statistically significant difference in MRSA detection rates between adults and children (p > 0.05), suggesting that age is not an independent risk factor for MRSA-related orbital cellulitis. It is noteworthy that reported MRSA detection rates vary considerably across different medical institutions and geographic regions (27，28). For example, MAJ Blake T and colleagues reported an MRSA detection rate of 25%, recommending that MRSA be considered a potential causative pathogen during initial empirical treatment of orbital cellulitis, with appropriate anti-MRSA agents incorporated into therapy (3). Therefore, taking into account global epidemiological trends and local prevalence data, early coverage of MRSA in severe or high-risk patients provides important clinical guidance for improving patient outcomes. This study also has certain limitations. First, the sample size was relatively small, and all data were derived from a single medical institution, which may limit the representativeness and generalizability of the findings. The extrapolation of the conclusion requires further verification through multi-center, large-scale studies.Second, variability in the quality of medical record documentation may have resulted in incomplete or biased information, potentially affecting the accuracy of the data and the reliability of the analyses. Third, The microbiological profile is not representative of the whole population in this study since the specimens were not taken from all. Therefore, future studies should expand the sample size, include data from multiple centers (multiple hospitals), and conduct more systematic comparative analyses focusing on different clinical characteristics of orbital cellulitis—such as etiological subtypes, disease severity, and treatment responses—to further validate and extend the conclusions of this study and provide more broadly applicable evidence for clinical practice. Conclusion In summary, this study revealed significant differences between adults and children with orbital cellulitis in terms of etiology, pathogen spectrum, and clinical course: pediatric patients predominantly present with acute rhinogenic infections caused mainly by Gram-positive bacteria and generally have favorable outcomes, whereas adult patients exhibit diverse etiologies, a more complex microbial spectrum, a higher likelihood of abscess formation, and a more protracted disease course. Based on these findings, this study emphasizes that age can serve as a key stratification factor in clinical decision-making, enabling the development of individualized diagnostic and therapeutic pathways. Targeted etiological evaluation, pathogen-based assessment, and tailored treatment selection can improve infection control, reduce complications, and enhance clinical outcomes. The results of this study underscore the necessity of implementing individualized treatment approaches in different patient populations and provide important guidance for clinical practice. Abbreviations ANC,Absolute Neutrophil Count WBC,White Blood Cell Count CRP,C-reactive protein NLR,Neutrophil-to-Lymphocyte Ratio MRSA,Methicillin-resistant Staphylococcus aureus Declarations Acknowledgements Not applicable. Author Contributions Methodology, PPJ; Validation, XLC, and LHY.; Formal analysis, DZ.; Investigation, TL,KLand PFH; Data curation, KXX.; Writing—original draft preparation, PPJ. and YD; Writing—review and Editing, PPJ. and RNM. All authors have read and agreed to the published version of the manuscript. Funding This research was supported by the Key Research and Development Plan Project in Xingtai City under Grant number 2025ZC051 and 2025ZC054. Data availability: The authors confirm that the data supporting the findings of this study are available within the article. More detailed raw data are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study was performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of Hebei Eye Hospital, China. Written informed consent was obtained from each patient or their parents (for children < 18 years of age) prior to participation in the study. Consent for publication Not applicable. References Wang, N. L.; Yang, L. Ophthalmology, 4th ed.; Peking University Medical Press: Beijing, China, 2019; p. 240. Yao, B.; Ding, Y.; Zhao, X.; Wang, B.; Liu, G.; Wang, F. Clinical Characteristics and Prognosis of Adult Orbital Cellulitis in a Tertiary General Hospital. J Ophthalmol . (2020) 8889341. https://doi.org/10.1155/2020/8889341 Cirks, B. T.; Claunch, K. M.; DePerrior, S.; Poitras, B., Adams, D. J.Microbiology and Epidemiology of Orbital Cellulitis in Pediatric and Young Adult Patients. Mil Med . (2025) 190(3-4), e593–e600. https://doi.org/10.1093/milmed/usae394 Mishra, S. K.; Kumar, S.; Kumari, A.; Sharma, N. A retrospective observational study of orbital cellulitis in children - Recent trends. J Family Med Prim Care . (2024) 13(10), 4712–4714. https://doi.org/10.4103/jfmpc.jfmpc_847_24 Wanstreet, T.; Kais, A.; Makary, C. A.; Cui, R.; Ramadan, H. H. Gender differences in the management of pediatric orbital cellulitis. Am J Otolaryngol. (2025) 46(5), 104661. https://doi.org/10.1016/j.amjoto.2025.104661 Vloka, C. N.; Summers, R. C.; DeSantis, D.; Hink, E. M. Incidence of orbital cellulitis in children: a population-based study. J AAPOS. (2025) 29(3), 104214. https://doi.org/10.1016/j.jaapos.2025.104214 Jiramongkolchai, P.; Lander, D. P.; Kallogjeri, D.; Olsen, M. A.; Keller, M.; Schneider, J. S.; Lee, J. J.; Jiramongkolchai, K.; Piccirillo, J. F. Trend of surgery for orbital cellulitis: An analysis of state inpatient databases. Laryngoscope. (2020) 130(3), 567–574. https://doi.org/10.1002/lary.28050 Yang Wen ; Dai Peng-Fei; Xue Da-Xi;Chang Hua-Lei; Chen Tao. Epidemiological analysis of ocular trauma in Shaanxi and surrounding areas. International Eye Science . (2022) ,22(02):352-356.DOI 10.3980/j.issn.1672-5123.2022.2.36 Yadalla, D.; Jayagayathri, R.; Padmanaban, K.; Ramasamy, R.; Rammohan, R.; Nisar, S. P.; Rangarajan, V.; Menon, V. Bacterial orbital cellulitis - A review. Indian J Ophthalmol . (2023) 71(7), 2687–2693. https://doi.org/10.4103/IJO.IJO_3283_22 Hayat, J.; Al-Musalam, L.; Al-Shaya, D.; Tawfiq, E.; Al-Sihan, M.; Behbehani, R. Pre-septal and Orbital Cellulitis: A Retrospective Analysis of Manifestations and Outcomes of a Tertiary Center in Kuwait. Cureus . (2024) 16(7), e65104. https://doi.org/10.7759/cureus.65104 Khurshied, S.; Shah, H. G.; Babar, A.; Afsar, A.; Zahid, M. A.; Nisa, M. Trends of Sinusitis-Associated Orbital Cellulitis in Pediatric Patients: A Retrospective Cohort Review. Cureus . (2025) 17(5), e84505. https://doi.org/10.7759/cureus.84505 Mei Fang; Chen Juan; Qian Jing; Chen Zhi-jun.Analysis of Diagnosis and Treatment of 165 Cases Pediatric Orbital Cellulitis .Journal of Sichuan University . (2019) 50(02):256-259.DOI:10.13464/j.scuxbyxb.2019.02.023 Wang Dan; Zhang Hao; Yang su-hong. Clinical analysis of orbital cellulitis in children. Chinese Journal of Strabismus & Pediatric Ophthalmology . (2019) 27(03):25-28+61.DOI:10.3969/J.ISSN.1005-328X.2019.03.008 Kaur, N. Study of prognostic outcome of cellulitis patients with diabetes mellitus. International Surgery Journal , (2022) 9(10), 1700–1705.https://doi.org/10.18203/2349-2902.isj20222359 Gibbons, A.; Cherkas, E.; Kaur, M.; Dharssi, S.; Elsharawi, R.; Ashraf, D. C.; Li, E. Inflammatory Markers as Predictors of Orbital Infection Severity. Ophthalmic Plast Reconstr Surg . (2025) 41(5), 530–534. https://doi.org/10.1097/IOP.0000000000002903 Cohen, N.; Erisson, S.; Anafy, A.; Palnizky-Soffer, G.; Cohen, E.; Capua, T.; Rimon, A.; Grisaru-Soen, G. Clinicians need to consider surgery when presented with some markers for severe paediatric orbital cellulitis. Acta Paediatr . (2020) 109(6), 1269–1270. https://doi.org/10.1111/apa.15125 Khurshied, S.; Shah, H. G.; Abdul Malik, W.; Maqbool, A.; Hussain, K.; Zahid, M. A.Characteristics of Patients Treated for Orbital Infections: A Retrospective Study at a Tertiary Care Hospital. Cureus . (2025) 17(2), e79004. https://doi.org/10.7759/cureus.79004 Maniaci, A.; Gagliano, C.; Lavalle, S.; van der Poel, N.; La Via, L.; Longo, A.; Russo, A.; Zeppieri, M. Ocular Manifestations of Pediatric Rhinosinusitis: A Comprehensive Review. Diseases . (2024) 12(10), 239. https://doi.org/10.3390/diseases12100239 P. Lakshmi; A. Jahnavi; N. Kranthi Priya; M. Komala Lakshmi; Dhivyesh N.A. Comparative Study on Cellulitis in Patients with and without Diabetes Mellitus.Journal of Advances in Medicine and Medical Research, (2025)37(10), 85-91.https://doi.org/10.9734/JAMMR/2025/V37I105949. O'Rourke, M.; Tang, Y. F.; Pick, Z.; Tan, J. S.; Tan, P. E. Z.; Athavale, D. D.; O'Donnell, B.; Selva, D.; Gajdatsy, A.; Hardy, T. G.; McNab, A.; Khong, J. J. Orbital Cellulitis Secondary to Dacryocystitis: A Case Series and Literature Review. Ophthalmic Plast Reconstr Surg . (2025) 41(3), 306–314. https://doi.org/10.1097/IOP.0000000000002834 Chen, Y. K.; Tu, H. P.; Chen, I. H. Clinical characteristics and prognosis of adult orbital cellulitis in a tertiary general hospital. Scientific reports . (2025) 15(1), 20585. https://doi.org/10.1038/s41598-025-06382-2 Ambati BK; Ambati J; Azar N; Stratton L; Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. (2000) 107(8):1450-1453.https://doi.org/10.1016/S0161-6420(00)00178-0 Hegde R, Sundar G. Orbital cellulitis-A review. TNOA J Ophthalmic Sci Res 2017;55:211‑9.https://doi.org/10.4103/tjosr.tjosr_9_18 Shih, E. J.; Chen, J. K.; Tsai, P. J.; & Bee, Y. S. Differences in characteristics, aetiologies, isolated pathogens, and the efficacy of antibiotics in adult patients with preseptal cellulitis and orbital cellulitis between 2000-2009 and 2010-2019. Br J Ophthalmol . (2023) 107(3), 331–336. https://doi.org/10.1136/bjophthalmol-2021-318986 Ang, T.; Cameron, C.; Tong, J. Y.; Wilcsek, G.; Tan, J.; Patel, S.; Selva, D. Methicillin-resistant Staphylococcus aureus-associated orbital cellulitis: a case series. Int Ophthalmol . (2023) 43(8), 2925–2933. https://doi.org/10.1007/s10792-023-02698-y Hsu, J.; Treister, A. D.; Ralay Ranaivo, H.; Rowley, A. H.; Rahmani, B. Microbiology of Pediatric Orbital Cellulitis and Trends in Methicillin-Resistant Staphylococcus aureus Cases. Clin Pediatr (Phila) . (2019) 58(10), 1056–1062. https://doi.org/10.1177/0009922819864587 Joseph, J.; Karolia, R.; Sharma, S.; Choudhary, H.; Naik, M. N. Microbiological profile and antibiotic susceptibility trends in orbital cellulitis in India: an analysis over 15 years. Orbit . (2022) 41(6), 726–732. https://doi.org/10.1080/01676830.2021.2002368 Meghna Sharma; Michael Taylor; Shiva Salehian; Alexandra Espinel; Kevin M Lloyd; Emily Ansusinha ; Rana F Hamdy.Clinical Epidemiology and Microbiology of Orbital Cellulitis in Children.J Pediatric Infect Dis Soc.(2025)15(1).https://doi.org/10.1093/JPIDS/PIAF113. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 21 Apr, 2026 Reviews received at journal 21 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviews received at journal 15 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers invited by journal 14 Apr, 2026 Editor assigned by journal 04 Apr, 2026 Submission checks completed at journal 04 Apr, 2026 First submitted to journal 01 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9297175","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625730246,"identity":"bfd3ffb4-cfa1-4dc3-abb7-a10c2e78333e","order_by":0,"name":"Peipei Jia","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peipei","middleName":"","lastName":"Jia","suffix":""},{"id":625730251,"identity":"17e8567a-6b56-4f21-98f3-472dee3b0ce3","order_by":1,"name":"Xiaolu Cao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACNvbmg4//8EjUM7Y3HyBOCx/PsWQDHhmLBOaeYwnEaZGTyDGT4LGpSGCf4WNApMMYgFokciTyeGfwfLzxhsFOTreBoJZjxRYGZySKJWf3bracw5BsbHaAkBbG5o03EnskGDfOObtNmofhQOI2glqYGQwkDv6TYNx/I+cZkVrYWIwkG3gkEhtn5LARqYWHLdmYgUfCmLHnmLHlHAMi/CI///HBxww8dXLAqHx4402FnRxBLShAgofIqEHWQqqOUTAKRsEoGBEAAKZAP1n1iVmvAAAAAElFTkSuQmCC","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaolu","middleName":"","lastName":"Cao","suffix":""},{"id":625730253,"identity":"d34af18f-f7dc-456d-bb93-0a298f13cdf1","order_by":2,"name":"Dan Zhang","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Zhang","suffix":""},{"id":625730258,"identity":"95ca5904-a341-46fa-b599-95593bd211b0","order_by":3,"name":"Pengfei Han","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Han","suffix":""},{"id":625730260,"identity":"23214aae-6383-44d2-be3d-1cb3f87fb108","order_by":4,"name":"Tao Li","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Li","suffix":""},{"id":625730262,"identity":"9b98b658-0840-4e4b-8458-1cb564ac8753","order_by":5,"name":"Yu Duan","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Duan","suffix":""},{"id":625730265,"identity":"9c3b0afd-f281-42b6-acfc-dcf807e914af","order_by":6,"name":"Kexin Xu","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kexin","middleName":"","lastName":"Xu","suffix":""},{"id":625730266,"identity":"336f2b5b-1de5-4327-b27a-19f9716e820e","order_by":7,"name":"Ke Li","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Li","suffix":""},{"id":625730271,"identity":"fa87c8ee-e30d-4ee8-a1fc-f5e869ade985","order_by":8,"name":"Lihui Yin","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lihui","middleName":"","lastName":"Yin","suffix":""},{"id":625730275,"identity":"8818adc3-0a31-422e-8fd9-96d51b182837","order_by":9,"name":"Ruoning Mi","email":"","orcid":"","institution":"Hebei Eye Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruoning","middleName":"","lastName":"Mi","suffix":""}],"badges":[],"createdAt":"2026-04-02 02:40:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9297175/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9297175/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107500730,"identity":"55843094-4939-4480-ad57-d4e0308627fa","added_by":"auto","created_at":"2026-04-22 05:49:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25964,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of treatment modalities between adult and pediatric patients with orbital cellulitis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9297175/v1/fa20e885d9d672328b94402e.png"},{"id":107500732,"identity":"5765f130-f100-4c9a-9f0f-46f689694f6b","added_by":"auto","created_at":"2026-04-22 05:49:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":78018,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of etiological factors between adult and pediatric patients with orbital cellulitis.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9297175/v1/4b4bcc06a2d3e342714d8bad.png"},{"id":107868829,"identity":"ecb3bd69-7c5c-4292-8e0d-e9ad7491121e","added_by":"auto","created_at":"2026-04-27 07:34:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":25756,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of pathogen distribution between adult and pediatric patients with orbital cellulitis.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9297175/v1/8b87e9a8238c0ccd3c87b82b.png"},{"id":107871671,"identity":"cd238f57-ad57-49e2-aba4-67d96f8d72b6","added_by":"auto","created_at":"2026-04-27 07:53:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":343343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9297175/v1/0b5a192f-54ff-46bf-a87b-0fc2a1eff351.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Characteristics and Differences in Pathogen Distribution of Orbital Cellulitis Between Children and Adults in Northern China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOrbital cellulitis is an acute and potentially life-threatening infectious disorder involving the soft tissues of the orbit, characterized by a rapid onset and aggressive clinical course (1). If not promptly treated, the disease may lead to severe complications such as optic neuritis, cavernous sinus thrombophlebitis, and intracranial infection, and can even be fatal (2). Therefore, early and accurate diagnosis and intervention are crucial for improving patient outcomes. However, systematic clinical data on orbital cellulitis remain limited both in China and worldwide, and comparative studies across different age groups are particularly scarce. In this study, we retrospectively collected and analyzed hospitalized cases diagnosed with orbital cellulitis over the past decade at a single tertiary ophthalmic center in northern China. Patients were stratified into pediatric and adult groups based on age. A comprehensive comparison was conducted regarding sex, geographical distribution, seasonal patterns, treatment approaches, hospitalization characteristics, etiological factors, pathogen profiles, and antimicrobial susceptibility patterns. The aim was to provide evidence-based guidance for age-specific individualized management strategies and to enhance clinicians\u0026rsquo; ability to recognize and manage this ophthalmic emergency.\u003c/p\u003e\n"},{"header":"Materials and Methods","content":"\u003cp\u003e2.1 Study Population\u003c/p\u003e\n\u003cp\u003eA retrospective review was conducted on the clinical records of 131 patients diagnosed with orbital cellulitis and treated at Hebei Eye Hospital between January 1, 2014, and December 31, 2023. The study protocol was approved by the Ethics Committee of Hebei Eye Hospital.\u003c/p\u003e\n\u003cp\u003e2.2 Clinical Data Collection\u003c/p\u003e\n\u003cp\u003eClinical information for all 131 hospitalized patients was extracted, including demographic characteristics (age, sex, residence region, and season of onset), etiological factors, treatment modalities, clinical manifestations, laboratory findings, and microbiological results.\u003c/p\u003e\n\u003cp\u003ePatients were classified into two groups based on age: the adult group (\u0026ge;18 years old) and the pediatric group (\u0026lt;18 years old). The adult group comprised 76 cases, with ages ranging from 19 to 86 years, and a median age of 51.5 years. The pediatric group included 55 cases, with ages ranging from 4 months to 17 years, and a median age of 4 years.\u003c/p\u003e\n\u003cp\u003e2.3 Inclusion criteria and exclusion criteria\u003c/p\u003e\n\u003cp\u003eInclusion criteria: 1) patients with a definite diagnosis of orbital cellulitis based on clinical symptoms (such as eyelid redness, pain, proptosis, and limited movement) and imaging examinations such as orbital CT/MRI; 2) patients who have been hospitalized for treatment and have met clinical cure criteria; 3) patients with complete clinical data that can meet the requirements for research data collection and analysis.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: 1) patients diagnosed with non-infectious orbital inflammation; 2) patients who only received outpatient treatment and were not hospitalized; 3) patients who were discharged halfway and did not meet the clinical cure criteria; 4) patients with incomplete clinical data and who were unable to complete data collection and analysis.\u003c/p\u003e\n\u003cp\u003e2.4 Specimen Collection and Culture \u003c/p\u003e\n\u003cp\u003eA single ophthalmologist collected appropriate amounts of secretions under sterile conditions for bacterial and fungal culture. Positive cultures were subjected to pathogen identification and antimicrobial susceptibility testing.\u003c/p\u003e\n\u003cp\u003e2.5 Reagents and Instruments \u003c/p\u003e\n\u003cp\u003eBlood agar plates and MacConkey agar plates were purchased from Zhengzhou Antu Biological Engineering Co., Ltd. Bacterial identification and antimicrobial susceptibility testing were performed using the VITEK 2 Compact automated microbial identification and susceptibility analysis system (bioM\u0026eacute;rieux, France) together with its corresponding identification and susceptibility cards. Quality control strains included Staphylococcus aureus (ATCC 25923), Escherichia coli (ATCC 25922), and Pseudomonas aeruginosa (ATCC 27853), all obtained from the American Type Culture Collection (ATCC).\u003c/p\u003e\n\u003cp\u003e2.6 Pathogen Identification and Antimicrobial \u003c/p\u003e\n\u003cp\u003eSusceptibility Testing Pathogen identification and antibiotic resistance analysis of isolated strains were conducted using the VITEK 2 Compact automated system, supplemented by manual antimicrobial susceptibility testing with the Kirby\u0026ndash;Bauer disk diffusion method. Interpretation of antimicrobial susceptibility results strictly followed the breakpoints specified in the Clinical and Laboratory Standards Institute (CLSI) document \u0026ldquo;Performance Standards for Antimicrobial Susceptibility Testing\u0026rdquo; (M100-Ed32, 2023).\u003c/p\u003e\n\u003cp\u003e2.7 Statistical Analysis \u003c/p\u003e\n\u003cp\u003eData analysis was performed using WHONET 5.6 software and processed using SPSS 25.0. Count data were expressed as number of strains and percentages (%). Differences between groups in sex, region, season, and treatment modality were analyzed using the \u0026chi;\u0026sup2; test; length of hospital stay was analyzed using the Mann\u0026ndash;Whitney U test; and pathogen detection was analyzed using Fisher\u0026rsquo;s exact test. A P value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e3.1 \u0026nbsp; \u0026nbsp; \u0026nbsp;Clinical Characteristics\u003c/p\u003e\n\u003cp\u003eRegarding sex distribution, data showed that the proportion of males was slightly higher than females in both the adult and pediatric groups, and the difference in sex composition between the two groups was not statistically significant (χ² = 0.702, p \u0026gt; 0.05). In terms of regional distribution, patients in both groups were predominantly from rural areas, and no significant difference was observed between adults and children (χ² = 0.351, p \u0026gt; 0.05). With respect to seasonal distribution, there was no significant difference in the seasonal pattern of disease onset between the two groups (χ² = 0.439, p \u0026gt; 0.05)(Table 1) .\u003c/p\u003e\n\u003cp\u003eHowever, a significant difference was found in treatment modalities between adults and children (χ² = 5.11, p ＜ 0.05), with the proportion of adults receiving surgical treatment markedly higher than that of children. Comparison of length of hospital stay also revealed a significant difference between the two groups (Mann–Whitney U = 1396.5, r = 0.46, p \u0026lt; 0.001). Specifically, the median hospital stay for adult patients was significantly longer than the pediatric patients(Table 1) (Figure 1) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Comparison of Clinical Characteristics Between Adult and Pediatric Patients With Orbital Cellulitis\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"526\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\"\u003e\u003cstrong\u003eClinical characteristics\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e\u003cstrong\u003eAdult group\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e\u003cstrong\u003ePediatric group\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003eSex\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003eMale\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e40（52.6%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e33（60.0%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003e0.402\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eFemale\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e36（47.1%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e22（40.0%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003eRegion\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003eRural\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e60（78.9%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e41（74.5%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003e0.554\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eUrban \u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e16（21.1%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e14（25.5%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"4\"\u003eSeason\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003eSpring\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e17（22.4%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e15（27.3%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" rowspan=\"4\"\u003e0.932\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eSummer\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e20（26.3%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e14（25.5%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eAutumn\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e19（25.0%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e13（23.6%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eWinter\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e20（26.3%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\"\u003e13（23.6%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003eTreatment modality\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003eSurgical treatment\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e34（44.7%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e14（25.5%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" rowspan=\"2\"\u003e0.024\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\"\u003eNon-surgical treatment\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e42（55.3%）\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e41（74.5%）\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"2\"\u003eMedian\u0026nbsp;hospital stay\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e11\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e7\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\"\u003e\u0026lt; 0.001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFigure 1. Comparison of treatment modalities between adult and pediatric patients with orbital cellulitis\u003c/p\u003e\n\u003cp\u003e3.2\u0026nbsp; \u0026nbsp; \u0026nbsp;Etiological Factors\u003c/p\u003e\n\u003cp\u003eThe results showed a highly significant difference in the distribution of etiological factors between the adult and pediatric groups with orbital cellulitis (χ² = 21.92, P \u0026lt; 0.001). The causes in children were predominantly rhinogenic (58.2%). In contrast, the etiological distribution in adults was more diverse, mainly including trauma (21.3%), lacrimal system diseases (18.7%), and rhinogenic factors (21.3%)(Figure 2) .\u003c/p\u003e\n\u003cp\u003eFigure 2:Comparison of etiological factors between adult and pediatric patients with orbital cellulitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.3\u0026nbsp; \u0026nbsp; \u0026nbsp; Microbiological Characteristics\u003c/p\u003e\n\u003cp\u003e3.3.1\u0026nbsp;\u0026nbsp;Positive Culture Rate\u003c/p\u003e\n\u003cp\u003eA total of 31 specimens were submitted from 55 pediatric patients; excluding duplicate isolates from the same individual, 25 pathogenic strains were isolated, yielding a positive rate of 80.6% (25/31). In the adult group, 57 specimens were submitted from 76 patients, and 46 pathogenic strains were isolated, with a positive rate of 80.7% (46/57).\u003c/p\u003e\n\u003cp\u003e3.3.2\u0026nbsp;\u0026nbsp;Distribution of Isolated Pathogens\u003c/p\u003e\n\u003cp\u003eThe results showed a significant statistical difference in the distribution of pathogen types between the adult and pediatric groups (P \u0026lt; 0.05). All pathogens isolated from the pediatric group were Gram-positive bacteria, predominantly Staphylococcus aureus and Streptococcus pneumoniae, with no Gram-negative bacteria or fungi detected. Although Gram-positive bacteria also predominated in the adult group (69.6%), a considerable proportion of Gram-negative bacteria (28.3%) and a small number of fungal isolates (2.2%) were identified (Figure\u0026nbsp;3) . The spectrum of pathogens in adults was more complex, including opportunistic organisms such as Klebsiella pneumoniae and Pseudomonas aeruginosa(Table\u0026nbsp;2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e:Distribution of isolated pathogens in adult and pediatric patients with orbital cellulitis\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cstrong\u003eBacterial species\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003ePediatric group (strains)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eAdult group (strains)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eGram-positive bacteria\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e25\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e32\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStaphylococcus aureus\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e14\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e10\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStreptococcus pneumoniae\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eGram-positive bacilli \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e3\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStaphylococcus capitis \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eGroup A Streptococcus\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e2\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e4\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStaphylococcus hominis\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStaphylococcus epidermidis\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e14\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eGram-negative bacteria\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e13\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eKlebsiella pneumoniae \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eCitrobacter koseri\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eMorganella morganii \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eProteus mirabilis\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eAcinetobacter haemolyticus \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003ePseudomonas putida \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eEnterobacter cloacae \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eStenotrophomonas maltophilia\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003ePseudomonas aeruginosa \u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eFungi\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e0\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e1\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e25\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e46\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFigure 3: Comparison of pathogen distribution between adult and pediatric patients with orbital cellulitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.3.3\u0026nbsp;\u0026nbsp;Antibiotic Resistance Analysis\u003c/p\u003e\n\u003cp\u003eThe results showed that the difference in MRSA detection rates between the adult and pediatric groups was not statistically significant (P \u0026gt; 0.05)(Table\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e:Distribution of MRSA in adult and pediatric groups\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"666\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cstrong\u003eBacterial species\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cstrong\u003ePediatric group\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e(strains) \u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cstrong\u003eAdult group\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e(strains)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003eStaphylococcus aureus\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e14\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e10\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003eMethicillin-resistant Staphylococcus aureus (MRSA)\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e5\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003eMRSA detection rate\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e35.7%\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e50.0%\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThrough a comparative analysis of the clinical and microbiological characteristics of orbital cellulitis in adults and children in northern China, this study revealed a series of significant differences in disease composition, treatment strategies, and pathogen profiles, which hold important implications for clinical practice.\u003c/p\u003e\n\u003cp\u003eAlthough no significant sex difference was observed between adult and pediatric patients with orbital cellulitis, the proportion of males was higher than females in both groups, a trend also reported in multiple studies (3). Mukund et al. (4) found that male children accounted for up to 70% of pediatric orbital cellulitis cases. The higher susceptibility of males to orbital cellulitis may be associated with behavior-related factors (such as increased outdoor activities leading to a higher risk of trauma) and sex-related immunological differences (5,6). In addition, studies have shown that male patients are more likely to require surgical intervention than female patients (5,7).\u003c/p\u003e\n\u003cp\u003eThe incidence of orbital cellulitis was significantly higher in rural areas than in urban areas. This regional disparity may be attributed to multiple factors (8): limited medical resources in rural regions, insufficient diagnostic and treatment capabilities for periorbital infections at primary healthcare facilities, delayed healthcare-seeking behavior due to transportation barriers, economic constraints, or lower health awareness among rural residents, and higher occupational exposure risks in agricultural settings, such as plant-related injuries and animal contact, which increase the likelihood of infection.\u003c/p\u003e\n\u003cp\u003eSeasonal factors are widely recognized as important environmental contributors to the onset of orbital cellulitis.Some studies have reported that the incidence of orbital cellulitis is higher in autumn and winter, which may be related to the increased prevalence of respiratory tract infections and sinusitis during colder seasons (9,10,11). In this study, however, no obvious seasonal pattern was observed. Both adult and pediatric cases were distributed relatively evenly throughout the year. This distribution pattern may reflect the diverse etiologies of orbital cellulitis, such as sinusitis, trauma, odontogenic infections, and lacrimal system diseases, each of which follows its own epidemiological pattern; these differences may neutralize one another, resulting in a relatively stable year-round incidence.\u003c/p\u003e\n\u003cp\u003eThe appropriate selection of therapeutic strategies represents a pivotal determinant of disease progression and clinical prognosis in orbital cellulitis. Notably, the proportion of patients undergoing surgical intervention was significantly higher in the adult cohort than in the pediatric cohort, a finding that is consistent with previous reports in the literature (12). \u0026nbsp;The medical treatment of orbital cellulitis is a basic treatment, especially suitable for patients with mild conditions and no surgical indications. Its core goal is to rapidly control infection, reduce orbital edema and inflammation, and prevent progression to severe complications. The major measures include anti-infective treatment, anti-inflammatory detumescence, symptomatic support, and local adjuvant therapy. The purposes of surgical treatment for orbital cellulitis are: surgical drainage of the formed abscess to quickly eliminate the infection lesions and prevent further spread of inflammation; optic nerve decompression when the infection seriously threatens visual function; surgery as an active intervention for patients whose clinical conditions (such as fever, pain, proptosis, limited movement, etc.) remain unchanged or even worsen after adequate antibiotic treatment. Additionally, some surgeries are related to the etiology and aim to address the underlying cause of infection, such as removing traumatic foreign bodies, debridement and suturing, tumor resection, resection of infected lesions, or surgical treatment of primary diseases such as chronic dacryocystitis.Differences in treatment strategies mainly arise from two aspects: first, children usually respond well to antibiotic therapy, and considering the risks associated with anesthesia and the potential impact of surgery on craniofacial development, clinicians tend to prefer conservative treatment in pediatric cases (13); second, adults often have more complex etiologies (such as odontogenic infections or retained foreign bodies), making them more prone to abscess formation, which represents a clear indication for surgical intervention. Kaur (14) elucidated that among patients requiring surgical intervention, debridement is the most commonly performed surgical procedure, accounting for 61.5% of all surgical cases.In addition, previous studies have shown that early surgical management often leads to better clinical outcomes in adult patients (9), supporting the rationale for prioritizing surgical intervention in this population. Notably, Cohen et al. also reported that elevated C-reactive protein(CRP) levels may serve as an important predictor of surgical need in orbital cellulitis (15,16). This finding provides clinicians with an objective reference for assessing whether adult patients require surgical intervention and may help optimize clinical decision-making.\u003c/p\u003e\n\u003cp\u003eLength of hospital stay is a key indicator for the comprehensive assessment of disease severity, clinical heterogeneity, and healthcare burden in patients with orbital cellulitis. In the present study, the mean duration of hospitalization was significantly longer in adult patients than in pediatric patients.This difference is primarily attributable to two factors: first, the proportion of adults requiring surgery was substantially higher, and the surgical procedure itself, along with the necessary postoperative monitoring and observation, directly prolonged the hospitalization period; second, compared with children, adult patients often have multiple chronic comorbidities, resulting in a higher risk of postoperative complications and slower physiological recovery, which inevitably leads to longer recovery and hospitalization times. Although immune maturity and immunosuppression have been implicated in previous studies, immune status was not specifically evaluated in our cohort. Alison Gibbons et al. further reported that higher levels of inflammatory markers absolute neutrophil count(ANC), white blood cell count(WBC), CRP, and neutrophil-to-lymphocyte ratio(NLR) were associated with longer hospital stays (15).\u003c/p\u003e\n\u003cp\u003eThe underlying etiology of orbital cellulitis plays a decisive role in the formulation of individualized treatment strategies. The present study demonstrates that there are fundamental differences in the etiological distribution of orbital cellulitis between adult and pediatric patients. In pediatric patients, causes were highly concentrated, with rhinogenic factors playing a predominant role, which is consistent with previous reports (10,17). The paranasal sinuses in children are not fully developed, with relatively wide ostia, and the bony wall separating the sinuses from the orbit is thinner and more permeable. These anatomical features facilitate the spread of sinus infection into the orbit through weak areas of the medial orbital wall or via venous communications. In addition, the immune system in children is still maturing and remains functionally inadequate (18), which further compromises host defense against infection. Together, these factors markedly increase the risk of orbital cellulitis in the pediatric population. In contrast, the etiological spectrum in adults is more heterogeneous. Besides rhinogenic factors, trauma and lacrimal system diseases are also major causes. Adults are more frequently engaged in high-risk activities, leading to an increased incidence of eyelid and periocular trauma. P. Lakshmi(19) pointed out that trauma is the most common cause of orbital cellulitis in adults.Moreover, with advancing age, the incidence of obstructive lacrimal diseases such as dacryocystitis gradually increases, and recurrent dacryocystitis and dacryolithiasis are important risk factors for dacryocystitis complicated by orbital cellulitis (20). Additionally, adult soft tissue spaces and fascial structures are more compact, a characteristic that may amplify the impact of traumatic injuries and local organic lesions (such as lacrimal outflow obstruction), thereby increasing the proportion of non-rhinogenic etiologies. Furthermore, previous studies have reported that patients with comorbidities, impaired immune function, or pre-existing ocular conditions have a significantly higher risk of developing orbital cellulitis (21), and that immunosuppression is closely associated with unfavorable outcomes, particularly vision loss (20). This fundamental etiological difference necessitates distinct diagnostic approaches in clinical practice: in pediatric patients, clinicians should first evaluate for sinus infection and design interventions that take into account sinus development and immune immaturity; in adult patients, a comprehensive assessment of medical history, history of trauma, and lacrimal system disease is essential, along with careful evaluation of lacrimal drainage function, to accurately identify the underlying cause and implement targeted treatment, ultimately improving patient prognosis.\u003c/p\u003e\n\u003cp\u003eDifferences in microbiological characteristics constitute the core rationale for implementing differentiated clinical management strategies in adult and pediatric patients with orbital cellulitis and directly inform the selection of empiric antimicrobial therapy. The results of this study showed that the pathogen spectrum of orbital cellulitis differed significantly between adults and children: all pathogens isolated from the pediatric group were Gram-positive bacteria, whereas the adult group exhibited a more diverse microbiological profile, including Gram-positive bacteria, Gram-negative bacteria, and even fungi. Yadalla D reported that pediatric cases are often caused by a single aerobic pathogen, whereas adults are more likely to present with polymicrobial infections (9). In terms of bacterial composition, the major pathogens isolated in this study were Streptococcus species and Staphylococcus aureus, which is consistent with previous findings (3). Staphylococcus epidermidis was detected in the adult group, but not in the pediatric group. This difference may be associated with the different etiological compositions of the two groups: Staphylococcus epidermidis infections in adults are mainly attributed to lacrimal causes (5 cases) and post-traumatic infections (5 cases), while the etiology in children is predominantly rhinogenic infections. H. influenzae was not detected in the pediatric group, which may be related to the difficulty in the culture of this fastidious bacterium, as well as the widespread vaccination of Hib vaccine in China(22,23).Based on these microbiological characteristics, empirical antimicrobial therapy should be tailored accordingly. For pediatric patients, antibiotics targeting Gram-positive bacteria should be prioritized; for adult patients\u0026mdash;particularly those with severe disease or complex underlying conditions\u0026mdash;broad-spectrum antibiotics covering both Gram-positive and Gram-negative pathogens are recommended, with additional antifungal coverage considered when risk factors are present. It is noteworthy that individuals with systemic comorbidities, impaired immune function, or prior ocular implants are more susceptible to infections caused by highly resistant or aggressive pathogens such as Pseudomonas aeruginosa, which may increase treatment difficulty and worsen prognosis (21).\u003c/p\u003e\n\u003cp\u003eMRSA, as one of the important pathogens of orbital cellulitis, has drawn increasing clinical attention due to its infection characteristics and the challenges it poses for management. The incidence of MRSA-related ocular infections has shown a continuous upward trend across many regions worldwide (24). Compared with other pathogens, MRSA infections typically exhibit a more aggressive clinical course. Its antimicrobial resistance and high-virulence mechanisms\u0026mdash;such as toxin production, adhesion factors, and immune evasion\u0026mdash;collectively contribute to increased treatment complexity (25). MRSA-induced orbital cellulitis is often associated with a prolonged disease course and may cause severe complications across different age groups (25,26). The results of this study showed no statistically significant difference in MRSA detection rates between adults and children (p \u0026gt; 0.05), suggesting that age is not an independent risk factor for MRSA-related orbital cellulitis. It is noteworthy that reported MRSA detection rates vary considerably across different medical institutions and geographic regions (27，28). For example, MAJ Blake T and colleagues reported an MRSA detection rate of 25%, recommending that MRSA be considered a potential causative pathogen during initial empirical treatment of orbital cellulitis, with appropriate anti-MRSA agents incorporated into therapy (3). Therefore, taking into account global epidemiological trends and local prevalence data, early coverage of MRSA in severe or high-risk patients provides important clinical guidance for improving patient outcomes.\u003c/p\u003e\n\u003cp\u003eThis study also has certain limitations. First, the sample size was relatively small, and all data were derived from a single medical institution, which may limit the representativeness and generalizability of the findings. The extrapolation of the conclusion requires further verification through multi-center, large-scale studies.Second, variability in the quality of medical record documentation may have resulted in incomplete or biased information, potentially affecting the accuracy of the data and the reliability of the analyses. Third, The microbiological profile is not representative of the whole population in this study since the specimens were not taken from all. Therefore, future studies should expand the sample size, include data from multiple centers (multiple hospitals), and conduct more systematic comparative analyses focusing on different clinical characteristics of orbital cellulitis\u0026mdash;such as etiological subtypes, disease severity, and treatment responses\u0026mdash;to further validate and extend the conclusions of this study and provide more broadly applicable evidence for clinical practice.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, this study revealed significant differences between adults and children with orbital cellulitis in terms of etiology, pathogen spectrum, and clinical course: pediatric patients predominantly present with acute rhinogenic infections caused mainly by Gram-positive bacteria and generally have favorable outcomes, whereas adult patients exhibit diverse etiologies, a more complex microbial spectrum, a higher likelihood of abscess formation, and a more protracted disease course. Based on these findings, this study emphasizes that age can serve as a key stratification factor in clinical decision-making, enabling the development of individualized diagnostic and therapeutic pathways. Targeted etiological evaluation, pathogen-based assessment, and tailored treatment selection can improve infection control, reduce complications, and enhance clinical outcomes. The results of this study underscore the necessity of implementing individualized treatment approaches in different patient populations and provide important guidance for clinical practice.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eANC,Absolute Neutrophil Count\u003c/p\u003e\n\u003cp\u003eWBC,White Blood Cell Count\u003c/p\u003e\n\u003cp\u003eCRP,C-reactive protein\u003c/p\u003e\n\u003cp\u003eNLR,Neutrophil-to-Lymphocyte Ratio\u003c/p\u003e\n\u003cp\u003eMRSA,Methicillin-resistant Staphylococcus aureus\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eMethodology, PPJ; Validation, XLC, and LHY.; Formal analysis, DZ.; Investigation,\u0026nbsp;TL,KLand PFH; Data curation, KXX.; Writing\u0026mdash;original draft preparation, PPJ. and YD; Writing\u0026mdash;review and Editing, PPJ. and RNM.\u0026nbsp;All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Key Research and Development Plan Project in Xingtai City under Grant number 2025ZC051 and 2025ZC054.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article. More detailed raw data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the Declaration of Helsinki and was approved by the ethics committee of Hebei Eye Hospital, China. Written informed consent was obtained from each patient or their parents (for children \u0026lt; 18 years of age) prior to participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang, N. L.; Yang, L. Ophthalmology, 4th ed.; Peking University Medical Press: Beijing, China, 2019; p. 240.\u003c/li\u003e\n\u003cli\u003eYao, B.; Ding, Y.; Zhao, X.; Wang, B.; Liu, G.; Wang, F. Clinical Characteristics and Prognosis of Adult Orbital Cellulitis in a Tertiary General Hospital. \u003cem\u003eJ Ophthalmol\u003c/em\u003e. (2020) 8889341. https://doi.org/10.1155/2020/8889341\u003c/li\u003e\n\u003cli\u003eCirks, B. T.; Claunch, K. M.; DePerrior, S.; Poitras, B., Adams, D. J.Microbiology and Epidemiology of Orbital Cellulitis in Pediatric and Young Adult Patients. \u003cem\u003eMil Med\u003c/em\u003e . (2025) 190(3-4), e593\u0026ndash;e600. https://doi.org/10.1093/milmed/usae394\u003c/li\u003e\n\u003cli\u003eMishra, S. K.; Kumar, S.; Kumari, A.; Sharma, N. A retrospective observational study of orbital cellulitis in children - Recent trends.\u003cem\u003e J Family Med Prim Care\u003c/em\u003e. (2024) 13(10), 4712\u0026ndash;4714. https://doi.org/10.4103/jfmpc.jfmpc_847_24\u003c/li\u003e\n\u003cli\u003eWanstreet, T.; Kais, A.; Makary, C. A.; Cui, R.; Ramadan, H. H. Gender differences in the management of pediatric orbital cellulitis. \u003cem\u003eAm J Otolaryngol.\u003c/em\u003e (2025) 46(5), 104661. https://doi.org/10.1016/j.amjoto.2025.104661\u003c/li\u003e\n\u003cli\u003eVloka, C. N.; Summers, R. C.; DeSantis, D.; Hink, E. M. Incidence of orbital cellulitis in children: a population-based study. \u003cem\u003eJ AAPOS.\u003c/em\u003e (2025) 29(3), 104214. https://doi.org/10.1016/j.jaapos.2025.104214\u003c/li\u003e\n\u003cli\u003eJiramongkolchai, P.; Lander, D. P.; Kallogjeri, D.; Olsen, M. A.; Keller, M.; Schneider, J. S.; Lee, J. J.; Jiramongkolchai, K.; Piccirillo, J. F. Trend of surgery for orbital cellulitis: An analysis of state inpatient databases. \u003cem\u003eLaryngoscope.\u003c/em\u003e (2020) 130(3), 567\u0026ndash;574. https://doi.org/10.1002/lary.28050\u003c/li\u003e\n\u003cli\u003eYang Wen ; Dai Peng-Fei; Xue Da-Xi;Chang Hua-Lei; Chen Tao. Epidemiological analysis of ocular trauma in Shaanxi and surrounding areas.\u003cem\u003eInternational Eye Science\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e (2022) ,22(02):352-356.DOI 10.3980/j.issn.1672-5123.2022.2.36\u003c/li\u003e\n\u003cli\u003eYadalla, D.; Jayagayathri, R.; Padmanaban, K.; Ramasamy, R.; Rammohan, R.; Nisar, S. P.; Rangarajan, V.; Menon, V. Bacterial orbital cellulitis - A review. \u003cem\u003eIndian J Ophthalmol\u003c/em\u003e. (2023) 71(7), 2687\u0026ndash;2693. https://doi.org/10.4103/IJO.IJO_3283_22\u003c/li\u003e\n\u003cli\u003eHayat, J.; Al-Musalam, L.; Al-Shaya, D.; Tawfiq, E.; Al-Sihan, M.; Behbehani, R. Pre-septal and Orbital Cellulitis: A Retrospective Analysis of Manifestations and Outcomes of a Tertiary Center in Kuwait. \u003cem\u003eCureus\u003c/em\u003e. (2024) 16(7), e65104. https://doi.org/10.7759/cureus.65104\u003c/li\u003e\n\u003cli\u003eKhurshied, S.; Shah, H. G.; Babar, A.; Afsar, A.; Zahid, M. A.; Nisa, M. Trends of Sinusitis-Associated Orbital Cellulitis in Pediatric Patients: A Retrospective Cohort Review. \u003cem\u003eCureus\u003c/em\u003e. (2025) 17(5), e84505. https://doi.org/10.7759/cureus.84505\u003c/li\u003e\n\u003cli\u003eMei Fang; Chen Juan; Qian Jing; Chen Zhi-jun.Analysis of Diagnosis and Treatment of 165 Cases Pediatric Orbital Cellulitis\u003cem\u003e.Journal of Sichuan University\u003c/em\u003e. (2019) 50(02):256-259.DOI:10.13464/j.scuxbyxb.2019.02.023\u003c/li\u003e\n\u003cli\u003eWang Dan; Zhang Hao; Yang su-hong. Clinical analysis of orbital cellulitis in children.\u003cem\u003eChinese Journal of Strabismus \u0026amp; Pediatric Ophthalmology\u003c/em\u003e. (2019) 27(03):25-28+61.DOI:10.3969/J.ISSN.1005-328X.2019.03.008\u003c/li\u003e\n\u003cli\u003eKaur, N. Study of prognostic outcome of cellulitis patients with diabetes mellitus. \u003cem\u003eInternational Surgery Journal\u003c/em\u003e, (2022) 9(10), 1700\u0026ndash;1705.https://doi.org/10.18203/2349-2902.isj20222359\u003c/li\u003e\n\u003cli\u003eGibbons, A.; Cherkas, E.; Kaur, M.; Dharssi, S.; Elsharawi, R.; Ashraf, D. C.; Li, E. Inflammatory Markers as Predictors of Orbital Infection Severity.\u003cem\u003e Ophthalmic Plast Reconstr Surg\u003c/em\u003e . (2025) 41(5), 530\u0026ndash;534. https://doi.org/10.1097/IOP.0000000000002903\u003c/li\u003e\n\u003cli\u003eCohen, N.; Erisson, S.; Anafy, A.; Palnizky-Soffer, G.; Cohen, E.; Capua, T.; Rimon, A.; Grisaru-Soen, G. Clinicians need to consider surgery when presented with some markers for severe paediatric orbital cellulitis. \u003cem\u003eActa Paediatr\u003c/em\u003e. (2020) 109(6), 1269\u0026ndash;1270. https://doi.org/10.1111/apa.15125\u003c/li\u003e\n\u003cli\u003eKhurshied, S.; Shah, H. G.; Abdul Malik, W.; Maqbool, A.; Hussain, K.; Zahid, M. A.Characteristics of Patients Treated for Orbital Infections: A Retrospective Study at a Tertiary Care Hospital. \u003cem\u003eCureus\u003c/em\u003e . (2025) 17(2), e79004. https://doi.org/10.7759/cureus.79004\u003c/li\u003e\n\u003cli\u003eManiaci, A.; Gagliano, C.; Lavalle, S.; van der Poel, N.; La Via, L.; Longo, A.; Russo, A.; Zeppieri, M. Ocular Manifestations of Pediatric Rhinosinusitis: A Comprehensive Review. \u003cem\u003eDiseases\u003c/em\u003e . (2024) 12(10), 239. https://doi.org/10.3390/diseases12100239\u003c/li\u003e\n\u003cli\u003eP. Lakshmi; A. Jahnavi; N. Kranthi Priya; M. Komala Lakshmi; Dhivyesh N.A. Comparative Study on Cellulitis in Patients with and without Diabetes Mellitus.Journal of Advances in Medicine and Medical Research, (2025)37(10), 85-91.https://doi.org/10.9734/JAMMR/2025/V37I105949.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Rourke, M.; Tang, Y. F.; Pick, Z.; Tan, J. S.; Tan, P. E. Z.; Athavale, D. D.; O\u0026apos;Donnell, B.; Selva, D.; Gajdatsy, A.; Hardy, T. G.; McNab, A.; Khong, J. J. Orbital Cellulitis Secondary to Dacryocystitis: A Case Series and Literature Review. \u003cem\u003eOphthalmic Plast Reconstr Surg\u003c/em\u003e . (2025) 41(3), 306\u0026ndash;314. https://doi.org/10.1097/IOP.0000000000002834\u003c/li\u003e\n\u003cli\u003eChen, Y. K.; Tu, H. P.; Chen, I. H. Clinical characteristics and prognosis of adult orbital cellulitis in a tertiary general hospital. \u003cem\u003eScientific reports\u003c/em\u003e . (2025) 15(1), 20585. https://doi.org/10.1038/s41598-025-06382-2\u003c/li\u003e\n\u003cli\u003eAmbati BK; Ambati J; Azar N; Stratton L; Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. (2000) 107(8):1450-1453.https://doi.org/10.1016/S0161-6420(00)00178-0\u003c/li\u003e\n\u003cli\u003eHegde R, Sundar G. Orbital cellulitis-A review. TNOA J Ophthalmic Sci Res 2017;55:211‑9.https://doi.org/10.4103/tjosr.tjosr_9_18\u003c/li\u003e\n\u003cli\u003eShih, E. J.; Chen, J. K.; Tsai, P. J.; \u0026amp; Bee, Y. S. Differences in characteristics, aetiologies, isolated pathogens, and the efficacy of antibiotics in adult patients with preseptal cellulitis and orbital cellulitis between 2000-2009 and 2010-2019.\u003cem\u003eBr J Ophthalmol\u003c/em\u003e. (2023) 107(3), 331\u0026ndash;336. https://doi.org/10.1136/bjophthalmol-2021-318986\u003c/li\u003e\n\u003cli\u003eAng, T.; Cameron, C.; Tong, J. Y.; Wilcsek, G.; Tan, J.; Patel, S.; Selva, D. Methicillin-resistant Staphylococcus aureus-associated orbital cellulitis: a case series. \u003cem\u003eInt Ophthalmol \u003c/em\u003e. (2023) 43(8), 2925\u0026ndash;2933. https://doi.org/10.1007/s10792-023-02698-y\u003c/li\u003e\n\u003cli\u003eHsu, J.; Treister, A. D.; Ralay Ranaivo, H.; Rowley, A. H.; Rahmani, B. Microbiology of Pediatric Orbital Cellulitis and Trends in Methicillin-Resistant Staphylococcus aureus Cases. \u003cem\u003eClin Pediatr (Phila) \u003c/em\u003e. (2019) 58(10), 1056\u0026ndash;1062. https://doi.org/10.1177/0009922819864587\u003c/li\u003e\n\u003cli\u003eJoseph, J.; Karolia, R.; Sharma, S.; Choudhary, H.; Naik, M. N. Microbiological profile and antibiotic susceptibility trends in orbital cellulitis in India: an analysis over 15 years. \u003cem\u003eOrbit\u003c/em\u003e. (2022) 41(6), 726\u0026ndash;732. https://doi.org/10.1080/01676830.2021.2002368\u003c/li\u003e\n\u003cli\u003eMeghna Sharma; Michael Taylor; Shiva Salehian; Alexandra Espinel; Kevin M Lloyd; Emily Ansusinha ; Rana F Hamdy.Clinical Epidemiology and Microbiology of Orbital Cellulitis in Children.J Pediatric Infect Dis Soc.(2025)15(1).https://doi.org/10.1093/JPIDS/PIAF113.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"orbital cellulitis, eye infection, antibiotic resistance, pathogen distribution, age group","lastPublishedDoi":"10.21203/rs.3.rs-9297175/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9297175/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo investigate the differences in clinical features and pathogen distribution of orbital cellulitis between adults and children in northern China, and to provide evidence for precise clinical diagnosis and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective analysis was conducted on the clinical data of 131 patients with orbital cellulitis admitted to Hebei Eye Hospital between 2014 and 2023, including 76 adults and 55 children. The two groups were compared in terms of etiologies, treatment modalities, length of hospital stay, and microbiological results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e No significant differences were observed between groups in sex, geographical distribution, or seasonal variation. However, adults showed significantly higher rates of surgical intervention (44.7% vs. 25.5%, P \u0026lt; 0.05) and a longer median hospital stay (11 days vs. 7 days, P \u0026lt; 0.001) compared with children. Regarding etiologies, pediatric cases were predominantly attributed to rhinogenic infections (58.2%), whereas adult cases showed more heterogeneous causes, including trauma (21.3%) and lacrimal apparatus diseases (18.7%). Microbiological analyses revealed that all pathogens isolated from children were Gram-positive bacteria (100%), whereas adults exhibited a more diverse pathogen spectrum, including Gram-positive bacteria (69.6%), Gram-negative bacteria (28.3%), and fungi (2.2%). The overall microbial composition differed significantly between the two groups (P \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAdults and children with orbital cellulitis differ substantially in etiologies, pathogen profiles, and clinical manifestations. Age-specific individualized management is therefore essential: pediatric patients should be treated with emphasis on rhinogenic sources and adequate coverage of Gram-positive bacteria, while adult patients require consideration of more diverse etiologies and may benefit from broader-spectrum empirical antimicrobial regimens to optimize clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics and Differences in Pathogen Distribution of Orbital Cellulitis Between Children and Adults in Northern China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 05:49:21","doi":"10.21203/rs.3.rs-9297175/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-21T17:02:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-21T16:40:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36493746066726205164654129670353038910","date":"2026-04-19T13:57:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125210314385841866084427500376369562327","date":"2026-04-17T10:11:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T08:00:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282127950163808204457635203675800663937","date":"2026-04-14T17:57:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75070158061298464218128915755085712808","date":"2026-04-14T14:13:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-14T13:39:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-04T05:51:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-04T05:50:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2026-04-02T02:27:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36064f51-521f-4c23-8daa-f4afd2e09381","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T10:09:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 05:49:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9297175","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9297175","identity":"rs-9297175","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}