What are the best antibiotics for preseptal cellulitis?

From the Guidelines

For preseptal cellulitis, the recommended first-line antibiotic treatment is typically amoxicillin-clavulanate (Augmentin) at a dose of 875/125 mg orally twice daily for adults or 45 mg/kg/day divided twice daily for children for 7-10 days. This recommendation is based on the most recent and highest quality study available, which suggests that a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days 1. Alternative options include cephalexin (Keflex) 500 mg orally four times daily for adults or 25-50 mg/kg/day divided four times daily for children. For patients with penicillin allergies, clindamycin 300-450 mg orally four times daily for adults or 30-40 mg/kg/day divided three times daily for children is appropriate.

• Key considerations for treatment include:
  • The use of antibiotics active against streptococci, such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin 1
  • The potential need for hospitalization with intravenous antibiotics, such as ceftriaxone, ampicillin-sulbactam, or vancomycin, in severe cases, immunocompromised patients, or those with vision changes
  • The importance of warm compresses applied to the affected area for 15 minutes 3-4 times daily to improve circulation and antibiotic delivery to the infected tissues
  • The consideration of MRSA coverage with antibiotics such as trimethoprim-sulfamethoxazole (Bactrim) or doxycycline in more severe cases or if there's concern for MRSA 1 It is essential to note that the treatment should be individualized based on the patient's clinical response and the severity of the infection. Additionally, the use of antibiotics should be guided by the results of cultures and susceptibility testing, when available 1.

From the Research

Antibiotics for Preseptal Cellulitis

• The choice of antibiotic for preseptal cellulitis is significant, with common options including ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin 2
• These antibiotics target organisms that originate in the upper respiratory tract or from the skin, which are the most common causes of preseptal cellulitis 2
• The use of broad-spectrum antibiotics, including dual/triple therapy and methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics, has been found to decrease after the implementation of a clinical practice guideline (CPG) for pediatric preseptal cellulitis 3

Treatment Duration and Route of Administration

• The total duration of therapy for preseptal cellulitis has been decreasing in recent years, with durations of approximately 2 weeks becoming more common 2
• There is no evidence to support the superiority of intravenous antibiotics over oral antibiotics for the treatment of cellulitis, including preseptal cellulitis 4
• Ambulatory intravenous antibiotics with daily review have been found to be a safe and cost-effective alternative to inpatient admission for children with simple preseptal cellulitis who require parenteral antibiotics 5

Clinical Practice Guidelines

• The implementation of a CPG for pediatric preseptal cellulitis has been found to decrease the use of broad-spectrum antibiotics and reduce resource utilization, including blood testing and imaging 3
• A CPG can help guide the choice of antibiotic, dosage, and duration of therapy, as well as the transition from intravenous to oral therapy 2