What antibiotics are used to treat preseptal (periorbital) cellulitis of the eye?

From the Guidelines

For preseptal cellulitis of the eye, oral antibiotics active against streptococci, such as penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin, are the primary treatment. The choice of antibiotic should be based on the severity of the infection and the patient's allergy history. According to the Infectious Diseases Society of America guidelines 1, a 5-day course of antimicrobial therapy is as effective as a 10-day course, if clinical improvement has occurred by 5 days.

Key Considerations

• The recommended duration of antimicrobial therapy can be extended if the infection has not improved within the initial 5-day period 1.
• Treatment should cover common causative organisms including Staphylococcus aureus, Streptococcus species, and anaerobes.
• Warm compresses applied to the affected eye for 15 minutes 3-4 times daily can help reduce inflammation.
• Patients should be monitored closely for signs of worsening, including increased pain, vision changes, or eye movement restrictions, which may indicate progression to orbital cellulitis requiring immediate medical attention.

Antibiotic Options

• Amoxicillin-clavulanate (Augmentin) is typically recommended at a dose of 875/125 mg twice daily for adults or 45 mg/kg/day divided twice daily for children.
• Alternatives include cephalexin (500 mg four times daily for adults) plus trimethoprim-sulfamethoxazole, or clindamycin (300-450 mg four times daily) for penicillin-allergic patients.
• For more severe cases or those unresponsive to oral therapy, consider intravenous antibiotics such as ceftriaxone or ampicillin-sulbactam 1.

Monitoring and Follow-up

• If symptoms don't improve within 48-72 hours of starting antibiotics, reevaluation is necessary to consider alternative diagnoses or treatment approaches.
• Outpatient therapy is recommended for patients who do not have systemic signs of infection, altered mental status, or hemodynamic instability 1.

From the Research

Antibiotics for Preseptal Cellulitis

• The choice of antibiotic for preseptal cellulitis is crucial, and options include ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin 2
• The use of broad-spectrum antibiotics, including dual/triple therapy and methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics, has been decreased after the implementation of a clinical practice guideline (CPG) for pediatric preseptal cellulitis 3
• A systematic review and meta-analysis found no evidence to support the superiority of any one antibiotic over another for the treatment of cellulitis, and antibiotics with activity against MRSA did not add an advantage 4

Commonly Used Antibiotics

• Ampicillin-sulbactam, ceftriaxone, and vancomycin are commonly used antibiotics for the treatment of preseptal cellulitis 2, 5
• The use of vancomycin has increased over time, possibly due to the emergence of community-acquired MRSA 6, 5

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 use of intravenous antibiotics over oral antibiotics for the treatment of cellulitis 4
• The route of administration and treatment duration may vary depending on the severity of the infection and the patient's response to therapy 2, 4