What is the recommended oral antibiotic regimen for stepdown therapy in preseptal cellulitis?

From the Guidelines

The recommended oral antibiotic regimen for stepdown therapy in preseptal cellulitis typically includes amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for adults or 45 mg/kg/day divided twice daily for children, as it provides broad-spectrum coverage against streptococci and Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA) 1.

Key Considerations

• Alternative options include clindamycin 300-450 mg four times daily for adults or 30-40 mg/kg/day divided three times daily for children, especially in penicillin-allergic patients 1.
• Treatment duration generally ranges from 5 days, but may be extended if the infection has not improved within this time period, as recommended by the Infectious Diseases Society of America 1.
• Stepdown therapy is appropriate when patients show clinical improvement on intravenous antibiotics, including decreased periorbital swelling, pain, and fever resolution.
• It's essential to complete the full course of antibiotics even after symptoms resolve to prevent recurrence.
• Preseptal cellulitis is typically caused by Staphylococcus aureus and Streptococcus species, with increasing concern for MRSA, which is why broad-spectrum coverage is recommended.

Special Considerations

• If MRSA is suspected or confirmed, trimethoprim-sulfamethoxazole (TMP-SMX) or doxycycline (for patients over 8 years old) may be more appropriate choices.
• Close follow-up within 24-48 hours after transitioning to oral therapy is advised to ensure continued improvement.
• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are also recommended 1.

From the FDA Drug Label

The usual adult dose is one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 250 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours For more severe infections and infections of the respiratory tract, the dose should be one 875 mg/125 mg amoxicillin and clavulanate potassium tablet every 12 hours or one 500 mg/125 mg amoxicillin and clavulanate potassium tablet every 8 hours.

The recommended oral antibiotic regimen for stepdown therapy in preseptal cellulitis is amoxicillin-clavulanate (PO), with a dose of:

• 500 mg/125 mg every 12 hours
• or 250 mg/125 mg every 8 hours
• or 875 mg/125 mg every 12 hours for more severe infections 2

From the Research

Stepdown Oral Therapy for Preseptal Cellulitis

The recommended oral antibiotic regimen for stepdown therapy in preseptal cellulitis is based on the causative organisms and the clinical response to initial intravenous therapy.

• The choice of antibiotic should cover common pathogens such as β-hemolytic streptococci and methicillin-sensitive Staphylococcus aureus 3.
• Oral antibiotics such as penicillin, amoxicillin, and cephalexin are often used for non-purulent, uncomplicated cases of cellulitis 3.
• For cases where methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmed, alternative antibiotics may be necessary 4, 5.
• The total duration of therapy for preseptal cellulitis has been decreasing in recent years, with durations of approximately 2 weeks becoming more common 6.
• Antimicrobial stewardship programs can help guide the choice of antibiotic, dosage, and duration of therapy to ensure optimal treatment and minimize resistance 6.
• It is essential to note that the emergence of community-acquired MRSA has led to changes in empirical antimicrobial therapy, especially in orbital cellulitis 4.
• However, for simple cellulitis, beta-lactam antibiotics such as amoxicillin and cephalexin may still be effective, even in the era of community-acquired MRSA 7.