What is the recommended management for preseptal cellulitis?

Management of Preseptal Cellulitis

For typical preseptal cellulitis, a 5-day course of antibiotics active against streptococci is recommended as first-line therapy, with extension if no improvement occurs within this timeframe. 1

Diagnosis

• Preseptal cellulitis presents as diffuse, superficial, spreading skin infection around the eye with erythema, swelling, tenderness, and warmth
• Cultures are generally not necessary for typical cases 1
• Blood cultures should be obtained only in patients with:
  • Malignancy
  • Severe systemic features (high fever, hypotension)
  • Unusual predisposing factors (immersion injury, animal bites, neutropenia, immunodeficiency) 1

Antibiotic Selection

Mild Preseptal Cellulitis (Outpatient Management)

• First-line oral options:
  • Penicillin
  • Amoxicillin
  • Amoxicillin-clavulanate
  • Dicloxacillin
  • Cephalexin
  • Clindamycin 1

Moderate to Severe Preseptal Cellulitis (Consider Hospitalization)

• Intravenous options:
  • Cefazolin
  • Oxacillin/nafcillin
  • Penicillin 1

Special Circumstances for MRSA Coverage

MRSA coverage should be added when:

• Penetrating trauma is present
• Evidence of MRSA infection elsewhere
• Nasal colonization with MRSA
• Injection drug use
• Purulent drainage
• Systemic inflammatory response syndrome (SIRS) 1

MRSA treatment options include:

• IV: vancomycin, daptomycin, linezolid, or telavancin
• Oral: doxycycline, clindamycin, or SMX-TMP 1

Duration of Treatment

• 5 days for uncomplicated cases with clinical improvement 1
• Extend treatment if infection has not improved within 5 days 1

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema 1
• Treatment of predisposing factors (edema, underlying cutaneous disorders) 1
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in nondiabetic adult patients 1

Hospitalization Criteria

Hospitalization is recommended if:

• Concern for deeper or necrotizing infection
• Poor adherence to therapy
• Severe immunocompromise
• Outpatient treatment is failing
• SIRS, altered mental status, or hemodynamic instability 1

Prevention of Recurrence

For patients with recurrent episodes:

• Identify and treat predisposing conditions (edema, obesity, eczema, venous insufficiency) 1
• Consider prophylactic antibiotics for patients with 3-4 episodes per year:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks, or
  • Intramuscular benzathine penicillin every 2-4 weeks 1

Common Pitfalls and Caveats

1. Failing to distinguish between preseptal and orbital cellulitis (the latter being more serious and requiring more aggressive management)
2. Overuse of broad-spectrum antibiotics when narrow-spectrum agents targeting streptococci are often sufficient 2
3. Unnecessary blood cultures in uncomplicated cases 1
4. Extending antibiotic duration beyond 5 days when clinical improvement has occurred 1
5. Failing to address predisposing factors that may lead to recurrence 1

Recent evidence suggests that ambulatory intravenous antibiotic therapy with daily review is a safe and cost-effective alternative to inpatient admission for children with preseptal cellulitis requiring parenteral antibiotics 3.