What is the inpatient treatment for preseptal cellulitis?

Inpatient Treatment for Preseptal Cellulitis

For hospitalized patients with preseptal cellulitis, intravenous vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is the recommended empiric regimen, especially for severe infections. 1

Antibiotic Selection

First-line Therapy

• IV Vancomycin (15-20 mg/kg IV every 8-12 hours) 2

  • Provides coverage against MRSA and streptococci
  • Essential for cases with:
    • Systemic signs of infection
    • Evidence of MRSA elsewhere
    • Penetrating trauma history
    • Injection drug use
    • Systemic inflammatory response syndrome (SIRS)

• Plus one of the following for broader coverage:

  • Piperacillin-tazobactam (3.375 g every 6 h or 4.5 g every 8 h IV)
  • Imipenem/meropenem (500 mg every 6 h IV or 1 g every 8 h IV) 1

Alternative Options

• Linezolid (600 mg IV/PO twice daily) 1

  • Particularly useful when vancomycin fails
  • Has shown efficacy in MRSA preseptal cellulitis cases 3

• Daptomycin (4 mg/kg/dose IV once daily) 1

• Telavancin (10 mg/kg/dose IV once daily) 1

• Clindamycin (600 mg IV three times daily) 1, 2

  • Consider only if local MRSA resistance rates are low

Duration of Treatment

• 5-10 days of antimicrobial therapy is recommended 1
• Extend treatment if infection has not improved within this period 1
• Average duration in clinical practice is approximately 10 days 4

Adjunctive Measures

1. Elevation of the affected area to reduce edema 1
2. Treatment of predisposing factors:
   • Underlying sinusitis (most common predisposing factor in 52.9% of cases) 4
   • Skin lesions
   • Edema
   • Other cutaneous disorders 1
3. Surgical intervention when indicated:
   • Incision and drainage for abscess formation
   • Approximately 16.7-19.2% of hospitalized patients require surgical intervention 5

Monitoring and Follow-up

• Reassess within 48-72 hours of initiating therapy 2
• Monitor for:
  • Resolution of periorbital swelling, hyperemia, and edema (present in >90% of cases) 4
  • Signs of progression to orbital cellulitis
  • Potential complications (though rare with proper treatment) 4

Special Considerations

• For sinusitis-related preseptal cellulitis: Consider adding intranasal decongestants and corticosteroids, which may reduce the need for surgical intervention 5
• For MRSA infections not responding to vancomycin: Consider combination therapy with linezolid and rifampin 3
• For immunocompromised patients: Broader antimicrobial coverage may be necessary 1

Discharge Criteria

• Resolution of systemic signs of infection
• Improvement in local signs (decreased swelling, erythema)
• Ability to tolerate oral antibiotics
• No evidence of progression to orbital cellulitis

Common Pitfalls to Avoid

• Failure to identify and treat underlying predisposing conditions (especially sinusitis)
• Inadequate drainage of abscesses when present
• Premature discontinuation of antibiotics
• Failure to consider MRSA coverage in high-risk patients
• Delayed reassessment of treatment response

Prompt recognition and appropriate antibiotic therapy typically result in good outcomes with no permanent sequelae in most cases of preseptal cellulitis 4, 6.