What is the treatment for preseptal cellulitis?

Treatment of Preseptal Cellulitis

The first-line treatment for preseptal cellulitis is empiric broad-spectrum antibiotics targeting Staphylococcus and Streptococcus species, with oral antibiotics for mild cases and intravenous antibiotics for severe cases or those with systemic symptoms. 1

Antibiotic Selection

Mild to Moderate Cases

• Oral antibiotics:
  • Cephalexin 500 mg 3-4 times daily for 5-6 days
  • Amoxicillin-clavulanate 875/125 mg twice daily for 5-6 days
  • Clindamycin 300-450 mg three times daily for 5-6 days (for penicillin-allergic patients) 1

Severe Cases or Systemic Symptoms

• Intravenous antibiotics:
  • Vancomycin 15-20 mg/kg IV every 8-12 hours (if MRSA is suspected)
  • Sulbactam-ampicillin has shown good efficacy in clinical experience 2
  • Clindamycin 600 mg IV every 8 hours (alternative for penicillin-allergic patients) 1

Treatment Algorithm

1. Assess severity:

   • Mild: Minimal eyelid swelling, no systemic symptoms → Oral antibiotics
   • Severe: Marked eyelid swelling, fever, elevated inflammatory markers, or risk of progression → IV antibiotics

2. Initial empiric therapy:

   • Start with antibiotics targeting Staphylococcus and Streptococcus (most common pathogens)
   • Consider MRSA coverage if risk factors present or high local prevalence

3. Monitoring response:

   • Expect clinical improvement within 72 hours
   • If no improvement, consider:
     • Alternative pathogens (e.g., Proteus species as reported in some cases) 3
     • Need for surgical intervention
     • Obtaining cultures for resistant organisms 1

4. Duration of therapy:

   • Standard duration: 5-6 days for uncomplicated cases
   • May extend for severe cases or slow response 1

Supportive Measures

• Apply warm compresses to affected area 3-4 times daily
• Elevate head of bed to reduce edema
• Ensure adequate pain control with appropriate analgesics
• Consider ophthalmology consultation for cases with visual changes or severe presentation 1

Special Considerations

Pediatric Patients

• Children commonly present with preseptal cellulitis, often secondary to sinusitis
• IV antibiotics are frequently used during hospitalization with good outcomes 4
• Mean duration of antibiotic use (including after discharge) is approximately 10 days 4

Underlying Causes

• Address predisposing factors:
  • Sinusitis (common in children) 4
  • Acute dacryocystitis 5
  • Recent trauma or surgery 5

Potential Pitfalls and Caveats

1. Failure to recognize non-bacterial causes:

   • Viral preseptal cellulitis can mimic bacterial infection clinically 6
   • Consider viral testing in cases with poor response to antibiotics

2. Inadequate coverage for unusual pathogens:

   • If standard therapy fails, consider broader coverage or specific pathogens
   • Case reports show Proteus species can cause preseptal cellulitis requiring ciprofloxacin 3

3. Missing progression to orbital cellulitis:

   • Daily assessment for orbital signs is crucial (restricted eye movement, pain with eye movement, proptosis, vision changes)
   • Orbital cellulitis presents with higher inflammatory markers compared to preseptal cellulitis 2

4. Delayed surgical intervention:

   • Up to 50% of hospitalized patients may require surgical intervention 5
   • Common procedures include drainage of abscesses and management of underlying dacryocystitis

5. Inadequate follow-up:

   • Late complications can include subacute lid abscesses, eyelid necrosis, and cicatricial ectropion 5