What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

The first-line treatment for periorbital cellulitis is vancomycin 15-20 mg/kg IV every 8-12 hours, especially when MRSA is suspected or in severe cases. 1

Diagnosis and Severity Assessment

Before initiating treatment, it's crucial to:

1. Distinguish between periorbital and orbital cellulitis:

   • Periorbital cellulitis: Infection limited to eyelids (preseptal region)
   • Orbital cellulitis: More severe infection posterior to the septum, potentially requiring surgical intervention 1, 2

2. Assess severity:

   • Mild cases (eyelid <50% closed): Potential outpatient management with oral antibiotics
   • Moderate to severe cases: Require hospitalization for IV antibiotics 1

3. Obtain imaging (contrast-enhanced CT scan) if:

   • Proptosis is present
   • Visual acuity is impaired
   • Extraocular mobility is impaired or painful 1

Treatment Algorithm

First-line Treatment

• Vancomycin 15-20 mg/kg IV every 8-12 hours 1
  • Target trough concentrations: 15-20 mg/L for severe infections
  • Higher doses may be needed in younger patients, critically ill patients, or severe infections 1

Alternative Antibiotic Regimens

• Daptomycin: 6 mg/kg IV once daily (for vancomycin-resistant or intolerant patients)
• Linezolid: 600 mg IV twice daily
• Clindamycin: 600 mg IV every 8 hours (caution with erythromycin-resistant strains)
• Doxycycline: 100 mg orally twice daily (for penicillin-allergic patients)
• Eravacycline: 1 mg/kg every 12 hours (for severe infections or septic shock) 1

Oral Antibiotic Options

For mild cases or step-down therapy:

• Cephalexin: 500 mg 3-4 times daily for 5-6 days
• Clindamycin: 300-450 mg orally three times daily for 5-6 days
• Amoxicillin-clavulanate: 875/125 mg twice daily orally for 5-6 days 1

Adjunctive Therapy

Corticosteroids

• May be considered as an adjunct to reduce inflammation
• Should be initiated after 24-48 hours of antibiotic therapy
• Use with caution in patients with:
  • Uncontrolled diabetes
  • Active tuberculosis
  • Systemic fungal infections
  • Known hypersensitivity to corticosteroids 1

Supportive Care

• Apply warm compresses to the affected area 3-4 times daily
• Elevate the head of the bed to reduce edema
• Ensure adequate pain control with appropriate analgesics 1

Monitoring and Follow-up

• Expect clinical improvement within 72 hours
• If no improvement is seen:
  • Reevaluate treatment plan
  • Consider surgical intervention 1
• Monitor daily for:
  • Orbital signs
  • Potential intracranial complications (epidural/subdural abscess, brain abscess, venous thrombosis, meningitis)
  • Vancomycin trough levels 1

Special Considerations

Pediatric Patients

• Periorbital cellulitis occurs more frequently (83%) than orbital cellulitis (17%)
• 85% of children with periorbital cellulitis are younger than 5 years
• Most common predisposing factors: upper respiratory infection (68%) and trauma to eyelids (20%) 3

Surgical Intervention

• Required in approximately 6% of periorbital cellulitis cases
• Necessary for progression of orbital cellulitis in up to 49% of patients 3, 2
• Consider if medical management fails 1

Specialist Consultation

Consider consultation with:

• Otolaryngology
• Ophthalmology
• Infectious disease specialists 1

Common Pitfalls to Avoid

1. Failing to distinguish between periorbital and orbital cellulitis
2. Delaying imaging when diagnosis is uncertain
3. Not monitoring for clinical improvement within 72 hours
4. Inadequate vancomycin dosing or monitoring
5. Missing potential complications requiring surgical intervention