What is the recommended treatment for preseptal cellulitis?

Management of Preseptal Cellulitis

The recommended first-line treatment for preseptal cellulitis is amoxicillin-clavulanate due to its broad coverage against both aerobic and anaerobic bacteria. 1

Antibiotic Selection

First-line options:

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

For severe infections requiring IV therapy:

• Cefazolin: 1 g every 8 hours IV for 5-6 days 1
• For more severe cases: Vancomycin plus either piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem 1

Treatment Duration and Monitoring

• Standard duration: 5-6 days for uncomplicated cases 1
• Extended duration: 10-14 days for more severe infections 1
• Daily monitoring for the first 48-72 hours is essential to ensure response to antibiotics 1
• If no improvement within 72 hours, consider:
  • Changing antibiotics
  • Surgical consultation
  • Reassessment for deeper infection 1

Special Considerations

MRSA Coverage

Add MRSA coverage if risk factors are present:

• Prior MRSA infection
• Nasal colonization with MRSA
• Injection drug use
• Residence in long-term care facilities
• Athletes, children, men who have sex with men, prisoners, military recruits 1

MRSA Coverage Options:

• Trimethoprim-sulfamethoxazole
• Doxycycline
• Clindamycin (if local resistance rates are low)
• Linezolid (600 mg orally twice daily) for severe infections 1

Clinical Pearls

• Preseptal cellulitis is more common in children and typically has a good prognosis when treated promptly 2
• Laboratory values can help differentiate preseptal from orbital cellulitis; orbital cellulitis typically presents with higher white blood cell count, erythrocyte sedimentation rate, and C-reactive protein levels 3
• Sulbactam-ampicillin has been shown to be safe and effective in treating preseptal cellulitis in clinical experience 3
• The most common causative organism is Staphylococcus aureus, followed by coagulase-negative staphylococci 3

Prevention of Complications

• Elevate the affected area to reduce edema
• Treat predisposing factors such as sinusitis (which accounts for 52.9% of predisposing factors in some studies), edema, obesity, eczema, and venous insufficiency 1, 2
• Watch for signs of progression to orbital cellulitis or deeper infection requiring surgical intervention:
  • Systemic inflammatory response syndrome
  • Altered mental status
  • Hemodynamic instability 1

Hospitalization Criteria

Consider hospitalization for patients with:

• SIRS
• Altered mental status
• Hemodynamic instability
• Concern for deeper or necrotizing infection
• Poor adherence to therapy
• Severe immunocompromise
• Failure of outpatient treatment 1

Discharge Criteria

Patients may be discharged when:

• Visible improvement in local signs
• No signs of deeper or necrotizing infection
• Afebrile for at least 24 hours without antipyretics
• White blood cell count normalizing or trending toward normal 1

Rare Complications to Be Aware Of

In immunocompromised patients or with virulent strains like Streptococcus pyogenes, preseptal cellulitis can rarely progress to toxic shock syndrome and multiple metastatic abscesses. These cases require aggressive antibiotic therapy and possibly surgical debridement 4.