What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

The recommended first-line treatment for periorbital cellulitis is intravenous antibiotics targeting both streptococci and staphylococci, with oral dicloxacillin or cephalexin (500 mg four times daily for 5-7 days) for mild cases and vancomycin plus piperacillin-tazobactam or imipenem/meropenem for severe cases. 1

Classification and Diagnosis

Periorbital cellulitis must be distinguished from orbital cellulitis:

• Periorbital (preseptal) cellulitis: Infection limited to eyelid tissues anterior to the orbital septum
• Orbital (postseptal) cellulitis: More serious infection involving orbital contents posterior to the septum

Key clinical findings to differentiate:

• Orbital cellulitis presents with proptosis, impaired visual acuity, and painful/limited extraocular movements
• Periorbital cellulitis typically presents with eyelid edema, erythema, and tenderness without orbital signs

Treatment Algorithm

1. Mild Periorbital Cellulitis (Outpatient Management)

• Eyelid <50% closed, no systemic symptoms
• Antibiotic therapy:
  • First-line: Oral dicloxacillin or cephalexin 500 mg four times daily 1
  • Penicillin-allergic patients: Clindamycin 1
• Duration: 5 days (extend if not improved) 2
• Daily follow-up until improvement noted 2

2. Moderate-Severe Periorbital Cellulitis (Inpatient Management)

• Eyelid >50% closed, systemic symptoms, or failure of outpatient therapy
• Antibiotic therapy:
  • First-line: High-dose amoxicillin-clavulanate for comprehensive coverage 2
  • If MRSA risk factors present (prior MRSA infection, recent hospitalization): Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem 2, 1
• Duration: 5-7 days IV, then transition to oral therapy if improved 2

3. Complicated Cases (Orbital Involvement)

• Immediate hospitalization and contrast-enhanced CT scan 2
• Antibiotic therapy: Vancomycin (for possible resistant organisms) plus broad-spectrum coverage 2
• Consult otolaryngology, ophthalmology, and infectious disease specialists 2
• Surgical intervention may be required for abscess formation or lack of improvement within 24-48 hours 2

Supportive Measures

• Elevation of the affected area to reduce edema 2, 1
• Warm compresses several times daily 1
• Eyelid cleansing to remove crusts or discharge 1
• Treatment of predisposing factors (sinusitis, trauma, dental infections) 3, 4

Special Considerations

Pediatric Patients

• Most common in children under 5 years 4
• Upper respiratory infections (68%) and trauma (20%) are common predisposing factors 4
• Daily outpatient IV antibiotics with physician evaluation may be a safe alternative to admission in select uncomplicated cases 5

Recurrent Periorbital Cellulitis

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

Common Pitfalls

• Failing to distinguish between periorbital and orbital cellulitis, leading to inadequate treatment 1, 6
• Inadequate coverage for MRSA in high-risk patients 1
• Failure to elevate the affected area, delaying resolution 1
• Overlooking underlying conditions that can lead to recurrence 1
• Delayed surgical intervention when indicated 1

Emerging Treatments

The role of adjunctive corticosteroids remains unclear. A Cochrane review found insufficient evidence to draw conclusions about their use in periorbital and orbital cellulitis, highlighting the need for additional high-quality randomized controlled trials 7.