What is the treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

For periorbital cellulitis, high-dose amoxicillin-clavulanate is the first-line treatment, with hospitalization and IV antibiotics required for severe cases or those with concerning features. 1, 2

Diagnosis and Classification

Before initiating treatment, it's crucial to distinguish between periorbital (preseptal) and orbital (postseptal) cellulitis:

• Periorbital cellulitis: Involves only the eyelid with erythema, edema, and tenderness
• Orbital cellulitis: Involves structures of the orbit with proptosis, impaired visual acuity, and painful/limited extraocular movements

Treatment Algorithm

Mild Periorbital Cellulitis (Outpatient Management)

• First-line: High-dose amoxicillin-clavulanate for comprehensive coverage 1
• Alternative options (for penicillin allergy): Clindamycin 1, 2
• Duration: 5-7 days, extend if improvement is not noted 2
• Follow-up: Daily until definite improvement is observed 1

Severe Periorbital Cellulitis (Inpatient Management)

Hospitalization is required if:

• Eyelid is >50% closed
• Patient does not improve within 24-48 hours of oral therapy
• Progressive infection is observed
• Patient has systemic symptoms (fever, lethargy)

Inpatient antibiotic regimens:

• First-line: IV ceftriaxone with metronidazole (associated with shortest hospital stay - 3.8 days vs. 5.8 days for ceftriaxone alone) 3
• Alternative: IV vancomycin (if MRSA is suspected) plus either piperacillin-tazobactam or imipenem/meropenem 2
• Duration: Typically 5-7 days IV, followed by transition to oral therapy if improvement is noted 2

For Orbital Complications or Suspected Intracranial Involvement

• Immediate hospitalization
• Contrast-enhanced CT scan of head, orbits, and sinuses
• IV vancomycin (to cover possible methicillin-resistant S. pneumoniae) 1
• Consultation with otolaryngology, ophthalmology, and infectious disease specialists 1, 2
• Surgical intervention may be necessary (only required in 6-7% of cases) 4, 5

Supportive Care

• Elevation of the affected area to promote gravity drainage of edema 1, 2
• Warm compresses to the affected area several times daily 2
• Eyelid cleansing to remove crusts or discharge 2
• Consider intranasal decongestants and steroids (associated with reduced need for surgical intervention) 3

Causative Organisms and Considerations

• Most common pathogens: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Moraxella species 1
• In children, periorbital cellulitis is often secondary to upper respiratory infections (68%) 4
• In adults and older children, sinusitis is a more common predisposing factor 4

Prevention of Recurrence

For patients with recurrent episodes:

• Monthly intramuscular benzathine penicillin injections (1.2 MU in adults) or oral therapy with twice-daily doses of either 250 mg of erythromycin or 1 g of penicillin V 1, 2
• Treat underlying conditions (sinusitis, trauma, dental infections)
• Keep skin well hydrated with emollients
• Reduce underlying edema through elevation, compressive stockings, or diuretic therapy if appropriate 1, 2

Common Pitfalls

• Failing to distinguish between periorbital and orbital cellulitis
• Inadequate coverage for MRSA in high-risk patients
• Failure to elevate the affected area
• Delayed surgical intervention when indicated
• Overlooking underlying conditions that can lead to recurrence 2