What is the recommended treatment for preseptal cellulitis?

Treatment for Preseptal Cellulitis

For preseptal cellulitis, antimicrobial therapy active against streptococci is the primary treatment, with a standard 5-day course being as effective as longer courses if clinical improvement occurs within this timeframe. 1

First-Line Treatment Options

Mild to Moderate Cases (Outpatient)

• Oral antibiotics active against streptococci:
  • Penicillin
  • Amoxicillin
  • Amoxicillin-clavulanate
  • Dicloxacillin
  • Cephalexin
  • Clindamycin 1

Severe Cases (Requiring Hospitalization)

• Intravenous antibiotics:
  • Cefazolin 1-2 g IV every 8 hours
  • Clindamycin 600-900 mg IV every 8 hours 2

When to Consider MRSA Coverage

MRSA is an unusual cause of typical preseptal cellulitis, with studies showing that treatment with β-lactams is successful in 96% of patients 1. However, MRSA coverage may be prudent in cases with:

• Penetrating trauma
• Purulent drainage
• Concurrent evidence of MRSA infection elsewhere 1

MRSA Treatment Options

• Intravenous options: Vancomycin, daptomycin, linezolid, or telavancin
• Oral options: Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole 1

Duration of Treatment

• Standard duration is 5 days for uncomplicated cases 2
• Extend treatment if infection has not improved within this period 2
• The total course (including IV and oral) typically ranges from 5-7 days for uncomplicated skin infections 2

Indications for Hospitalization

Hospitalization is recommended for patients with:

• Systemic inflammatory response syndrome (SIRS)
• Altered mental status
• Hemodynamic instability
• Concern for deeper or necrotizing infection
• Poor adherence to therapy
• Severe immunocompromise
• Failure of outpatient treatment 2

Adjunctive Measures

• Elevation of the affected area to reduce edema 2
• Treatment of predisposing factors such as sinusitis, dacryocystitis, or trauma 3
• Daily follow-up until clear improvement is noted 2
• Consider surgical intervention for cases with abscess formation 3

Common Pathogens and Considerations

The most common pathogens in preseptal cellulitis are:

• Staphylococcus species
• Streptococcus species
• Less commonly: Haemophilus influenzae and other gram-negative organisms 3

In cases that don't respond to initial therapy within 36-48 hours, consider:

1. Alternative pathogens (like Proteus species) 4
2. Changing antibiotics (e.g., to fluoroquinolones like ciprofloxacin) 4
3. Obtaining cultures if possible, especially if surgical drainage is performed 3

Special Considerations

• For preseptal cellulitis secondary to sinusitis or upper respiratory infection (28.8% of cases), ensure adequate coverage for respiratory pathogens 3
• For cases secondary to acute dacryocystitis (32.6% of cases), consider ophthalmology consultation for possible dacryocystorhinostomy 3
• For post-traumatic or post-surgical cases (27.8% of cases), consider broader coverage including gram-negative organisms 3

Follow-up and Monitoring

• Patients should be followed up within 48-72 hours to assess response to treatment 2
• Watch for signs of progression including:
  • Proptosis
  • Impaired visual acuity
  • Restricted extraocular movements
  • Systemic symptoms of infection 2
• Consider hospitalization if no improvement within 24-48 hours of outpatient treatment 2

Potential Complications

Although preseptal cellulitis generally has a good prognosis, complications can include:

• Progression to orbital cellulitis
• Subacute lid abscesses
• Eyelid necrosis
• Cicatricial ectropion 3
• In rare cases, streptococcal toxic shock syndrome 5

Early and appropriate antibiotic therapy is crucial to prevent these complications and achieve favorable outcomes.