What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

The recommended treatment for periorbital cellulitis is high-dose amoxicillin-clavulanate for mild cases (eyelid <50% closed) on an outpatient basis with daily follow-up, while more severe cases require hospitalization and intravenous antibiotics. 1

Classification and Assessment

Periorbital cellulitis must be distinguished from orbital cellulitis:

• Periorbital (preseptal) cellulitis: Involves only the eyelid tissue anterior to the orbital septum
• Orbital (postseptal) cellulitis: Involves structures within the orbit posterior to the septum

Indications for Hospitalization:

• Failure to improve within 24-48 hours on oral therapy
• Progressive infection
• Proptosis
• Impaired visual acuity
• Impaired and/or painful extraocular mobility
• Systemic symptoms
• Age <1 year
• Immunocompromised status

Treatment Algorithm

1. Mild Periorbital Cellulitis (Outpatient Management)

• First-line therapy: High-dose amoxicillin-clavulanate 1
• Daily follow-up until definite improvement is noted
• Treatment duration: 5-7 days for uncomplicated cases 2
• If no improvement within 24-48 hours → hospitalize

2. Moderate to Severe Periorbital Cellulitis (Inpatient Management)

• Imaging: Contrast-enhanced CT scan (preferably coronal thin cut) of orbits and sinuses 1
• Empiric IV antibiotics:
  • Ceftriaxone plus clindamycin 3
  • If MRSA suspected: Add vancomycin 1, 2
• Specialist consultation:
  • Otolaryngology
  • Ophthalmology
  • Infectious disease (for guidance on antimicrobial selection)
• Treatment duration: Mean duration 8.6 days for intravenous therapy 3

3. Management of Complications

• Surgical intervention: Required in approximately 49% of orbital cellulitis cases 4
• Indications for surgery:
  • Subperiosteal abscess
  • Orbital abscess
  • Lack of response to medical therapy

Special Considerations

Predisposing Factors

• Sinusitis (most common - 43%) 5
• Upper respiratory infection (68% in periorbital cellulitis) 3
• Trauma to eyelids (20-25%) 5, 3
• Odontogenic infections (6%) 5

Common Pathogens

• Staphylococcus aureus (most common) 5, 3
• Streptococcus pneumoniae 3
• Staphylococcus epidermidis 3

Alternative Treatment Options

• For penicillin-allergic patients: Clindamycin 1, 2
• For MRSA coverage: Vancomycin, linezolid, daptomycin, or ceftaroline 2

Outpatient Intravenous Therapy

Recent evidence suggests that daily outpatient intravenous antibiotics with physician evaluation may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness 6. This approach showed a complication rate of only 3% (2/66 patients) with a mean duration of IV therapy of 4.1 days.

Adjunctive Measures

• Elevate the affected area to promote drainage of edema 2
• Identify and treat predisposing conditions (sinusitis, upper respiratory infections) 2
• Monitor daily for clinical response 2

Common Pitfalls

• Failure to distinguish between periorbital and orbital cellulitis
• Inadequate dosing of antibiotics
• Delayed recognition of need for surgical intervention
• Failure to address underlying conditions (especially sinusitis)
• Insufficient follow-up of outpatient cases

The evidence regarding the use of corticosteroids as adjunctive therapy is currently insufficient to draw conclusions about their effectiveness and safety in the treatment of periorbital cellulitis 7.