What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

For periorbital (preseptal) cellulitis, the recommended treatment is prompt administration of antibiotics effective against typical Gram-positive pathogens, particularly amoxicillin-clavulanate, with a standard duration of 5-10 days, individualized based on clinical response. 1

Classification and Initial Assessment

• Periorbital (Preseptal) Cellulitis: Inflammation anterior to the orbital septum, involving only the eyelid
• Orbital (Postseptal) Cellulitis: More serious infection involving structures of the orbit
• Key Assessment Findings:
  • Eyelid swelling, erythema, and tenderness
  • Check for proptosis, impaired visual acuity, or painful/impaired extraocular mobility (signs of orbital involvement)
  • Evaluate for potential sources: sinusitis (most common), trauma, odontogenic infections

Treatment Algorithm

1. Mild Preseptal Cellulitis (Outpatient Management)

• First-line therapy: High-dose amoxicillin-clavulanate 2, 1
• Alternative options (especially if MRSA suspected):
  • Clindamycin 600 mg orally three times daily 1
  • TMP-SMX plus a beta-lactam (e.g., amoxicillin) 1
  • Doxycycline (not for children <8 years) 1
• Duration: 5-6 days is as effective as longer courses for uncomplicated cases 2, 1
• Follow-up: Daily until definite improvement is noted 2

2. Moderate-Severe Preseptal Cellulitis (Inpatient Management)

Indications for hospitalization:

• No improvement within 24-48 hours of outpatient therapy
• Progressive infection
• Eyelid >50% closed
• Young age or inability to tolerate oral medications

Recommended regimens:

• First-line: IV ceftriaxone + metronidazole (associated with shortest hospital stay and reduced need for surgery) 3
• Alternatives:
  • IV amoxicillin-clavulanate 4
  • IV vancomycin (for suspected MRSA) 1
  • IV clindamycin 600 mg three times daily 1
  • IV linezolid 600 mg twice daily 1

3. Orbital Cellulitis (Postseptal)

• Immediate hospitalization
• Imaging: Contrast-enhanced CT scan of orbits and sinuses
• Antibiotics: IV vancomycin (for MRSA coverage) plus coverage for other pathogens 2
• Consultations: Otolaryngology, ophthalmology, and infectious disease
• Surgical evaluation: For drainage of subperiosteal or orbital abscesses

Special Considerations

• MRSA Coverage: Consider when risk factors present (previous MRSA infection, nasal colonization, injection drug use) 1
• Adjunctive Therapy:
  • Intranasal decongestants and corticosteroids may reduce need for surgical intervention 3
  • Treat underlying sinusitis aggressively
• Monitoring: Daily assessment for:
  • Response to therapy
  • Development of orbital involvement
  • Intracranial complications

Pitfalls and Caveats

• Avoid TMP-SMX alone for non-purulent cellulitis due to poor activity against streptococci 1
• Do not use tetracyclines in children under 8 years of age 1
• Never delay treatment if orbital or intracranial involvement is suspected
• Prior NSAID use may complicate the clinical picture and has been noted in some cases 4
• Obtain cultures from any purulent drainage to guide therapy 1
• Watch for complications: Permanent blindness, neurologic sequelae, or death can occur if not treated promptly and appropriately 2

Follow-up

• For mild cases treated as outpatients: Daily follow-up until definite improvement
• If no improvement within 24-48 hours or worsening symptoms: Hospitalize for IV antibiotics
• Consider imaging if orbital involvement is suspected

The most recent evidence supports shorter antibiotic courses (5-6 days) for uncomplicated cases 2, 1, with the combination of ceftriaxone and metronidazole showing promising results for more severe cases requiring hospitalization 3.