What is the treatment for preseptal cellulitis?

Treatment for Preseptal Cellulitis

For preseptal cellulitis, high-dose amoxicillin-clavulanate is the recommended first-line outpatient treatment for mild cases, while more severe cases require hospitalization for intravenous antibiotics with coverage against common pathogens including Streptococcus and Staphylococcus species. 1, 2

Outpatient Management

Mild Preseptal Cellulitis (eyelid <50% closed)

• First-line therapy: High-dose amoxicillin-clavulanate 1
• Alternative options (particularly if MRSA is suspected):
  • Clindamycin: 300-450 mg orally four times daily for adults; 30-40 mg/kg/day divided in 3 doses for children 2
  • Doxycycline: 100 mg orally twice daily (adults only, not for children under 8) 2
  • Minocycline: 200 mg loading dose, then 100 mg orally twice daily (adults only) 2

Monitoring Requirements

• Daily follow-up until definite improvement is noted 1
• Clinical improvement should be assessed within 48-72 hours 2
• If no improvement within 24-48 hours or if infection is progressive, hospitalization is indicated 1

Inpatient Management

Indications for Hospitalization

• No improvement within 24-48 hours of outpatient therapy
• Progressive infection
• Presence of proptosis, impaired visual acuity, or impaired/painful extraocular mobility
• Systemic toxicity
• Immunocompromised state
• Significant comorbidities 1, 2

Inpatient Treatment Options

• First-line IV options:
  • Vancomycin: 15-20 mg/kg/dose every 8-12 hours 2
  • Linezolid: 600 mg twice daily 2
  • Daptomycin: 4 mg/kg/day 2
  • Telavancin: 10 mg/kg/day 2

Special Considerations

• If MRSA is suspected, vancomycin should be included in the regimen 1
• For cases with orbital involvement, contrast-enhanced CT scan should be performed 1
• Consultation with otolaryngology, ophthalmology, and infectious disease specialists is appropriate for guidance regarding surgical intervention and antimicrobial selection 1

Treatment Duration

• 5-6 days is typically sufficient for uncomplicated cases 2
• Consider extending treatment if no improvement after 5 days 2
• Total duration (including IV-to-oral transition) typically averages 10 days 3

Causative Organisms and Considerations

• Streptococci are the most common causative organisms, followed by Staphylococcus aureus 2, 4
• Consider MRSA coverage if:
  • Purulent drainage or abscess is present
  • Prior MRSA infection or colonization
  • Penetrating trauma
  • History of injection drug use
  • Systemic inflammatory response syndrome 2

Warning Signs of Orbital Involvement

• Proptosis
• Pain with eye movements
• Restriction of extraocular movements/diplopia
• Vision changes
• Severe eyelid swelling with pain and erythema 2

Complications and Prognosis

• With prompt diagnosis and appropriate antibiotic therapy, preseptal cellulitis generally has a good prognosis 5, 4
• If left untreated, preseptal cellulitis can progress to orbital cellulitis or intracranial complications 5
• C-reactive protein >120 mg/L may suggest orbital rather than preseptal involvement 6

Preseptal cellulitis requires prompt treatment to prevent progression to more serious complications. The treatment approach should be guided by the severity of presentation, with close monitoring for clinical improvement within the first 48-72 hours.