What is the recommended treatment for preséptal cellulitis?

Treatment of Preseptal Cellulitis

For preseptal cellulitis, a 5-day course of antibiotics active against streptococci is recommended as first-line therapy, with extension if the infection has not improved within this time period. 1

Antibiotic Selection

Mild Cases (Outpatient)

• For typical cases without systemic signs of infection, use an antimicrobial agent active against streptococci 1:
  • Penicillin
  • Amoxicillin
  • Amoxicillin-clavulanate
  • Dicloxacillin
  • Cephalexin
  • Clindamycin

Moderate Cases (Systemic Signs)

• For cases with systemic signs of infection, consider coverage for both streptococci and methicillin-susceptible S. aureus (MSSA) 1
• Options include:
  • Cefazolin 1 g every 8 hours IV 1
  • Nafcillin 1-2 g every 4-6 hours IV 1

Severe Cases or Special Circumstances

• For patients with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS, use antibiotics effective against both MRSA and streptococci 1:

  • Vancomycin 15 mg/kg every 12 hours IV 1
  • Linezolid
  • Daptomycin
  • Telavancin

• For severely compromised patients, consider broad-spectrum coverage 1:

  • Vancomycin plus piperacillin-tazobactam or
  • Vancomycin plus imipenem/meropenem

Duration of Therapy

• The recommended duration is 5 days 1
• Treatment should be extended if infection has not improved within this time period 1
• In clinical practice, the total duration (including post-discharge) may range from 7-10 days based on clinical response 2

Adjunctive Measures

• Elevation of the affected area to promote drainage of edema 1
• Identify and treat predisposing factors such as sinusitis, which is a common cause in preseptal cellulitis cases 2, 3
• Systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in non-diabetic adult patients to reduce inflammation 1

Hospitalization Criteria

• Hospitalization is recommended for 1:
  • Patients with SIRS, altered mental status, or hemodynamic instability
  • Concern for deeper or necrotizing infection
  • Poor adherence to therapy
  • Severely immunocompromised patients
  • Failure of outpatient treatment

Diagnostic Considerations

• Blood cultures are not routinely recommended for typical cases 1, 4
• Blood cultures should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites 1, 5
• Imaging studies (CT, MRI) are typically reserved for cases where orbital involvement is suspected 3

Special Considerations

• Preseptal cellulitis must be distinguished from orbital cellulitis, which is a medical emergency 6, 3
• Key differentiating features include:
  • Presence of ophthalmoplegia, proptosis, or diplopia suggests orbital involvement 3
  • Higher C-reactive protein levels (>120 mg/L) may indicate orbital cellulitis 3
  • Fever and sinusitis are more common in orbital cellulitis 3

Prevention of Recurrence

• For patients with 3-4 episodes per year despite treatment of predisposing factors, consider prophylactic antibiotics 1:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks, or
  • Intramuscular benzathine penicillin every 2-4 weeks