What is the recommended management for periorbital cellulitis?

Management of Periorbital Cellulitis

The recommended management for periorbital cellulitis includes prompt antibiotic therapy targeting streptococci and staphylococci, with hospitalization and imaging indicated for cases with systemic symptoms or signs of orbital involvement. 1

Classification and Diagnosis

• Periorbital (preseptal) cellulitis involves only the eyelid, while postseptal (intraorbital) inflammation involves structures of the orbit 1
• Diagnosis is primarily clinical, based on eyelid swelling, erythema, and tenderness without orbital involvement 1
• Sinusitis is the most common predisposing condition (43%), followed by trauma (25%) and odontogenic infections (6%) 2
• Blood cultures are not routinely recommended for typical cases but should be considered in immunocompromised patients 1

Treatment Algorithm

Mild Periorbital Cellulitis (eyelid <50% closed, no systemic symptoms)

• Outpatient management with oral antibiotics active against streptococci and staphylococci 1
• High-dose amoxicillin-clavulanate is recommended for comprehensive coverage 1
• Daily follow-up until definite improvement is noted 1
• Treatment duration is typically 5 days, extending if no improvement is seen 1, 3

Moderate to Severe Periorbital Cellulitis (any of the following)

• Eyelid >50% closed
• Systemic symptoms (fever, elevated WBC)
• No improvement within 24-48 hours of oral therapy
• Progressive infection

Management:

• Hospitalization for intravenous antibiotic therapy 1
• Empiric coverage should include agents effective against both streptococci and staphylococci 1
• Vancomycin is recommended if MRSA is suspected (history of MRSA, penetrating trauma, injection drug use) 1
• Consider contrast-enhanced CT scan if proptosis, impaired visual acuity, or painful extraocular mobility is present 1
• Consultation with otolaryngology, ophthalmology, and infectious disease specialists is appropriate 1

Specific Antibiotic Regimens

• For mild cases: High-dose amoxicillin-clavulanate orally 1, 4
• For moderate to severe cases requiring hospitalization:
  • Ceftriaxone plus metronidazole has been associated with shorter hospital stays (3.8 days vs. 5.8 days with ceftriaxone alone) 5
  • Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem for severe infections 1
• For penicillin-allergic patients: Clindamycin or linezolid plus cefixime 1

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema 1, 4
• Intranasal decongestants and corticosteroids may reduce the need for surgical intervention 5
• Treat underlying sinusitis, which is present in up to 90% of orbital cellulitis cases 6

Surgical Intervention

• Surgical intervention is required in approximately 16-19% of cases 5
• Indications for surgery include:
  • Formation of subperiosteal or orbital abscess
  • Deterioration of vision
  • No improvement despite 24-48 hours of appropriate antibiotic therapy
  • Intracranial extension 1, 6

Monitoring and Follow-up

• Daily assessment until definite improvement is noted 1
• Monitor for signs of orbital involvement (proptosis, ophthalmoplegia, decreased visual acuity) 1, 6
• Watch for intracranial complications including epidural or subdural abscess, brain abscess, venous thrombosis, and meningitis 1

Prevention of Recurrence

• Identify and treat predisposing conditions such as sinusitis, dental infections, or trauma 2
• Treat fissuring, scaling, or maceration that may harbor pathogens 1

Common Pitfalls

• Failure to recognize progression from periorbital to orbital cellulitis, which can lead to permanent blindness if not treated promptly 1
• Inadequate antibiotic coverage for both streptococci and staphylococci 1
• Not obtaining imaging when signs of orbital involvement are present 1
• Failure to consult appropriate specialists (ophthalmology, otolaryngology) for moderate to severe cases 1, 7