What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

For periorbital cellulitis, the recommended first-line treatment is antibiotics active against streptococci, which are the most common causative pathogens, with consideration for MRSA coverage only in specific high-risk situations. 1, 2

Antibiotic Selection

Mild to Moderate Cases (Outpatient Management)

• Oral antibiotics active against streptococci are recommended for uncomplicated periorbital cellulitis 1, 2:
  • Amoxicillin-clavulanate (first choice for comprehensive coverage) 1, 3
  • Cephalexin (500 mg four times daily) 4
  • Clindamycin (for penicillin-allergic patients) 1, 4
  • Dicloxacillin 1, 2

Severe Cases (Inpatient Management)

• Parenteral antibiotics are indicated for patients with severe infection, systemic signs, or concerning features 1, 3:
  • First-generation cephalosporin (cefazolin) 1, 2
  • Penicillinase-resistant penicillin (nafcillin or oxacillin) 1, 2
  • Vancomycin (for suspected MRSA or in penicillin-allergic patients) 1

Duration of Therapy

• The recommended duration is 5 days, with extension if the infection has not improved within this period 1, 2
• For severe cases or orbital involvement, longer courses (7-10 days) may be necessary 3, 5

Hospitalization Criteria

• Hospitalization is recommended for 1, 3:
  • Patients with systemic inflammatory response syndrome (SIRS) 2, 4
  • Altered mental status 1, 4
  • Hemodynamic instability 1, 2
  • Concern for deeper or orbital involvement 3, 6
  • Children under 1 year of age 6, 5
  • Reduced visual acuity, proptosis, or ophthalmoplegia (signs of orbital involvement) 6, 5

Diagnostic Considerations

• CT scan is essential to differentiate periorbital from orbital cellulitis when there are concerning features 6, 5
• Blood cultures are generally not necessary for typical cases but should be considered in patients with malignancy, severe systemic features, or unusual predisposing factors 1, 7

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema 1, 2
• Treatment of predisposing factors, such as sinusitis (present in up to 90% of orbital cellulitis cases) 3, 7
• Systemic corticosteroids could be considered in non-diabetic adult patients to reduce inflammation and hasten resolution 1, 4

Surgical Intervention

• Surgical intervention is rarely needed for uncomplicated periorbital cellulitis (only about 3-7% of cases) 6, 8, 5
• Consider surgical consultation for patients with:
  • Subperiosteal or orbital abscess 6, 5
  • Failure to respond to appropriate antibiotic therapy within 24-48 hours 1, 5
  • Signs of orbital involvement (proptosis, ophthalmoplegia, vision changes) 6, 5

Special Considerations

• MRSA coverage should be considered in cases associated with:
  • Penetrating trauma 1, 4
  • Evidence of MRSA infection elsewhere 1, 2
  • Purulent drainage 1, 4
  • History of injection drug use 2, 4
• Home intravenous antibiotic therapy with once-daily ceftriaxone may be considered for children with moderate periorbital cellulitis who are otherwise stable, as it has been shown to be non-inferior to hospital treatment 9

Prevention of Recurrence

• Identify and treat predisposing conditions such as sinusitis 3, 5
• For patients with frequent episodes, consider prophylactic antibiotics such as oral penicillin or erythromycin 1, 4

Common Pitfalls to Avoid

• Don't miss orbital involvement - always assess for proptosis, ophthalmoplegia, and visual changes 6, 5
• Don't delay imaging in cases with concerning features or failure to improve 6, 5
• Don't automatically add MRSA coverage for typical non-purulent periorbital cellulitis without specific risk factors 2, 4
• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 1, 4