What is the recommended treatment for facial cellulitis?

Treatment of Facial Cellulitis

For facial cellulitis, empirical therapy with antibiotics active against streptococci and staphylococci is recommended, with high-dose amoxicillin-clavulanate as first-line treatment for mild to moderate cases, and vancomycin plus piperacillin-tazobactam or a carbapenem for severe cases requiring hospitalization. 1

Classification and Diagnosis

• Facial cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue presenting with local signs of inflammation including warmth, erythema, pain, and swelling 2, 3
• Periorbital cellulitis specifically involves only the eyelid, while postseptal inflammation involves structures of the orbit 1
• Diagnosis is primarily clinical, based on physical examination findings of erythema, swelling, and tenderness 1, 3
• Blood cultures are not routinely recommended for typical cases but should be considered in immunocompromised patients or those with systemic symptoms 2, 1

Treatment Algorithm

Mild to Moderate Facial Cellulitis (Outpatient Management)

• High-dose amoxicillin-clavulanate is recommended as first-line therapy for comprehensive coverage of both streptococci and staphylococci 1
• For penicillin-allergic patients, clindamycin is an effective alternative that covers both streptococci and community-acquired MRSA 4, 1
• Treatment duration is typically 5 days, extending if no improvement is seen 2, 1
• For nonpurulent facial cellulitis, empirical therapy for β-hemolytic streptococci is recommended 4
• For purulent facial cellulitis, empirical coverage for CA-MRSA should be considered pending culture results 4

Moderate to Severe Facial Cellulitis (Inpatient Management)

• Hospitalization is recommended for patients with:

  • Systemic signs of infection
  • Concern for deeper or necrotizing infection
  • Periorbital involvement with risk of orbital spread
  • Immunocompromise
  • Failure of outpatient therapy 2, 1

• Intravenous antibiotic options include:

  • Vancomycin (if MRSA is suspected) plus either piperacillin-tazobactam or a carbapenem for severe infections 1
  • For complicated skin and soft tissue infections, empirical therapy for MRSA should be considered pending culture data 4

Specific Antibiotic Regimens

Outpatient Oral Options:

• High-dose amoxicillin-clavulanate (first-line) 1
• Clindamycin (covers both streptococci and CA-MRSA) 4, 1
• Trimethoprim-sulfamethoxazole (for CA-MRSA coverage) 4
• Doxycycline or minocycline (for CA-MRSA coverage) 4
• Linezolid (for coverage of both β-hemolytic streptococci and CA-MRSA) 4

Inpatient Intravenous Options:

• Vancomycin (for MRSA coverage) 4, 1
• Vancomycin plus piperacillin-tazobactam or imipenem/meropenem for severe infections 1

Special Considerations for Periorbital Cellulitis

• Periorbital cellulitis requires prompt treatment due to risk of orbital involvement and potential vision loss 1, 5
• Daily assessment until definite improvement is noted is recommended 1
• Monitor for signs of orbital involvement (proptosis, ophthalmoplegia, pain with eye movement, vision changes) 1
• Surgical consultation is indicated for:
  • Formation of subperiosteal or orbital abscess
  • Deterioration of vision
  • No improvement despite 24-48 hours of appropriate antibiotic therapy 1

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema and inflammatory substances 2, 1
• Treatment of predisposing factors such as underlying skin conditions 2
• Consider systemic corticosteroids in non-diabetic adult patients with severe inflammation 2

Management of Recurrent Facial Cellulitis

• Search for and address local causes such as chronic skin conditions 2
• Treat predisposing conditions such as edema, eczema, or other skin disorders 2
• For recurrent S. aureus infections, consider a 5-day decolonization regimen including intranasal mupirocin and daily chlorhexidine washes 2
• Consider prophylactic antibiotics in patients with 3-4 episodes per year despite treatment of predisposing factors 2

Common Pitfalls and Caveats

• Failure to recognize progression from periorbital to orbital cellulitis can lead to permanent blindness if not treated promptly 1
• Inadequate antibiotic coverage for both streptococci and staphylococci can lead to treatment failure 1
• Not obtaining imaging when signs of orbital involvement are present can delay diagnosis and treatment 1
• The use of rifampin as a single agent or as adjunctive therapy for the treatment of skin and soft tissue infections is not recommended 4
• Facial cellulitis, especially periorbital, can progress rapidly and requires close monitoring due to proximity to critical structures 1, 5