What are the recommended antibiotics for preseptal cellulitis?

Antibiotic Treatment for Preseptal Cellulitis

First-line treatment for preseptal cellulitis should be a 5-day course of antibiotics active against streptococci, with MRSA coverage only needed in specific risk situations. 1

First-Line Antibiotic Options

• For mild preseptal cellulitis, oral antibiotics effective against streptococci and staphylococci are recommended:

  • Penicillin or amoxicillin if streptococcal infection is suspected 1
  • Dicloxacillin or cephalexin if S. aureus coverage is desired 1
  • Amoxicillin-clavulanate for broader coverage of mixed infections 1

• For moderate to severe cases requiring hospitalization:

  • Cefazolin IV (adults: 1g every 8h; children: 33 mg/kg/dose) 1
  • Nafcillin IV (adults: 1-2g every 4-6h; children: 50 mg/kg/dose) 1

Duration of Therapy

• A 5 to 6-day course of antibiotics is recommended for preseptal cellulitis 2, 1
• Treatment should be extended if the infection has not improved within this time period 2, 1
• Recent evidence shows that shorter courses (5-6 days) are as effective as longer courses (10-12 days) for nonpurulent cellulitis 2

When to Consider MRSA Coverage

MRSA coverage should be added in the following situations:

• Penetrating trauma, especially from illicit drug use 2, 1
• Presence of purulent drainage 2, 1
• Evidence of MRSA infection elsewhere 2, 1
• History of injection drug use 2, 1
• Systemic inflammatory response syndrome (SIRS) 2, 1
• Lack of response to beta-lactam antibiotics 1

MRSA Treatment Options

• For outpatient MRSA treatment:

  • Trimethoprim-sulfamethoxazole 2, 1
  • Clindamycin (noting increasing resistance) 2, 1
  • Doxycycline 2
  • Consider adding a beta-lactam for streptococcal coverage 1

• For inpatient MRSA treatment:

  • Vancomycin IV 2, 1
  • Linezolid IV/oral 1, 3
  • Daptomycin IV 2, 1
  • Telavancin IV 2, 1

Special Considerations

• For severe infections with systemic involvement, broader coverage may be needed 2
• In cases of vancomycin failure, combination therapy with linezolid and rifampin has been reported effective 3
• Clindamycin has been commonly used in pediatric cases, often in combination with ceftriaxone 4

Distinguishing Preseptal from Orbital Cellulitis

• Preseptal cellulitis involves only the eyelid, while orbital cellulitis affects deeper orbital structures 1
• Orbital cellulitis typically presents with:
  • Proptosis 1
  • Impaired visual acuity 1
  • Impaired or painful extraocular mobility 1
  • Higher inflammatory markers (WBC, ESR, CRP) compared to preseptal cellulitis 5

Hospitalization Criteria

• Hospitalization is recommended for:
  • Signs of orbital involvement 1
  • Severe systemic symptoms 2
  • Failure to improve within 24-48 hours on outpatient therapy 1
  • Immunocompromised patients 2
  • Poor adherence to therapy 2

Common Pitfalls to Avoid

• Not considering MRSA in high-risk cases 1
• Failing to identify and treat underlying conditions (sinusitis, dental infections) 1, 4
• Not extending treatment duration when clinical improvement is inadequate 2
• Missing orbital involvement that requires more aggressive management 1, 6