What is commonly used to treat periorbital cellulitis?

Treatment of Periorbital Cellulitis

High-dose amoxicillin-clavulanate is the first-line treatment for periorbital cellulitis, providing comprehensive coverage against the most common causative organisms. 1

Causative Organisms and Antibiotic Selection

• Periorbital cellulitis is most commonly caused by Streptococcus species (particularly group A streptococci) and Staphylococcus aureus 2
• Sinusitis (43%) is the most frequent predisposing condition, followed by trauma (25%) and odontogenic infections (6%) 3
• For empiric therapy, antibiotics should cover both streptococci and staphylococci 2

Treatment Algorithm

Mild Cases (Outpatient Management)

• For mild cases with eyelid less than 50% closed, outpatient treatment with high-dose amoxicillin-clavulanate is appropriate 1
• Alternative oral options include:
  • Dicloxacillin, cephalexin, clindamycin, or erythromycin (unless local resistance patterns indicate otherwise) 2
  • Oral ciprofloxacin combined with clindamycin has shown effectiveness similar to IV therapy in some studies 4
• Treatment duration typically ranges from 5-7 days, but should be extended if infection has not resolved 1
• Daily follow-up is necessary until definite improvement is noted 1

Moderate to Severe Cases (Inpatient Management)

• Hospitalization criteria include:
  • Progressive infection despite 24-48 hours of outpatient therapy 1
  • Proptosis, impaired visual acuity, or painful/impaired extraocular mobility 1
  • Systemic signs of infection 1
• Parenteral therapy options include:
  • Penicillinase-resistant penicillin (nafcillin) 2
  • First-generation cephalosporin (cefazolin) 2
  • Ceftriaxone plus clindamycin (mean duration 8.6 days in pediatric studies) 5
  • Sulbactam-ampicillin has shown good efficacy with lower recurrence rates compared to penicillin plus chloramphenicol 3

Special Considerations

• MRSA Coverage: If MRSA is suspected based on local prevalence or risk factors, appropriate coverage should include vancomycin, clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 1
• Penicillin Allergy: For patients with severe penicillin allergies, clindamycin or vancomycin are appropriate alternatives 2
• Imaging: CT scan with IV contrast is the most useful imaging modality to differentiate preseptal from postseptal involvement and identify potential complications 1, 6
• Surgical Intervention: While most cases respond to antibiotics alone, approximately 6% of patients may require surgical intervention, particularly for drainage of abscesses or management of extensive sinus disease 5, 6

Monitoring and Follow-up

• Patients with mild cases treated as outpatients should be reassessed within 24-48 hours 1
• For hospitalized patients, daily assessment is necessary to monitor response to therapy 1
• Some centers have successfully implemented daily outpatient IV antibiotic administration with physician evaluation as an alternative to admission for select cases 7

Common Pitfalls

• Failing to distinguish between periorbital (preseptal) and orbital (postseptal) cellulitis, which requires different management approaches 6
• Not considering MRSA coverage when risk factors are present 1
• Inadequate duration of therapy or failure to reassess response after initial treatment 1
• Delaying appropriate imaging in cases with concerning features such as proptosis, visual changes, or ophthalmoplegia 1