What is the recommended management for preseptal cellulitis?

Management of Preseptal Cellulitis

First-line treatment for preseptal cellulitis should include antibiotics active against streptococci, which are the most common causative organisms, with MRSA coverage only in specific risk situations. 1

Antibiotic Selection

Outpatient Treatment (Mild Cases)

• For mild preseptal cellulitis without systemic symptoms, oral antibiotics effective against streptococci and staphylococci are recommended 1:
  • First-line options:
    • Penicillin or amoxicillin (if streptococcal infection is strongly suspected) 1
    • Dicloxacillin or cephalexin (if S. aureus coverage is desired) 1
    • Amoxicillin-clavulanate (for broader coverage of mixed infections) 1

Inpatient Treatment (Moderate to Severe Cases)

• For moderate to severe cases requiring hospitalization, intravenous antibiotics are recommended 1:
  • Cefazolin IV (1g every 8h in adults) 1
  • Nafcillin IV (1-2g every 4-6h in adults) 1

MRSA Considerations

• MRSA is not a typical cause of non-purulent preseptal cellulitis, and routine MRSA coverage is unnecessary 2, 1
• Consider MRSA coverage only in specific situations 1:
  • Presence of penetrating trauma 2, 1
  • Evidence 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 1:

  • Trimethoprim-sulfamethoxazole 2, 1
  • Clindamycin 2, 1
  • Linezolid 1
  • Consider adding a beta-lactam for streptococcal coverage 1

• For inpatient MRSA treatment 2, 1:

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

Duration of Therapy

• A 5-day course of antimicrobial therapy is as effective as a 10-day course if clinical improvement has occurred by day 5 2, 1
• Treatment should be extended if the infection has not improved within this time period 2, 1

Hospitalization Criteria

• Consider hospitalization if 2, 3, 1:
  • Presence of SIRS (fever, tachycardia, tachypnea, leukocytosis) 2, 3
  • Altered mental status 2
  • Hemodynamic instability 2
  • Concern for deeper or necrotizing infection 2
  • Poor adherence to therapy 2
  • Severe immunocompromise 2
  • Failure of outpatient treatment 2
  • Progressive infection or no improvement within 24-48 hours 1
  • Signs of orbital involvement (proptosis, impaired visual acuity, painful/impaired extraocular movement) 1, 4

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema and inflammatory substances 2, 3
• Identify and treat predisposing conditions such as sinusitis, odontogenic infections, insect bites, or periocular trauma 2, 5
• Consider systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) in non-diabetic adult patients with cellulitis 2
• For recurrent episodes (3-4 per year), prophylactic antibiotics may be considered 2:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks 2
  • Intramuscular benzathine penicillin every 2-4 weeks 2

Distinguishing Preseptal from Orbital Cellulitis

• Preseptal cellulitis involves only the eyelid, whereas orbital cellulitis involves structures of the orbit 1, 4
• Key differentiating features of orbital cellulitis include 4:
  • Diplopia (double vision) 4
  • Ophthalmoplegia (restricted eye movement) 4
  • Proptosis (bulging of the eye) 4
  • Higher C-reactive protein levels (CRP >120 mg/L) 4
  • More common in older children (mean age 7.5 years vs 3.9 years for preseptal) 4
  • Higher incidence of fever (82.2% vs 51.5%) 4
  • Higher association with sinusitis (77.8% vs 2%) 4

Management of Complications

• If orbital involvement is suspected, obtain CT imaging to detect complications such as subperiosteal abscesses 1, 4
• For severe cases with orbital involvement, consultation with ophthalmology, otolaryngology, and infectious disease specialists is appropriate 1
• Surgical drainage may be required for abscesses, particularly those with volumes exceeding 1250 ml 6

Common Pitfalls to Avoid

• Failing to distinguish between preseptal and orbital cellulitis, which have different management approaches and outcomes 1, 4
• Not considering MRSA in cases with specific risk factors 1
• Inadequate duration of therapy when clinical improvement is delayed 2, 1
• Missing underlying predisposing conditions that may lead to recurrent infections 2, 5