What is the treatment for preseptal cellulitis?

Treatment of Preseptal Cellulitis

For preseptal cellulitis, first-line treatment should include antibiotics active against beta-hemolytic streptococci, such as penicillin, amoxicillin, dicloxacillin, or cephalexin for 5 days, extending treatment if no improvement is seen within this period. 1

Antimicrobial Selection Based on Severity

Mild to Moderate Preseptal Cellulitis (Outpatient Treatment)

• First-line therapy should target streptococci with oral options including:
  • Penicillin, amoxicillin, dicloxacillin, or cephalexin 1
  • For penicillin-allergic patients: clindamycin or erythromycin 1
• Standard treatment duration is 5 days, extending if infection has not improved 2, 1

Severe Preseptal Cellulitis (Requiring Hospitalization)

• Indications for hospitalization include:
  • Systemic inflammatory response syndrome (SIRS) 2
  • Altered mental status or hemodynamic instability 2
  • Concern for deeper infection 2
  • Immunocompromised patient 2
  • Failed outpatient treatment 2
• For severe infections, recommended treatment:
  • Vancomycin or another antimicrobial effective against both MRSA and streptococci 2, 1
  • For severely compromised patients: vancomycin plus either piperacillin-tazobactam or imipenem/meropenem 2

Special Considerations for MRSA Coverage

• Consider MRSA coverage when preseptal cellulitis is associated with:
  • Penetrating trauma 2
  • Evidence of MRSA infection elsewhere 2
  • Nasal colonization with MRSA 2
  • Injection drug use 2
  • Purulent drainage 1

Pediatric Considerations

• Treatment approach for children is similar to adults, with antibiotics active against streptococci 3
• Oral options for outpatient treatment include penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cefalexin, or clindamycin 3
• Avoid tetracyclines in children under 8 years old 3

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema 2, 1
• Identify and treat predisposing conditions:
  • Sinusitis (common predisposing factor) 4, 5
  • Edema 2
  • Fissuring, scaling, or maceration in interdigital spaces 2, 1
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adult patients to hasten resolution 2, 1

Monitoring and Follow-up

• Patients should show improvement within 24-48 hours of appropriate antibiotic therapy 2
• If no improvement is seen within 72 hours, consider:
  • Changing antibiotics 1
  • Imaging to rule out orbital involvement or abscess formation 5
  • Hospital admission for IV antibiotics 2

Prevention of Recurrence

• Identify and treat predisposing conditions such as sinusitis, edema, and toe web abnormalities 2, 1
• For patients with 3-4 episodes per year despite addressing predisposing factors, consider prophylactic antibiotics such as oral penicillin or erythromycin twice daily for 4-52 weeks 2

Common Pitfalls to Avoid

• Failure to differentiate between preseptal and orbital cellulitis - check for diplopia, ophthalmoplegia, and proptosis which are only present in orbital cellulitis 5
• Not elevating the affected area, which delays improvement 2, 1
• Inadequate treatment duration when clinical improvement is not evident after 5 days 2, 1
• Failure to recognize potential complications requiring urgent intervention, such as progression to orbital cellulitis 5, 6