What is the next best treatment for a 7-year-old patient with preseptal cellulitis who has failed Augmentin (amoxicillin-clavulanate) treatment?

Treatment for Preseptal Cellulitis After Augmentin Failure in a 7-Year-Old

Clindamycin is the recommended next-line therapy for a 7-year-old with preseptal cellulitis who has failed Augmentin (amoxicillin-clavulanate) treatment. 1

Treatment Algorithm

• For preseptal cellulitis that has failed high-dose amoxicillin-clavulanate (Augmentin), the American Academy of Pediatrics recommends clindamycin as the appropriate next step in therapy 1
• The specific recommended regimen is:
  • Clindamycin (to cover penicillin-resistant S. pneumoniae) plus cefixime 1
  • Alternative options if there is high community prevalence of clindamycin-resistant S. pneumoniae:
    • Linezolid plus cefixime 1
    • Levofloxacin (though this is less preferred in children) 1

Dosing Considerations

• Clindamycin dosing for children: 30-40 mg/kg/day divided every 8 hours (not to exceed 1.8 g/day) 1
• For severe infections, the higher end of the dosing range should be used 1
• Duration of therapy should be 7-10 days, with reassessment after 48-72 hours to ensure clinical improvement 1

Pathogen Considerations

• Preseptal cellulitis in children is commonly caused by:
  • Streptococcus pneumoniae (including penicillin-resistant strains)
  • Beta-hemolytic streptococci
  • Staphylococcus aureus (including MRSA in some communities) 1
• Augmentin failure suggests possible resistant organisms, which is why clindamycin is recommended as it covers both resistant pneumococci and MRSA 1

Monitoring and Follow-up

• Close follow-up within 24-48 hours is essential to ensure improvement 1
• If the patient does not improve within 24-48 hours on clindamycin therapy, hospitalization for intravenous antibiotics should be considered 1, 2
• Watch for signs of progression to orbital cellulitis, including:
  • Proptosis
  • Impaired visual acuity
  • Impaired or painful extraocular mobility 1, 3

Special Considerations

• If there is high prevalence of clindamycin-resistant S. pneumoniae in your community, linezolid is the preferred alternative 1
• For children with severe preseptal cellulitis or signs of systemic toxicity, hospitalization for intravenous antibiotics is recommended 1, 4
• Imaging (contrast-enhanced CT) should be considered if there is:
  • No improvement after 24-48 hours of appropriate therapy
  • Signs of orbital involvement
  • Severe swelling that prevents adequate examination 1, 3

Common Pitfalls to Avoid

• Failing to obtain cultures before changing antibiotics, which can guide definitive therapy 1, 5
• Not considering underlying sinusitis, which is a common predisposing factor for preseptal cellulitis in children 2, 6
• Overlooking the need for close follow-up to monitor for potential progression to orbital cellulitis 1, 3
• Continuing ineffective therapy despite lack of clinical improvement within 48 hours 1