What is the recommended treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

The first-line treatment for periorbital cellulitis is oral amoxicillin-clavulanate for uncomplicated cases, while severe cases require parenteral antibiotics such as cefazolin, nafcillin, or oxacillin. 1, 2

Classification and Initial Assessment

• Periorbital (preseptal) cellulitis is an infection limited to the eyelids anterior to the orbital septum, while orbital (postseptal) cellulitis involves the contents of the orbit and is more serious 3
• Diagnosis is based on clinical presentation with signs including erythema, tenderness, and induration of the eyelid 2
• CT scan with IV contrast is the most useful imaging modality to differentiate preseptal from postseptal involvement when orbital involvement is suspected 2

Treatment Algorithm

Uncomplicated/Mild Cases (Outpatient Management)

• Oral amoxicillin-clavulanate is the first-line treatment for comprehensive coverage of common causative organisms (Streptococcus species and Staphylococcus aureus) 1, 2
• For penicillin-allergic patients, clindamycin is the recommended alternative 1
• Treatment duration should be 5 days initially, with extension if the infection has not improved within this period 1, 2
• Daily follow-up until definite improvement is noted 2
• Elevation of the affected area to promote gravity drainage of edema is recommended as an adjunctive measure 1, 4

Moderate to Severe Cases (Inpatient Management)

• Hospitalization is indicated for:
  • Systemic inflammatory response syndrome (SIRS) 1
  • Altered mental status or hemodynamic instability 1
  • Proptosis, impaired visual acuity, or impaired/painful extraocular mobility 2
  • Failure to improve within 24-48 hours of outpatient therapy 2
  • Progressive infection 2
• Parenteral antibiotic options include:
  • First-generation cephalosporin (cefazolin) 1, 2
  • Penicillinase-resistant penicillin (nafcillin or oxacillin) 1, 2
• For severe penicillin allergies, clindamycin or vancomycin are appropriate alternatives 2

Special Considerations

• MRSA coverage should be considered in cases with:
  • Penetrating trauma 1, 4
  • Evidence of MRSA infection elsewhere 1
  • Purulent drainage 1
  • History of injection drug use 1
  • Previous MRSA infection or known colonization 4
  • Local high prevalence of MRSA 4
  • Failure to respond to beta-lactam therapy 4
• Appropriate MRSA coverage includes vancomycin, clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 2
• Systemic corticosteroids could be considered in non-diabetic adult patients to reduce inflammation and hasten resolution 1
• Surgical intervention may be necessary in approximately 7% of cases, particularly for subperiosteal or orbital abscesses 5

Monitoring and Follow-up

• Re-evaluate patients within 24-48 hours to assess response to therapy 2, 4
• Consider changing antibiotics if no improvement after 48 hours 4
• For hospitalized patients, daily assessment is necessary 2
• Consider additional imaging if there is clinical suspicion of progression to orbital involvement or intracranial complications 2

Common Pitfalls to Avoid

• Don't automatically add MRSA coverage for typical non-purulent periorbital cellulitis without specific risk factors 1
• Don't extend treatment unnecessarily beyond 5 days if clinical improvement has occurred 1
• Avoid delaying appropriate imaging in cases with concerning features such as proptosis, visual changes, or ophthalmoplegia 2
• Be cautious about prior treatment with non-steroidal anti-inflammatory medications, which was noted in some cases with complications 5
• Don't miss identifying and treating predisposing conditions such as sinusitis, which is particularly important for preventing recurrence 1, 2