Treatment of Periorbital Cellulitis
High-dose amoxicillin-clavulanate is the first-line treatment for periorbital cellulitis, providing comprehensive coverage of the most common causative organisms including Streptococcus species and Staphylococcus aureus. 1
Outpatient vs. Inpatient Decision
Mild cases with eyelid less than 50% closed can be managed as outpatients with oral antibiotics and mandatory daily follow-up until definite improvement is documented 1. However, hospitalization is required if:
- No improvement within 24-48 hours of outpatient therapy 1
- Progressive infection despite treatment 1
- Presence of proptosis, impaired visual acuity, or painful/impaired extraocular movements 1
- Systemic signs of infection (fever, toxicity) 1
Antibiotic Selection Algorithm
For Outpatient Management (Mild Cases)
- First-line: High-dose amoxicillin-clavulanate orally 1
- Duration: 5-7 days, extended if infection has not improved 1
- Reassessment: Within 24-48 hours mandatory 1
For Inpatient Management (Moderate to Severe Cases)
- Parenteral options: Nafcillin (penicillinase-resistant penicillin) or cefazolin (first-generation cephalosporin) 2, 1
- Alternative regimen: Ceftriaxone plus clindamycin has shown effectiveness in pediatric series 3
- Severe penicillin allergy: Clindamycin or vancomycin 2, 1
MRSA Coverage (When Suspected)
Add specific MRSA-directed therapy including vancomycin, clindamycin, trimethoprim-sulfamethoxazole, or doxycycline 1. Consider MRSA when:
- Recent fluoroquinolone or antibiotic use
- Recent hospitalization
- Known MRSA colonization or previous infection
- Failure to respond to initial beta-lactam therapy
Treatment Duration and Monitoring
- Standard duration: 5-7 days for uncomplicated cases 1
- Extended therapy: Continue if infection has not adequately improved 1
- Daily assessment: Required for hospitalized patients to monitor therapeutic response 1
- Imaging: CT scan of orbits with IV contrast should be performed if clinical suspicion of progression to orbital involvement or intracranial complications develops 1
Surgical Intervention
Surgical drainage is indicated in approximately 7-12% of cases, specifically when 3, 4:
- Subperiosteal or orbital abscess is present
- Failure of medical management after 24-48 hours
- Progressive vision loss or ophthalmoplegia
- Large abscess on imaging (>10mm)
Consultation with otolaryngology, ophthalmology, and infectious disease is recommended for orbital complications 1.
Adjunctive Therapies
Corticosteroids are not routinely recommended for periorbital cellulitis. While one small trial showed potential benefit in orbital cellulitis (not periorbital), the evidence is insufficient with very low certainty, and no major benefit was demonstrated for length of stay, duration of antibiotics, or visual outcomes 5. The risk of immune suppression and worsening infection outweighs uncertain benefits 5.
Critical Pitfalls to Avoid
- Delaying imaging when concerning features present (proptosis, vision changes, ophthalmoplegia, severe pain) 1
- Missing MRSA risk factors and failing to provide appropriate coverage 1
- Inadequate follow-up of outpatient cases—must reassess within 24-48 hours 1
- Insufficient treatment duration or premature discontinuation before complete resolution 1
- Failing to identify progression from preseptal to orbital cellulitis, which requires more aggressive management 1
Microbiology Considerations
The most common pathogens are Staphylococcus aureus and Streptococcus species (including S. pneumoniae), which is why empiric coverage must target both 2, 1, 3. Blood and skin cultures are frequently negative, but when positive, S. aureus predominates 6, 3. Sinusitis is the most frequent predisposing factor (43-79% of cases), followed by trauma (20-25%) 6, 3, 4.