Management of Preseptal Cellulitis
For mild preseptal cellulitis with less than 50% eyelid closure, initiate outpatient treatment with high-dose amoxicillin-clavulanate and ensure daily follow-up until definite improvement is noted. 1
Initial Assessment and Risk Stratification
The diagnosis is clinical, based on erythema, tenderness, and induration of the eyelid without signs of orbital involvement (no proptosis, no visual changes, no painful or restricted extraocular movements). 1
Key decision point: Determine severity based on:
- Degree of eyelid closure (less than vs. greater than 50%)
- Presence of systemic signs (fever, toxicity)
- Visual function (acuity, extraocular movements, pain with eye movement)
- Proptosis (indicates orbital involvement)
Treatment Algorithm
Mild Cases (Outpatient Management)
Antibiotic selection: High-dose amoxicillin-clavulanate is the first-line agent, providing comprehensive coverage against the most common causative organisms (Staphylococcus aureus and Streptococcus species). 1
Duration: 5-7 days typically, but extend if infection has not improved. 1
Mandatory follow-up: Reassess within 24-48 hours to ensure clinical improvement. 1
Moderate to Severe Cases (Inpatient Management)
Hospitalization criteria:
- No improvement or progression within 24-48 hours of outpatient therapy
- Eyelid closure greater than 50%
- Systemic signs of infection
- Any signs suggesting orbital involvement (proptosis, impaired visual acuity, impaired/painful extraocular mobility)
Parenteral antibiotic options:
- Nafcillin (penicillinase-resistant penicillin) OR
- Cefazolin (first-generation cephalosporin)
- Alternative regimen: Ceftriaxone plus clindamycin (shown effective in pediatric series)
For severe penicillin allergy: Clindamycin or vancomycin. 1
MRSA Coverage Considerations
When to add MRSA coverage: If risk factors are present (prior MRSA infection, recent hospitalization, failure of initial therapy), add vancomycin, clindamycin, trimethoprim-sulfamethoxazole, or doxycycline. 1
Note that clindamycin resistance in streptococci has been reported, though 99.5% of S. pyogenes strains remain susceptible. 2
Imaging Indications
CT scan of orbits with IV contrast is the most useful imaging modality to differentiate preseptal from postseptal involvement. 1
Obtain imaging when:
- Clinical suspicion of progression to orbital involvement
- Proptosis present
- Visual changes or ophthalmoplegia
- Concern for intracranial complications
- No response to appropriate therapy
Monitoring Requirements
Outpatient cases: Daily follow-up until definite improvement, then reassess within 24-48 hours. 1
Hospitalized patients: Daily assessment to monitor response to therapy. 1
Critical Pitfalls to Avoid
- Delaying imaging when concerning features are present (proptosis, visual changes, ophthalmoplegia). 1
- Not considering MRSA coverage when risk factors exist or initial therapy fails. 1
- Inadequate treatment duration or failure to reassess after initial treatment. 1
- Assuming common pathogens only: While Staphylococcus and Streptococcus are most common, alternate pathogens (including gram-negative organisms like Proteus) should be considered when patients fail to respond to initial therapy. 3
- Underestimating severity in immunocompromised patients: Adults with immunocompromising factors can develop severe complications including toxic shock syndrome and metastatic abscesses. 4
Special Populations
Immunocompromised patients or those with trauma: Higher risk for severe complications; lower threshold for hospitalization and broader antibiotic coverage. 4
Pediatric patients: Sinusitis is a common predisposing factor (52.9% of cases with identifiable risk factors). 5 The shift away from Haemophilus influenzae B due to vaccination has made Staphylococcus and Streptococcus species the predominant pathogens. 6
Consultation Triggers
Consult ophthalmology, otolaryngology, and infectious disease if orbital complications develop or if there is progression despite appropriate therapy. 1