What is the treatment for preseptal cellulitis?

Treatment of Preseptal Cellulitis

For mild preseptal cellulitis without systemic signs, initiate outpatient treatment with high-dose oral amoxicillin-clavulanate, ensuring mandatory reassessment within 24-48 hours to prevent progression to vision-threatening orbital cellulitis. 1

Critical Distinction: Preseptal vs. Orbital Cellulitis

The most important initial step is distinguishing preseptal from orbital cellulitis, as management differs dramatically and misdiagnosis can lead to permanent vision loss or life-threatening complications 2.

Clinical features that indicate orbital (not preseptal) cellulitis requiring immediate hospitalization:

• Proptosis 1
• Impaired or painful extraocular movements 1
• Decreased visual acuity 1
• Ophthalmoplegia 1

Preseptal cellulitis characteristics:

• Infection confined to eyelids and soft tissues anterior to the orbital septum 2
• Periorbital swelling, hyperemia, and edema without globe involvement 3
• Visual acuity remains normal 3
• Extraocular movements unrestricted and painless 3

Outpatient Treatment Algorithm for Mild Preseptal Cellulitis

Criteria for outpatient management: 1

• Eyelid less than 50% closed
• No proptosis or visual changes
• No systemic signs of infection (fever, altered mental status, hemodynamic instability)
• Reliable follow-up available

First-line antibiotic therapy:

• High-dose amoxicillin-clavulanate is the recommended first-line oral antibiotic, providing comprehensive coverage of the most common causative organisms including Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, and Moraxella species 1
• Alternative oral options include cephalexin, dicloxacillin, or clindamycin 2

Treatment duration:

• 5-7 days is typically sufficient 1
• Extend treatment if infection has not improved within this timeframe 2, 1

Mandatory follow-up:

• Reassess within 24-48 hours to ensure clinical improvement 1
• Failure to improve or any worsening requires immediate escalation to intravenous therapy and imaging 1

Inpatient Treatment for Moderate-to-Severe Preseptal Cellulitis

Hospitalization criteria: 2

• Systemic signs of infection (fever, tachycardia, hypotension)
• Eyelid more than 50% closed
• Inability to adequately examine the eye
• Poor adherence to outpatient therapy anticipated
• Immunocompromised patients
• Age less than 1 year

Intravenous antibiotic regimens:

• Broad-spectrum IV antibiotics covering typical Gram-positive pathogens 2
• Options include IV amoxicillin-clavulanate, cefazolin, or ceftriaxone 1, 3
• Mean duration of IV therapy is typically 4 days before transitioning to oral antibiotics 3
• Total antibiotic duration averages 10 days 3

MRSA Coverage Considerations

When to add MRSA coverage: 2

• Penetrating trauma or history of injection drug use
• Purulent drainage present
• Known MRSA colonization or previous MRSA infection
• Failure to respond to initial beta-lactam therapy
• Community-acquired MRSA is increasingly recognized as a causative organism 4

MRSA-active antibiotics:

• IV options: vancomycin, daptomycin, linezolid 2
• Oral options: clindamycin, doxycycline, or trimethoprim-sulfamethoxazole (though activity against streptococci is uncertain) 2
• If dual coverage needed: clindamycin alone OR combination of trimethoprim-sulfamethoxazole/doxycycline plus a beta-lactam 2

Imaging Indications

CT orbits with IV contrast is the most useful imaging modality when needed: 2

• Differentiates preseptal from postseptal cellulitis and orbital abscess 2
• Identifies underlying sinusitis (particularly ethmoid sinusitis, the most common source) 2
• Detects complications such as superior ophthalmic vein thrombosis, cavernous sinus thrombosis, or subdural empyema 2

When to obtain imaging:

• Any clinical features suggesting orbital involvement (proptosis, ophthalmoplegia, visual changes) 1
• Failure to improve with appropriate antibiotics within 24-48 hours 1
• Inability to adequately examine the eye due to severe swelling 2

Adjunctive Measures

Supportive care: 2

• Elevation of the affected area to promote gravity drainage of edema
• Treatment of predisposing factors such as sinusitis, trauma, or tinea pedis
• Warm compresses may provide symptomatic relief

Critical Pitfalls to Avoid

Delaying imaging when warning signs are present: 1

• Any proptosis, visual changes, or ophthalmoplegia mandates immediate CT imaging
• Clinical examination alone cannot reliably distinguish preseptal from orbital cellulitis 2

Inadequate follow-up after initiating outpatient therapy: 1

• Failure to reassess within 24-48 hours can allow progression to orbital involvement
• Preseptal cellulitis can progress rapidly to the orbit and intracranial structures 3

Not considering MRSA when risk factors present: 1, 4

• Community-acquired MRSA now accounts for up to 39% of orbital cellulitis cases in some regions 4
• Empiric beta-lactam monotherapy may fail in these cases

Treating as simple cellulitis when sinusitis is the source: 2

• 52.9% of preseptal cellulitis cases have sinusitis as a predisposing factor 3
• Ethmoid sinusitis is the most common source and may require specific management 2

Special Populations

Immunocompromised patients: 5

• Consider broader coverage including Gram-negative organisms
• Lower threshold for hospitalization and IV therapy
• Preseptal cellulitis with Streptococcus pyogenes can be severe in immunocompromised adults and may progress to toxic shock syndrome 5

Pediatric patients: 3, 6

• Preseptal cellulitis is most common in childhood 3
• Generally has good prognosis with appropriate treatment 3
• Vaccination against Haemophilus influenzae B has shifted the causative organism profile toward Staphylococcus/Streptococcus species 6