What is the recommended treatment for periocular cellulitis?

Treatment of Periocular Cellulitis

For periocular (periorbital) cellulitis, initiate prompt intravenous antibiotics with ceftriaxone plus clindamycin or metronidazole, targeting streptococci and staphylococci, with hospitalization for patients with systemic signs or those under 5 years of age. 1, 2

Initial Assessment and Risk Stratification

Distinguish between periorbital and orbital cellulitis immediately, as orbital cellulitis carries risk of vision loss, meningitis, and death. 3 Key clinical features to assess:

• Periorbital cellulitis involves tissue anterior to the orbital septum—presents with eyelid erythema, edema, and tenderness without proptosis or restricted eye movements 1
• Orbital cellulitis involves tissue posterior to the orbital septum—presents with proptosis, ophthalmoplegia, pain with eye movement, and vision changes 3
• Age matters: 85% of periorbital cellulitis occurs in children under 5 years, while 62% of orbital cellulitis occurs in those over 5 years 1

Predisposing Factors to Identify

• Upper respiratory infection (68% of periorbital cases) 1
• Sinusitis (43-79% of cases, especially in orbital cellulitis) 1, 4, 2
• Trauma to eyelids (20-25% of cases) 1, 4
• Odontogenic infections (6% of cases) 4

Antibiotic Selection

First-Line Regimen (Strongest Evidence)

Intravenous ceftriaxone PLUS metronidazole is the optimal initial regimen, associated with:

• Shortest hospital stay (3.8 days vs 5.8 days for ceftriaxone alone) 2
• Reduced need for surgical intervention 2
• Effective against the predominant pathogens: Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes 1, 4

Dosing:

• Ceftriaxone 1 g IV every 24 hours (adults) or 50-75 mg/kg/day IV (children) 5, 2
• Metronidazole 500 mg IV every 8 hours (adults) or 7.5 mg/kg every 8 hours (children) 5, 2

Alternative Regimens

• Sulbactam-ampicillin (co-amoxiclav): Broad spectrum coverage with lower recurrence rates (3% vs 17% with penicillin-chloramphenicol) 4
  • Dosing: 3 g IV every 6 hours (adults) 5
• Ceftriaxone plus clindamycin: Effective in 85% of hospitalized children 1
  • Mean treatment duration: 8.6 days 1

Note: Blood and skin cultures are frequently negative (74% culture positivity when obtained), but obtain them in severe cases 1, 4

Duration of Therapy

• 7-10 days is the typical duration for periocular cellulitis 4
• Continue IV antibiotics until clinical improvement (reduction in erythema, edema, and systemic symptoms), then consider transition to oral therapy 1, 2
• Mean IV antibiotic duration in successful cases: 8.6 days 1

Hospitalization Criteria

Admit all patients with periocular cellulitis who have: 6, 1

• Age under 5 years (higher risk population)
• Systemic inflammatory response syndrome (SIRS)—fever, tachycardia, leukocytosis
• Concern for orbital involvement
• Inability to tolerate oral intake
• Poor adherence anticipated

Outpatient management is NOT recommended for periocular cellulitis given the risk of progression to orbital cellulitis and serious complications. 1, 3

Adjunctive Measures

• Intranasal decongestants and corticosteroids: Associated with reduced progression to surgery when sinusitis is present 2
• Elevation of affected area: Promotes drainage of edema 5, 6
• Treat underlying sinusitis aggressively if present 1, 4, 2

Surgical Intervention

Surgery is required in 16.7% of children and 19.2% of adults who fail medical management. 2 Indications include:

• Abscess formation (subperiosteal or orbital)
• Progressive proptosis despite antibiotics
• Vision deterioration
• No improvement after 24-48 hours of IV antibiotics 1, 2

Corticosteroid Consideration

Evidence for adjunctive corticosteroids is insufficient and of very low certainty. 3 One small trial (21 participants) showed no clear benefit in length of stay, duration of antibiotics, or visual outcomes when corticosteroids were added after initial antibiotic response. 3 Do not routinely use systemic corticosteroids for periocular cellulitis given lack of evidence and theoretical risk of immune suppression worsening infection.

Common Pitfalls to Avoid

• Do not treat periocular cellulitis as simple cellulitis with oral antibiotics alone—this is a potentially sight-threatening infection requiring IV therapy 1, 2
• Do not assume MRSA coverage is needed—streptococci are the predominant pathogens, and routine MRSA coverage is unnecessary unless purulent drainage is present 5, 6
• Do not delay ophthalmology consultation if any concern for orbital involvement exists 1, 7
• Do not use ceftriaxone monotherapy—combination with metronidazole or clindamycin improves outcomes 2