What is the recommended treatment for preseptal cellulitis?

Treatment of Preseptal Cellulitis

For mild preseptal cellulitis with less than 50% eyelid closure, treat as an outpatient with high-dose amoxicillin-clavulanate (Augmentin) for comprehensive coverage of streptococci, staphylococci, and anaerobes, with mandatory daily follow-up until definite improvement is noted. 1

Initial Assessment and Risk Stratification

Clinical Features to Evaluate

• Eyelid involvement severity: Measure the degree of eyelid closure—if less than 50% closed, outpatient management is appropriate 1
• Presence of orbital signs: Check specifically for proptosis, impaired visual acuity, or painful/impaired extraocular movements, which indicate progression to orbital cellulitis requiring immediate hospitalization 1
• Systemic features: Assess for fever, altered mental status, hypotension, or signs of systemic toxicity 1, 2
• Predisposing factors: Identify sinusitis (most common, present in 52.9% of pediatric cases), odontogenic infections, periocular trauma, or insect bites 2, 3

Imaging Decisions

• CT scan indications: Order contrast-enhanced CT (preferably coronal thin cut) if proptosis, visual changes, or impaired extraocular mobility are present 1
• Routine imaging not needed: For typical preseptal cellulitis without orbital signs, imaging is unnecessary 4, 3

Antibiotic Selection by Severity

Mild Cases (Outpatient Management)

• First-line therapy: High-dose amoxicillin-clavulanate (Augmentin 875/125 mg twice daily in adults; weight-based dosing in children) provides comprehensive coverage for streptococci, staphylococci, and anaerobes 1, 5
• Alternative oral agents: Cephalexin 500 mg four times daily, dicloxacillin, or clindamycin for penicillin-allergic patients 5, 6
• Duration: 5 days if clinical improvement occurs; extend only if no improvement within this period 5, 6

Moderate to Severe Cases (Hospitalization Required)

• Hospitalization criteria: Eyelid closure greater than 50%, lack of improvement within 24-48 hours of outpatient therapy, progressive infection, or any orbital signs 1
• Intravenous regimens: The most commonly used combinations in pediatric studies include clindamycin (72.8% of cases) plus ceftriaxone (54.4%), with vancomycin added for suspected MRSA or severe cases 3
• Broad-spectrum coverage: Vancomycin plus ceftriaxone provides coverage for methicillin-resistant organisms and typical pathogens 1, 3

MRSA Considerations

MRSA coverage is generally unnecessary for typical preseptal cellulitis, as beta-lactam therapy succeeds in 96% of cases 1, 5. However, consider adding MRSA coverage with vancomycin (IV) or clindamycin (oral) in these specific situations:

• Penetrating trauma or history of injection drug use 5, 6
• Purulent drainage present 5, 6
• Evidence of MRSA infection elsewhere 5, 6
• Failure of initial beta-lactam therapy 1

Monitoring and Follow-Up

Outpatient Management

• Daily follow-up mandatory: Patients treated as outpatients require daily evaluation until definite improvement is documented 1
• Escalation criteria: If no improvement within 24-48 hours or if infection progresses, admit for IV antibiotics 1
• Mean treatment duration: Studies show average antibiotic duration of 10 days (including oral continuation after discharge) with mean hospital stay of 4 days when admission is required 2, 3

Inpatient Management

• Multidisciplinary consultation: For orbital involvement or complications, obtain ophthalmology, otolaryngology, and infectious disease consultations 1
• Surgical intervention: Consider drainage if subperiosteal abscess develops 4

Common Pitfalls to Avoid

• Don't miss orbital cellulitis: Always assess for proptosis, visual changes, and extraocular movement abnormalities—these require immediate hospitalization and CT imaging 1
• Don't delay imaging in severe cases: If orbital signs are present, obtain contrast-enhanced CT immediately before starting IV antibiotics 1
• Don't extend antibiotics unnecessarily: 5 days is sufficient for uncomplicated cases with clinical improvement 5, 6
• Don't add routine MRSA coverage: Reserve for specific risk factors only, as typical preseptal cellulitis responds to beta-lactams 1, 5

Special Populations

Pediatric Considerations

• Preseptal cellulitis is most common in children with mean age around 42 months 3
• Sinusitis is the most common predisposing factor (52.9% of cases) 2
• Clindamycin plus ceftriaxone is the most frequently used IV combination in hospitalized children 3

Immunocompromised Patients

• Adults with immunocompromising factors (malignancy, severe immunodeficiency) are at higher risk for complications including streptococcal toxic shock syndrome 7
• Consider broader coverage and lower threshold for hospitalization 1, 7