What is the recommended treatment for eyelid cellulitis?

Treatment of Eyelid Cellulitis (Preseptal Cellulitis)

For eyelid cellulitis without orbital involvement, start with oral antibiotics targeting streptococci: amoxicillin-clavulanate 875/125 mg twice daily or cephalexin 500 mg four times daily for 5 days, extending treatment only if no improvement occurs by day 5. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, distinguish preseptal (eyelid-only) from orbital cellulitis by examining for:

• Proptosis (forward displacement of the eye)
• Impaired or painful extraocular movements
• Decreased visual acuity
• Presence of any of these findings mandates immediate hospitalization and imaging 1

Mild preseptal cellulitis presents with eyelid erythema, warmth, swelling, and tenderness without the above orbital signs and can be managed outpatient 1, 3.

First-Line Antibiotic Selection

For Typical Cases (No MRSA Risk Factors)

Oral therapy options targeting streptococci and methicillin-sensitive S. aureus:

• Amoxicillin-clavulanate for broader mixed infection coverage 1
• Cephalexin (500 mg four times daily in adults; 33 mg/kg/dose in children) 2, 1
• Dicloxacillin if S. aureus coverage is specifically desired 1
• Penicillin or amoxicillin if pure streptococcal infection is suspected 1

The IDSA guidelines emphasize that β-hemolytic streptococci are the primary pathogens in typical cellulitis, and MRSA is uncommon (successful treatment with β-lactams in 96% of cases) 2.

When to Add MRSA Coverage

Add MRSA-active antibiotics if any of these risk factors are present: 1, 2

• Penetrating trauma or recent injection drug use
• Purulent drainage from the eyelid
• Known MRSA colonization or infection elsewhere
• Lack of response to initial β-lactam therapy after 24-48 hours
• Systemic inflammatory response syndrome (fever, tachycardia, hypotension)

MRSA treatment options for outpatient management:

• Clindamycin 300-450 mg three times daily (covers both streptococci and MRSA as monotherapy) 1, 4
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily PLUS a β-lactam (amoxicillin or cephalexin) for dual streptococcal/MRSA coverage 1, 2
• Doxycycline 100 mg twice daily PLUS a β-lactam (only for patients ≥8 years old) 1, 2

Critical caveat: TMP-SMX and doxycycline have uncertain activity against β-hemolytic streptococci, so they should not be used as monotherapy for typical cellulitis without purulent drainage 2.

Inpatient Management for Severe Cases

Hospitalize if: 1, 2

• Orbital involvement suspected (proptosis, vision changes, painful eye movements)
• Systemic signs present (high fever, altered mental status, hemodynamic instability)
• Patient unable to take oral medications or has poor adherence
• Immunocompromised state
• Failure of outpatient therapy

Intravenous antibiotic options:

• Cefazolin 1 g every 8 hours (adults) or 33 mg/kg/dose (children) 1
• Nafcillin 1-2 g every 4-6 hours (adults) or 50 mg/kg/dose (children) 1, 2
• For MRSA coverage: Vancomycin, linezolid, or daptomycin 1, 2
• For severe infections with concern for polymicrobial etiology: Vancomycin plus piperacillin-tazobactam or a carbapenem 2, 1

Duration of Therapy

Treat for 5 days if clinical improvement occurs by day 5 2, 1. This shorter duration is as effective as 10-day courses for uncomplicated cellulitis based on high-quality evidence 2.

Extend treatment beyond 5 days only if: 2

• No improvement in erythema, swelling, or tenderness by day 5
• Progression of infection despite appropriate antibiotics
• Immunocompromised patient or virulent organism identified

Adjunctive Measures

Essential supportive care: 2

• Warm compresses to the affected eyelid
• Elevation of the head of the bed to promote gravity drainage
• Treatment of predisposing conditions (blepharitis, meibomian gland dysfunction, skin trauma)

Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in nondiabetic adults to reduce inflammation and hasten resolution, though evidence is limited 2.

Follow-Up and Red Flags

Re-evaluate within 24-48 hours if: 1, 3

• No improvement or worsening symptoms
• Development of orbital signs (vision changes, proptosis, painful eye movements)
• Systemic deterioration

If no improvement occurs, consider: 1, 3

• Switching to MRSA-active antibiotics if not already prescribed
• Obtaining imaging (CT orbit) to rule out orbital extension or abscess
• Consultation with ophthalmology, otolaryngology, or infectious disease

Common Pitfalls to Avoid

• Do not routinely add MRSA coverage without specific risk factors, as this promotes resistance and is unnecessary in 96% of typical cellulitis cases 2
• Do not use TMP-SMX or doxycycline as monotherapy for cellulitis without purulent drainage, as streptococcal coverage is uncertain 2
• Do not continue antibiotics beyond 5 days if clinical improvement has occurred, as this increases toxicity without added benefit 2
• Do not miss orbital cellulitis by failing to assess for proptosis, vision changes, and eye movement abnormalities 1, 3
• Never use tetracyclines in children <8 years old due to tooth discoloration risk 1