What is the treatment for cellulitis around the eye?

Treatment of Cellulitis Around the Eye

For preseptal cellulitis (eyelid only), start oral antibiotics targeting streptococci and methicillin-sensitive Staphylococcus aureus with cephalexin, dicloxacillin, or amoxicillin-clavulanate for 5 days if clinical improvement occurs; however, if orbital involvement is present (proptosis, impaired vision, painful eye movements), this requires urgent hospitalization, imaging, ophthalmology consultation, and IV antibiotics. 1

Critical First Step: Distinguish Preseptal from Orbital Cellulitis

The most important clinical decision is determining whether infection is limited to the eyelid (preseptal) or involves orbital structures (orbital cellulitis), as management differs dramatically 1:

Preseptal cellulitis features:

• Eyelid swelling, erythema, and warmth
• Normal vision
• Normal eye movements (no pain with extraocular movements)
• No proptosis 1

Orbital cellulitis warning signs requiring urgent hospitalization:

• Proptosis (eye bulging forward)
• Impaired or painful extraocular movements
• Decreased visual acuity
• Diplopia
• Severe pain with eye movements 1

Outpatient Treatment for Preseptal Cellulitis

First-line antibiotic options (choose one) 1:

• Cephalexin 500 mg every 6 hours (adults) or 33 mg/kg/dose (children)
• Dicloxacillin 500 mg every 6 hours (adults)
• Amoxicillin-clavulanate 875/125 mg twice daily (adults) - provides broader coverage for mixed infections 1

Treatment duration: 5 days is as effective as 10 days if clinical improvement occurs by day 5 1, 2

When to Add MRSA Coverage

Do not routinely cover MRSA for typical preseptal cellulitis 1, 2. Add MRSA-active antibiotics only when specific risk factors are present 1:

• Penetrating trauma to the eye area
• Purulent drainage from the infection site
• Evidence of MRSA infection elsewhere on the body
• History of injection drug use
• Systemic inflammatory response syndrome (SIRS)
• Lack of response to initial beta-lactam antibiotics after 24-48 hours 1

MRSA treatment options for outpatient management 1:

• Clindamycin alone 300-450 mg every 8 hours (covers both streptococci and MRSA)
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily PLUS a beta-lactam (amoxicillin or cephalexin) for streptococcal coverage
• Doxycycline (only if age >8 years) PLUS a beta-lactam 1

Inpatient Treatment for Moderate-to-Severe Cases

Hospitalize immediately if 1:

• No improvement within 24-48 hours of outpatient treatment
• Progressive infection despite antibiotics
• Any orbital cellulitis warning signs present
• Patient unable to take oral medications

IV antibiotic options 1:

• Cefazolin 1 g every 8 hours (adults) or 33 mg/kg/dose (children)
• Nafcillin 1-2 g every 4-6 hours (adults) or 50 mg/kg/dose (children)

For MRSA coverage in hospitalized patients 1:

• Vancomycin IV (dose adjusted to trough levels)
• Linezolid 600 mg IV or oral every 12 hours
• Daptomycin IV (not for children <1 year)

Orbital Cellulitis Management

Orbital cellulitis requires urgent multidisciplinary care 1, 3:

• Immediate ophthalmology consultation (same day)
• CT scan of orbits and sinuses to assess extent and identify complications
• IV antibiotics (cefazolin or nafcillin, add vancomycin if MRSA risk factors)
• Consultation with otolaryngology if sinusitis is the source
• Infectious disease consultation for severe cases 1

Monitor for life-threatening complications 3:

• Cavernous sinus thrombosis (bilateral eye involvement, severe headache, altered mental status)
• Intracranial abscess
• Vision loss
• Septic emboli 3

Alternative Oral Regimen for Orbital Cellulitis

One study demonstrated that oral ciprofloxacin plus clindamycin can be as effective as IV therapy for selected orbital cellulitis cases, with mean hospital stay of 4.4 days and no complications 4. However, this approach should only be considered in consultation with ophthalmology and is not standard guideline-recommended therapy 4.

Common Pitfalls to Avoid

• Do not start corticosteroids before ophthalmology examination, as this may worsen infectious causes like herpetic keratitis or mask accurate diagnosis 5
• Do not assume all periorbital swelling is cellulitis - consider allergic reactions, trauma, insect bites, and other mimics 2, 6
• Do not routinely add MRSA coverage without specific risk factors, as this promotes resistance and is unnecessary in typical cases 1, 2
• Do not treat for 10 days if clinical improvement occurs by day 5 - shorter courses (5 days) are equally effective and reduce antibiotic exposure 1, 2
• Do not delay imaging and specialist consultation if any orbital involvement is suspected, as complications can be vision- or life-threatening 1, 3

Follow-Up Strategy

Reassess within 24-48 hours for outpatient cases to ensure clinical improvement 1. If worsening or no improvement occurs, hospitalize immediately and broaden antibiotic coverage 1. For hospitalized patients, daily ophthalmology assessment is appropriate if orbital involvement exists 7.