Treatment of Preseptal Cellulitis
For mild to moderate preseptal cellulitis, initiate oral antibiotics targeting beta-hemolytic streptococci—specifically penicillin, amoxicillin, dicloxacillin, or cephalexin—for 5 days, extending treatment only if no improvement occurs. 1
Outpatient Management (Mild to Moderate Cases)
First-Line Antibiotic Selection
- Oral antibiotics active against streptococci are the cornerstone of treatment, including penicillin, amoxicillin, dicloxacillin, or cephalexin for 5 days 1
- For penicillin-allergic patients, clindamycin or erythromycin are appropriate alternatives 1
- High-dose amoxicillin-clavulanate provides comprehensive coverage when treating preseptal cellulitis associated with acute bacterial sinusitis (eyelid <50% closed) 2
When to Consider MRSA Coverage
- Add MRSA-active antibiotics only when specific risk factors are present: penetrating trauma, evidence of MRSA infection elsewhere, nasal MRSA colonization, injection drug use, or purulent drainage 1
- Routine empirical MRSA coverage is not indicated for typical preseptal cellulitis without these risk factors 1
Treatment Duration
- Standard duration is 5 days, with extension only if clinical improvement has not occurred by day 5 1
- Patients should demonstrate improvement within 24-48 hours of appropriate antibiotic therapy 1
Hospitalization Criteria and Severe Cases
Indications for Admission
- Systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability 1
- Concern for deeper infection or orbital involvement 1
- Immunocompromised patients 1
- Failed outpatient treatment 1
- If the patient does not improve within 24-48 hours or if infection is progressive, hospitalization for intravenous antimicrobial therapy is appropriate 2
Intravenous Antibiotic Selection
- For severe infections requiring hospitalization, use vancomycin or another antimicrobial effective against both MRSA and streptococci 1
- Appropriate antimicrobial therapy for intraorbital complications includes vancomycin to cover possible methicillin-resistant S. pneumoniae 2
Pediatric Considerations
Antibiotic Selection in Children
- Treatment approach mirrors adults, with antibiotics active against streptococci 1
- Oral options include penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cefalexin, or clindamycin 1
- For mild preseptal cellulitis in children (eyelid <50% closed), high-dose amoxicillin-clavulanate with daily follow-up until definite improvement is noted 2
When to Escalate Care in Children
- If proptosis, impaired visual acuity, or impaired/painful extraocular mobility is present, hospitalize the patient and perform contrast-enhanced CT 2
- Consultation with otolaryngology, ophthalmology, and infectious disease is appropriate for guidance regarding surgical intervention and antimicrobial selection 2
Adjunctive Measures
- Elevate the affected area to promote gravity drainage of edema and inflammatory substances, hastening improvement 1
- Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adult patients to hasten resolution 1
- Identify and treat predisposing conditions such as sinusitis, edema, and toe web abnormalities to reduce recurrence risk 1
Monitoring and Follow-Up
- If no improvement within 72 hours, consider changing antibiotics, imaging to rule out orbital involvement or abscess formation, or hospital admission for IV antibiotics 1
- For patients with 3-4 episodes per year despite addressing predisposing factors, consider prophylactic antibiotics such as oral penicillin or erythromycin twice daily for 4-52 weeks 1
Common Pitfalls to Avoid
- Not elevating the affected area delays improvement and prolongs recovery 1
- Inadequate treatment duration when clinical improvement is not evident after 5 days 1
- Failing to recognize progression to orbital cellulitis—watch for diplopia, ophthalmoplegia, and proptosis, which are only present in orbital (not preseptal) cellulitis 3
- C-reactive protein >120 mg/L suggests orbital rather than preseptal involvement and warrants CT imaging 3