What is the treatment for preseptal cellulitis?

Treatment of Preseptal Cellulitis

For mild to moderate preseptal cellulitis, treat with oral antibiotics targeting beta-hemolytic streptococci—specifically penicillin, amoxicillin, dicloxacillin, or cephalexin for 5 days, extending treatment only if no improvement occurs within this period. 1

First-Line Antibiotic Selection

Outpatient Treatment (Mild to Moderate Cases)

• Oral antibiotics active against streptococci are the cornerstone of therapy, including penicillin, amoxicillin, dicloxacillin, or cephalexin 1
• For pediatric patients with preseptal cellulitis associated with acute bacterial sinusitis (eyelid <50% closed), high-dose amoxicillin-clavulanate provides comprehensive coverage 1
• For penicillin-allergic patients, use clindamycin or erythromycin 1
• Standard treatment duration is 5 days, extending only if clinical improvement has not occurred 1

When to Consider MRSA Coverage

MRSA coverage is not routinely indicated for typical preseptal cellulitis. However, consider adding vancomycin or another anti-MRSA agent when: 1

• Penetrating trauma is present
• Evidence of MRSA infection elsewhere
• Known nasal colonization with MRSA
• History of injection drug use
• Purulent drainage is present

Hospitalization Criteria and Severe Cases

Hospitalize patients who meet any of the following criteria: 1

• Systemic inflammatory response syndrome (SIRS)
• Altered mental status or hemodynamic instability
• Concern for deeper infection or orbital involvement
• Immunocompromised status
• Failed outpatient treatment

Severe Infection Management

• For severe infections requiring hospitalization, use vancomycin or another antimicrobial effective against both MRSA and streptococci 1
• In neonates requiring intravenous therapy, administer antibiotics over 60 minutes to reduce the risk of bilirubin encephalopathy 1
• Appropriate antimicrobial therapy for intraorbital complications includes vancomycin to cover possible methicillin-resistant S. pneumoniae 1

Pediatric-Specific Considerations

• Treatment approach for children mirrors adults, with antibiotics active against streptococci 1
• Oral options for outpatient treatment include penicillin, amoxicillin, amoxicillin-clavulanate, dicloxacillin, cefalexin, or clindamycin 1
• If proptosis, impaired visual acuity, or impaired/painful extraocular mobility develops, immediately hospitalize and perform contrast-enhanced CT 1
• Daily follow-up is mandatory until definite improvement is noted 1
• Consultation with otolaryngology, ophthalmology, and infectious disease is appropriate for guidance regarding surgical intervention and antimicrobial selection 1

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema—this is critical and failure to do so delays improvement 1
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adult patients to hasten resolution 1

Monitoring and Follow-Up

• Patients should show improvement within 24-48 hours of appropriate antibiotic therapy 1
• If no improvement occurs within 72 hours, take the following actions: 1
  • Consider changing antibiotics
  • Obtain imaging to rule out orbital involvement or abscess formation
  • Admit for intravenous antibiotics
• C-reactive protein >120 mg/L suggests orbital rather than preseptal involvement and warrants CT imaging 2

Prevention of Recurrence

• Identify and treat predisposing conditions such as sinusitis, edema, and toe web abnormalities 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, which significantly delays improvement 1
• Inadequate treatment duration when clinical improvement is not evident after 5 days 1
• Empirically covering MRSA without specific risk factors 1
• Failing to recognize that diplopia, ophthalmoplegia, and proptosis indicate orbital (not preseptal) cellulitis and require immediate CT imaging 2
• Using fluoroquinolones as first-line therapy—while one case report showed response to ciprofloxacin for Proteus species 3, these agents have inadequate streptococcal coverage for typical preseptal cellulitis