What is the recommended management for preseptal cellulitis?

Management of Preseptal Cellulitis

Treat preseptal cellulitis with oral beta-lactam monotherapy (cephalexin, amoxicillin, or amoxicillin-clavulanate) for 5 days in uncomplicated cases, reserving intravenous antibiotics for patients with systemic toxicity, inability to tolerate oral medications, or concern for progression to orbital cellulitis. 1, 2

Initial Assessment and Risk Stratification

Distinguish preseptal from orbital cellulitis immediately, as orbital involvement requires aggressive management and carries risk of vision loss and intracranial complications. 3, 4

Key differentiating features to assess:

• Proptosis, ophthalmoplegia, and diplopia are ONLY present in orbital cellulitis and mandate immediate CT imaging and IV antibiotics 3
• Fever is present in 82% of orbital cellulitis versus only 52% of preseptal cases 3
• CRP >120 mg/L strongly suggests orbital involvement (sensitivity for orbital cellulitis) 3
• Sinusitis is present in 78% of orbital cellulitis but only 2% of preseptal cases 3

Preseptal cellulitis presents with:

• Eyelid swelling and edema (100% of cases) 5
• Periorbital hyperemia (93% of cases) 6
• Fever (41% of cases) 5
• Eye discharge (30% of cases) 5
• Normal extraocular movements, no proptosis, no vision changes 3, 4

First-Line Antibiotic Selection

Outpatient Oral Therapy (Uncomplicated Cases)

Beta-lactam monotherapy is the standard of care, achieving 96% success rates even in high MRSA prevalence settings. 1, 7

Recommended oral regimens:

• Cephalexin 500 mg four times daily 1, 2
• Amoxicillin (dose appropriate for age/weight) 1, 2
• Amoxicillin-clavulanate 875/125 mg twice daily (provides broader coverage if sinusitis-related) 1
• Dicloxacillin 250-500 mg every 6 hours 1, 2

MRSA coverage is NOT routinely necessary for typical preseptal cellulitis, as streptococci are the predominant pathogens. 1, 7 However, add MRSA-active therapy if:

• Penetrating trauma or insect bite with purulent drainage 1, 7
• Known MRSA colonization or concurrent MRSA infection 1, 7
• Failure of beta-lactam therapy after 48 hours 1

For MRSA coverage when needed:

• Clindamycin 300-450 mg orally every 6 hours (covers both streptococci and MRSA, avoiding combination therapy) 1, 2
• Use clindamycin only if local MRSA resistance rates are <10% 1

Intravenous Therapy (Hospitalized Patients)

Hospitalize patients with:

• Systemic inflammatory response syndrome (SIRS) or sepsis 1, 2
• Age <1 year 6, 5
• Inability to tolerate oral medications 7
• Concern for progression to orbital cellulitis 3, 4
• Severe immunocompromise 1, 2
• Rapidly progressive infection 7

All hospitalized patients received broad-spectrum IV antibiotics in clinical series, with excellent outcomes and no progression to complications. 6, 3

Most commonly used IV regimens (based on pediatric case series):

• Clindamycin IV (used in 73% of hospitalized cases) 5
• Ceftriaxone IV (used in 54% of hospitalized cases) 5
• Combination: Clindamycin + Ceftriaxone provides both streptococcal and MRSA coverage 5

Alternative IV options:

• Cefazolin 1-2 g IV every 8 hours (for uncomplicated cases without MRSA risk) 1
• Vancomycin 15-20 mg/kg IV every 8-12 hours (if MRSA coverage needed) 1, 7
• Vancomycin + piperacillin-tazobactam (for severe cases with systemic toxicity or concern for necrotizing infection) 1

Treatment Duration

Treat for 5 days if clinical improvement occurs; extend only if symptoms have not improved within this timeframe. 1, 2, 7

• Traditional 7-14 day courses are no longer necessary for uncomplicated cases 1
• Mean duration in hospitalized pediatric series was 10 days (including oral continuation after discharge) 6
• Mean hospital stay was 4 days in pediatric series 6

Reassess at 24-48 hours to verify clinical response, as treatment failure indicates either resistant organisms or progression to orbital cellulitis. 1

Imaging Indications

CT scan is NOT routinely needed for typical preseptal cellulitis but is mandatory if:

• Any concern for orbital involvement (proptosis, ophthalmoplegia, vision changes) 3, 4
• Failure to improve after 48 hours of appropriate antibiotics 3
• Severe systemic toxicity 3
• Age <1 year with high fever 5

In one pediatric series, CT was performed in 43% of preseptal cellulitis cases, confirming diagnosis and ruling out orbital extension. 5

Adjunctive Measures

• Elevate the head of the bed to promote gravitational drainage of periorbital edema 1, 2
• Treat underlying sinusitis if present (52.9% of cases have sinusitis as predisposing factor) 6
• Consider systemic corticosteroids (prednisone 30-40 mg daily for 7 days) in non-diabetic adults to hasten resolution, though evidence is limited 7

Critical Pitfalls to Avoid

• Do NOT delay CT imaging if any orbital signs are present (proptosis, ophthalmoplegia, diplopia, vision changes) 3, 4
• Do NOT reflexively add MRSA coverage for typical preseptal cellulitis without specific risk factors 1, 7
• Do NOT use doxycycline or trimethoprim-sulfamethoxazole as monotherapy, as streptococcal coverage will be inadequate 1, 7
• Do NOT extend treatment beyond 5 days if clinical improvement has occurred 1, 2
• Do NOT obtain blood cultures in uncomplicated cases, as yield is extremely low (positive in <5% of typical cases) 1, 6

Special Populations

Adults with Immunocompromise

Preseptal cellulitis caused by Streptococcus pyogenes can be severe in immunocompromised adults, with risk of streptococcal toxic shock syndrome and metastatic abscesses. 8 These patients require:

• Aggressive IV antibiotic therapy 8
• Close monitoring for systemic complications 8
• Surgical debridement if abscesses develop 8

Pediatric Considerations

• Preseptal cellulitis is most common in children with mean age 3.5-4 years 6, 3
• Sinusitis is the most common predisposing factor (53% of cases) 6
• Prognosis is excellent with appropriate treatment, with no complications reported in large pediatric series 6, 3