What is the recommended treatment for a child diagnosed with preseptal cellulitis?

Treatment of Preseptal Cellulitis in Children

For mild preseptal cellulitis in children, initiate outpatient treatment with high-dose oral amoxicillin-clavulanate and mandate reassessment within 24-48 hours to ensure clinical improvement and prevent progression to vision-threatening orbital cellulitis. 1, 2, 3

Initial Clinical Assessment

Before initiating treatment, you must distinguish preseptal from orbital cellulitis, as misdiagnosis can lead to permanent vision loss or life-threatening complications. 3

Key features indicating preseptal (not orbital) cellulitis include: 1, 3

• Infection confined to eyelids and soft tissues anterior to the orbital septum
• Periorbital swelling, hyperemia, and edema without globe involvement
• Absence of proptosis, impaired/painful extraocular movements, decreased visual acuity, or ophthalmoplegia

Red flags requiring immediate hospitalization and imaging: 1, 3

• Proptosis
• Impaired or painful extraocular movements
• Decreased visual acuity or vision changes
• Ophthalmoplegia or diplopia
• Eyelid more than 50% closed

Outpatient Management Algorithm (Mild Cases)

Criteria for outpatient treatment: 1, 3

• Eyelid less than 50% closed
• No proptosis or visual changes
• No systemic signs of infection (no fever, no altered mental status)
• Reliable follow-up available within 24-48 hours

First-line antibiotic therapy: 1, 2, 3

• High-dose amoxicillin-clavulanate is the preferred first-line agent, providing comprehensive coverage against Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, and Staphylococcus aureus 1, 2
• Treatment duration: 5-7 days, extending if no improvement is evident 1, 2

Alternative oral antibiotics (if penicillin allergy): 2, 3

• Clindamycin
• Cephalexin
• Dicloxacillin

Critical caveat: Young children (especially under 36 months) with associated upper respiratory tract infections are at higher risk for Haemophilus influenzae bacteremia and metastatic infection, making amoxicillin-clavulanate particularly important in this population. 4

Mandatory Follow-up and Monitoring

Reassessment within 24-48 hours is non-negotiable. 1, 2, 3 At follow-up, assess:

• Visual acuity 3
• Extraocular movements 3
• Degree of eyelid swelling 3
• Presence of proptosis 3
• Pupillary response 3

If no improvement within 24-48 hours or worsening at any time: 1, 2, 3

• Hospitalize for IV antibiotics
• Obtain CT orbits with IV contrast to rule out orbital involvement or abscess formation
• Consider MRSA coverage if risk factors present

Inpatient Management (Moderate-to-Severe Cases)

Hospitalization criteria: 2, 3

• Systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability
• Eyelid more than 50% closed
• Inability to adequately examine the eye due to severe swelling
• Concern for deeper infection or orbital involvement
• Immunocompromised patients
• Failed outpatient treatment
• Poor adherence to outpatient therapy anticipated

Intravenous antibiotic regimens: 2, 3

• IV amoxicillin-clavulanate
• IV cefazolin or ceftriaxone
• For severe infections or MRSA risk: add vancomycin 2, 3

Recent data from an Iranian referral hospital showed clindamycin (72.8%) and ceftriaxone (54.4%) were the most commonly used antibiotics in hospitalized children, often in combination. 5

MRSA Coverage Considerations

Add MRSA-active antibiotics when: 2, 3

• Penetrating trauma present
• Purulent drainage evident
• Known MRSA colonization or previous MRSA infection
• History of injection drug use (rare in children but relevant in adolescents)
• Evidence of MRSA infection elsewhere

MRSA-active options: 3

• IV: vancomycin, daptomycin, linezolid
• Oral: clindamycin, doxycycline, trimethoprim-sulfamethoxazole

Imaging Indications

Obtain CT orbits with IV contrast when: 1, 3

• Clinical features suggest orbital involvement (proptosis, impaired extraocular movements, visual changes)
• Failure to improve with antibiotics within 24-48 hours
• Inability to adequately examine the eye due to severe swelling
• Need to identify underlying sinusitis (present in 10.3% of pediatric cases) 5
• Concern for complications (superior ophthalmic vein thrombosis, cavernous sinus thrombosis, subdural empyema)

Critical Pitfalls to Avoid

Never start corticosteroids before ophthalmology evaluation, as this may worsen ocular conditions due to infection. 3

Never use fluoroquinolones as first-line therapy due to inadequate streptococcal coverage, despite their approval for uncomplicated cellulitis. 2

Never delay CT imaging when proptosis, visual changes, or ophthalmoplegia are present, as this can lead to delayed diagnosis of orbital cellulitis. 1

Never provide inadequate follow-up after initiating outpatient therapy—failure to reassess within 24-48 hours can allow progression to orbital involvement. 1, 2

Never fail to consider the clinical context: Children with local trauma, abscesses, or insect bites typically have staphylococcal or streptococcal infections, while those with upper respiratory symptoms are more likely to have Haemophilus influenzae. 4

Adjunctive Measures

• Elevate the affected area to promote gravity drainage of edema 2
• Identify and treat predisposing conditions such as sinusitis, odontogenic infections, or periocular trauma 2, 5