What is the treatment for periorbital cellulitis?

Treatment of Periorbital Cellulitis

For mild periorbital cellulitis with less than 50% eyelid closure, initiate outpatient treatment with high-dose amoxicillin-clavulanate and ensure daily follow-up until definite improvement is noted. 1

Initial Assessment and Classification

Before initiating treatment, distinguish periorbital (preseptal) from orbital (postseptal) cellulitis, as this fundamentally changes management:

• Periorbital cellulitis presents with erythema, tenderness, and induration of the eyelid WITHOUT proptosis, impaired visual acuity, or painful/impaired extraocular movements 1
• CT scan of the orbits with IV contrast is the most useful imaging modality when clinical examination cannot definitively differentiate preseptal from postseptal involvement or when complications are suspected 1
• Obtain CT imaging immediately if proptosis, visual changes, or ophthalmoplegia are present 1

Outpatient Treatment Algorithm (Mild Cases)

Criteria for outpatient management:

• Eyelid less than 50% closed 1
• No proptosis, visual impairment, or ophthalmoplegia 1
• No systemic signs of infection 1
• Patient can self-monitor with reliable follow-up 1

First-line antibiotic:

• High-dose amoxicillin-clavulanate is the American Academy of Pediatrics' recommended initial treatment for comprehensive coverage of the most common causative organisms (Streptococcus species and Staphylococcus aureus) 1
• Treatment duration: 5-7 days, extending only if infection has not improved 1
• Mandatory reassessment: Within 24-48 hours to verify clinical response 1

Inpatient Treatment Algorithm (Moderate to Severe Cases)

Indications for hospitalization:

• No improvement within 24-48 hours of outpatient therapy 1
• Progressive infection 1
• Proptosis, impaired visual acuity, or impaired/painful extraocular mobility 1
• Systemic signs of infection (fever, tachycardia, altered mental status) 1
• Eyelid closure greater than 50% 1

Parenteral antibiotic options:

• Nafcillin (penicillinase-resistant penicillin) OR cefazolin (first-generation cephalosporin) for standard coverage 1
• Alternative regimen: Ceftriaxone plus clindamycin has shown effectiveness in pediatric series and provides broader coverage 1, 2
• For severe penicillin allergies: Clindamycin or vancomycin 1

Treatment duration: 7-10 days for hospitalized patients, with daily assessment to monitor response 1

MRSA Coverage Considerations

Add MRSA-active antibiotics when specific risk factors are present:

• Indications for MRSA coverage: Purulent drainage, penetrating trauma, known MRSA colonization, or failure of initial beta-lactam therapy 1
• MRSA-active options: Vancomycin, clindamycin (if local resistance <10%), trimethoprim-sulfamethoxazole, or doxycycline 1
• Important caveat: Clindamycin should only be used if local MRSA clindamycin resistance rates are less than 10% 1

Surgical Intervention and Specialist Consultation

Consult ophthalmology, otolaryngology, and infectious disease when:

• Orbital complications develop (proptosis, vision changes, ophthalmoplegia) 1
• Subperiosteal or orbital abscess identified on CT 1
• Clinical deterioration despite appropriate antibiotics 1

Surgical drainage indicated for:

• Documented abscess formation 1
• Progressive infection despite 24-48 hours of IV antibiotics 1

Monitoring and Follow-up Protocol

For outpatient cases:

• Reassess within 24-48 hours of initiating treatment 1
• If no improvement or worsening, hospitalize immediately and obtain CT imaging 1

For hospitalized patients:

• Daily clinical assessment mandatory 1
• Obtain CT imaging if clinical suspicion of progression to orbital involvement or intracranial complications 1
• Monitor for complications including vision loss, abscess formation, cavernous sinus thrombosis, or meningitis 1

Common Pitfalls to Avoid

• Delaying imaging in cases with concerning features such as proptosis, visual changes, or ophthalmoplegia—this can lead to irreversible complications 1
• Not considering MRSA coverage when risk factors are present (purulent drainage, treatment failure, known colonization) 1
• Inadequate treatment duration or failure to reassess response after initial treatment—always verify clinical improvement at 24-48 hours 1
• Failing to distinguish periorbital from orbital cellulitis—orbital cellulitis requires more aggressive management and has higher complication rates 1

Microbiology Context

The most common pathogens are Staphylococcus aureus and Streptococcus species, which is why empiric coverage must target both organisms 1, 2. Historical data also identified Haemophilus influenzae as a common pathogen, though this has decreased significantly with widespread Hib vaccination 3. Streptococcus milleri has been isolated in some pediatric series 4.