What antibiotics are used to treat preseptal (periorbital) cellulitis associated with sinusitis?

From the Guidelines

For preseptal sinusitis, the recommended first-line antibiotic treatment is amoxicillin-clavulanate (Augmentin) at a dose of 45 mg/kg/day divided twice daily for children, typically for 10-14 days, as suggested by the American Academy of Pediatrics 1.

Key Considerations

• The diagnosis of acute bacterial sinusitis is made when a child presents with persistent illness, worsening course, or severe onset, and clinicians should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course 1.
• Amoxicillin with or without clavulanate is the first-line treatment of acute bacterial sinusitis, and clinicians should reassess initial management if there is either a caregiver report of worsening or failure to improve within 72 hours of initial management 1.
• The treatment of patients with presumed allergy to penicillin has been controversial, but recent publications indicate that the risk of a serious allergic reaction to second- and third-generation cephalosporins in patients with penicillin or amoxicillin allergy appears to be almost nil and no greater than the risk among patients without such allergy 1.

Alternatives and Additional Considerations

• Alternatives for penicillin-allergic patients include doxycycline 100 mg twice daily for adults (not for children under 8), or a respiratory fluoroquinolone like levofloxacin 500 mg daily 1.
• For more severe cases or those with risk factors for resistant organisms, consider broader coverage with a third-generation cephalosporin or consultation with an infectious disease specialist.
• Treatment should be accompanied by nasal saline irrigation, decongestants like pseudoephedrine, and analgesics for pain relief.
• Patients should see improvement within 48-72 hours; if symptoms worsen or don't improve, reevaluation is necessary to consider resistant organisms or complications.

Rationale

• Antibiotics are effective because they target the common bacterial pathogens in sinusitis including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, which often spread from the sinuses to the preseptal space via direct extension or through the venous system.
• The American College of Physicians and the Centers for Disease Control and Prevention recommend using clinical signs and symptoms to differentiate bacterial from viral causes, and amoxicillin-clavulanate is the preferred agent for empirical antibiotics 1.

From the Research

Antibiotics for Preseptal Sinusitis

• The use of antibiotics for preseptal sinusitis is a common practice, with the goal of treating the underlying bacterial infection 2, 3, 4, 5, 6.
• The choice of antibiotic depends on various factors, including the severity of symptoms, patient allergies, and the likelihood of resistance to certain antibiotics 2, 3.
• Commonly used antibiotics for preseptal sinusitis include amoxicillin, amoxicillin-clavulanate, cefuroxime, cefpodoxime, and cefdinir 2, 3.
• For patients with a beta-lactam allergy, alternative antibiotics such as doxycycline or a respiratory fluoroquinolone may be used 3.
• The optimal duration of antibiotic therapy is unknown, but treatment is typically continued until the patient becomes free of symptoms and then for an additional 7 days 2.

Effectiveness of Antibiotics

• Studies have shown that antibiotics can be effective in treating preseptal sinusitis, with success rates ranging from 87% to 88% 6.
• A comparison of levofloxacin and amoxicillin-clavulanate found that both antibiotics were effective in treating acute sinusitis, but levofloxacin was better tolerated 6.
• A systematic review of 19 studies found that antibiotics were effective in reducing symptoms and improving quality of life in patients with acute sinusitis 5.

Considerations and Precautions

• The use of antibiotics for preseptal sinusitis should be weighed against the potential risks of adverse effects and the development of antibiotic resistance 4, 5.
• Diagnostic testing, such as imaging or antral puncture, may be necessary to confirm the presence of a bacterial infection and guide antibiotic therapy 2, 3.
• Supportive care, including saline irrigation, nasal steroids, and decongestants, may also be helpful in reducing symptoms and improving outcomes 3.