What is the recommended management for bilateral preseptal cellulitis?

Management of Bilateral Preseptal Cellulitis

For bilateral preseptal cellulitis, hospitalization with intravenous antibiotics is strongly recommended due to the increased severity and risk of systemic complications associated with bilateral involvement. 1

Initial Assessment and Risk Stratification

The bilateral nature of this presentation is a critical red flag that warrants aggressive management. You must immediately assess for:

• Visual acuity in both eyes – any decrease mandates immediate hospitalization 1
• Extraocular movements – pain or restriction indicates orbital involvement requiring IV therapy 1
• Proptosis – presence requires immediate hospitalization and CT imaging 1, 2
• Degree of eyelid closure – if either eyelid is >50% closed, hospitalize 1, 2
• Systemic signs – fever, tachycardia, hypotension, or altered mental status require admission 3, 1

Bilateral involvement itself suggests more severe infection or systemic predisposition, making outpatient management inappropriate in most cases. 1

Hospitalization Criteria (Met by Bilateral Disease)

The Infectious Diseases Society of America recommends hospitalization for moderate-to-severe preseptal cellulitis, which bilateral presentation represents by definition. 1 Additional absolute indications include:

• Systemic inflammatory response syndrome (SIRS) 3
• Inability to adequately examine both eyes due to swelling 1
• Immunocompromised status 3
• Extremes of age (infants or elderly) 1

Intravenous Antibiotic Regimen

First-line IV therapy should be broad-spectrum covering typical Gram-positive pathogens:

• IV amoxicillin-clavulanate (preferred for comprehensive coverage) 1, 2
• Ceftriaxone (alternative broad-spectrum option) 1
• Cefazolin (adequate Gram-positive coverage) 1

MRSA Coverage Indications

Add vancomycin 15-20 mg/kg IV every 8-12 hours if any of the following are present: 3, 1, 2

• Penetrating trauma to either eye
• Purulent drainage
• Known MRSA colonization or previous infection
• Injection drug use history
• Failed outpatient therapy
• Local MRSA prevalence warrants empiric coverage

For severe infections with systemic signs, start vancomycin empirically alongside beta-lactam coverage. 3

Imaging Requirements

Obtain contrast-enhanced CT of both orbits immediately if: 1, 2

• Any clinical features suggesting orbital involvement (proptosis, restricted movements, vision changes)
• Severe bilateral swelling preventing adequate examination
• No improvement after 24-48 hours of appropriate antibiotics
• Any uncertainty about distinguishing preseptal from postseptal disease

CT with IV contrast is the imaging modality of choice because it differentiates preseptal from orbital cellulitis, identifies abscesses, detects underlying sinusitis, and reveals complications like superior ophthalmic vein or cavernous sinus thrombosis. 1

Treatment Duration and Monitoring

• Total antibiotic course: 7-14 days 1
• Transition to oral therapy after 48-72 hours of IV treatment once clear clinical improvement is documented 1
• Patients should show improvement within 24-48 hours of appropriate therapy 3, 1

If no improvement within 72 hours: 3

• Change antibiotic regimen
• Obtain imaging if not already done
• Consider ophthalmology and infectious disease consultation 3

Oral Transition Therapy

Once clinically improved on IV therapy, transition to:

• High-dose amoxicillin-clavulanate 875/125 mg PO twice daily (adults) 2
• Clindamycin 300-450 mg PO every 6 hours (if penicillin-allergic and local MRSA clindamycin resistance <10%) 3, 2

Critical Pitfalls to Avoid

• Never start corticosteroids before ophthalmology evaluation – this may worsen infectious ocular conditions 1
• Do not use fluoroquinolones as first-line therapy – inadequate streptococcal coverage despite FDA approval for cellulitis 3
• Do not attempt outpatient management of bilateral disease – the bilateral nature indicates severity requiring hospitalization 1
• Elevate both affected areas to promote gravity drainage of edema 3

Specialist Consultation

Consult ophthalmology, otolaryngology, and infectious disease for guidance on: 3

• Surgical intervention if abscess develops
• Antimicrobial selection in complex cases
• Management of underlying sinusitis (present in >50% of cases) 4

The bilateral presentation fundamentally changes risk stratification from what might otherwise be mild unilateral disease, necessitating inpatient IV therapy as the standard of care.