What is the first-line treatment for preseptal cellulitis in pediatric patients?

From the Guidelines

The first-line treatment for preseptal cellulitis in pediatric patients is oral antibiotics that cover Staphylococcus aureus and Streptococcus species, with amoxicillin-clavulanate being the preferred initial therapy. According to the guidelines for the diagnosis and management of skin and soft tissue infections, amoxicillin-clavulanate (40 mg/kg/day divided into three doses, maximum 875 mg per dose) for 7-10 days is typically recommended as the initial therapy 1. For patients with penicillin allergy, alternatives include clindamycin (30-40 mg/kg/day divided into three doses, maximum 450 mg per dose) or trimethoprim-sulfamethoxazole plus cefdinir if MRSA is a concern.

Key Considerations

• Patients should be monitored for improvement within 24-48 hours of starting antibiotics, as stated in the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years 1.
• If the child appears toxic, has significant pain or vision changes, or fails to improve with oral therapy, hospitalization for intravenous antibiotics may be necessary.
• Warm compresses applied to the affected eye several times daily can help reduce inflammation.
• Parents should be instructed to return immediately if the child develops worsening eyelid swelling, eye pain, vision changes, or if the eye becomes difficult to open, as these may indicate progression to orbital cellulitis, which is a medical emergency requiring immediate intervention.

Additional Recommendations

• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period, as recommended by the practice guidelines for the diagnosis and management of skin and soft tissue infections 1.
• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended.
• Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability.

Priorities for Further Research

• Rapid and specific diagnostic assays are needed for identification of microbes that cause cellulitis, as highlighted in the priorities for further research by the infectious diseases society of America 1.
• Inexpensive agents are needed that are effective against groups A, B, C, and G streptococci as well as staphylococci including MRSA.
• Investigations are needed to determine the pathogenesis of soft tissue infections caused by streptococci.

From the Research

First-Line Treatment for Pediatric Preseptal Cellulitis

• The first-line treatment for pediatric preseptal cellulitis is not explicitly stated in the provided studies, but the choice of antibiotic is crucial in managing the infection 2, 3, 4.
• According to the study by 3, oral antibiotics such as cephalexin are commonly prescribed for noncomplicated, nonfacial cellulitis in children.
• The study by 4 found that the implementation of a clinical practice guideline (CPG) led to a decrease in the use of broad-spectrum antibiotics, including dual/triple therapy and MRSA active antibiotics, for pediatric preseptal cellulitis.
• Another study by 2 suggests that antibiotics such as ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin are often used in the treatment of preseptal and orbital cellulitis.

Antibiotic Choices

• The choice of antibiotic depends on the severity of the infection and the suspected causative organism 2, 3.
• First-generation cephalosporins, such as cephalexin, are commonly used for noncomplicated, nonfacial cellulitis in children 3.
• Broad-spectrum antibiotics, including dual/triple therapy and MRSA active antibiotics, may be used in more severe cases or when the causative organism is unknown 2, 4.

Treatment Outcomes

• The study by 3 found that treatment with oral antibiotics was effective and required fewer visits and less time in the emergency department compared to intravenous treatment.
• The study by 4 found that the implementation of a CPG led to a decrease in the use of broad-spectrum antibiotics and a reduction in resource utilization, including blood testing and imaging.
• The study by 5 found that nearly half of patients with preseptal and orbital cellulitis had a CT-scan performed, and systemic corticosteroids were used in 19.7% of patients.