What is the management of a patient with bilateral periorbital preseptal cellulitis in the Emergency Department (ED)?

From the Guidelines

For a patient with bilateral periorbital preseptal cellulitis in the emergency department, prompt assessment and treatment are essential, and empiric antibiotic therapy should be initiated immediately, typically with coverage for Staphylococcus aureus and Streptococcus species, such as amoxicillin-clavulanate 875/125 mg twice daily, or clindamycin 300-450 mg four times daily for penicillin-allergic patients, for 5 days, as this duration has been shown to be as effective as a 10-day course in uncomplicated cases 1. Begin with a thorough evaluation including vital signs, visual acuity, extraocular movements, and examination for signs of orbital involvement (proptosis, ophthalmoplegia, pain with eye movement). Obtain blood cultures if the patient appears toxic or febrile. For mild to moderate cases in adults, oral options are suitable, but for severe cases or young children, consider IV antibiotics such as ampicillin-sulbactam 3 g every 6 hours or ceftriaxone 1-2 g daily plus metronidazole 500 mg every 8 hours. Patients with moderate to severe infection, significant facial swelling, systemic symptoms, or those who are immunocompromised should be admitted for IV antibiotics and monitoring. CT scan of the orbits with contrast is indicated if there's concern for orbital involvement, abscess formation, or if the patient isn't responding to initial therapy. Warm compresses can help with comfort and drainage. Patients suitable for outpatient management should have close follow-up within 24-48 hours. The distinction between preseptal and orbital cellulitis is critical, as the latter is a medical emergency requiring more aggressive management, and vancomycin may be considered for coverage of methicillin-resistant Staphylococcus aureus in severe cases 1. Elevation of the affected area and treatment of predisposing factors are also recommended 1. In cases where there is no improvement within the initial treatment period, consideration of broader spectrum antibiotics or further diagnostic workup may be necessary, and the patient's condition should be closely monitored for any signs of worsening or complications 1.

From the Research

Management of Periorbital Preseptal Cellulitis

• The patient should be evaluated for signs of infection, such as redness, swelling, and warmth around the eye 2.
• Antibiotics are often used in the treatment of preseptal cellulitis, with common choices including ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin 3.
• The choice of antibiotic should be guided by the severity of the infection and the potential for resistance, with broad-spectrum antibiotics reserved for more severe cases 4.
• Antimicrobial stewardship programs can help optimize antibiotic use and reduce the risk of resistance 3, 4.

Diagnostic Evaluation

• A thorough clinical evaluation, including a physical examination and medical history, is essential for diagnosing preseptal cellulitis 2, 5.
• Imaging studies, such as CT scans, may be necessary to distinguish between preseptal and orbital cellulitis 5.
• Laboratory tests, such as complete blood counts and blood cultures, may also be ordered to guide antibiotic therapy 4.

Treatment

• Antibiotic therapy should be initiated promptly, with the goal of optimizing pharmacodynamic target attainment 3.
• The duration of therapy is typically around 2 weeks, but may be adjusted based on clinical and laboratory improvement 3.
• Transition from intravenous to oral antibiotics may be possible when there are clear signs of clinical and laboratory improvement 3.