Periorbital Cellulitis (Preseptal Cellulitis) Empiric Therapy

Periorbital cellulitis, also known as preseptal cellulitis, is a common infection of the eyelid and periorbital soft tissues characterized by acute eyelid erythema and edema. Initial antibiotic therapy is empiric. In most cases, a causative pathogen is not identified.

The antibiotic choice should be directed toward the most common causative agents (namely, organisms that typically cause upper respiratory infections and sinusitis). Such common organisms include Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, other streptococcal species, and anaerobes.[1, 2]

Clinical improvement should occur within 24-48 hours. If the patient worsens, consider an underlying orbital process or resistant organism(s). In some cases, the treatment duration depends on disease severity.

In adult patients who are nontoxic and who will comply with appropriate follow-up, treatment can be with oral antibiotics on an outpatient basis. However, most pediatric patients require admission; intravenous (IV) antibiotics should be started.

The condition should be treated initially as orbital cellulitis in children younger than one year, patients who are difficult to examine, and immunocompromised patients. Patients who undergo outpatient treatment should be seen daily to ensure clinical improvement.

Once clinical improvement is noted, the patient can be switched to oral antibiotics.[3]

Empiric therapeutic regimens for periorbital cellulitis are outlined below, including those for outpatient and inpatient treatment.[4, 5, 6]

For organism-specific treatment, see Periorbital Cellulitis Organism-Specific Therapy.

Outpatient treatment recommendations

Monotherapy

Clindamycin covers S aureus (including methicillin-resistant S aureus [MRSA]), S pneumoniae, most other streptococci, and anaerobes[7] but has poor H influenzae coverage.[8] Age-based clindamycin regimens are as follows:

• Pediatric: 10-20 mg/kg/day PO divided q8h for 10-14 days (maximum of 1.8 g/day)
• Adult: 600 mg PO q8h for 10-14 days{ref11)

​​Combination therapy

Consider combination therapy in patients who are not immunized against H influenzae or in patients who cannot take clindamycin. Options are as follows:

Trimethoprim-sulfamethoxazole (covers S aureus [including MRSA], S pneumoniae, and H influenzae)

• Pediatric: Trimethoprim 8-10 mg/kg/day PO/IV divided q12h for 10 days
• Adult: Trimethoprim 160 mg PO q12h for 10 days or

Doxycycline (covers S aureus [including MRSA], S pneumoniae, and H influenzae)

• Children older than 8 years: 2-4 mg/kg/day PO divided q12h for 7-10 days
• Adult: 100 mg PO q12h for 1 day, then 100 mg PO q24h for 10-14 days

​​​Trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline fail to adequately cover group A Streptococcus. Moreover, doxycycline is contraindicated in children younger than 8 years. Therefore, combination therapy with TMP-SMX or doxycycline, along with one of the following, is recommended:

Amoxicillin-clavulanate (covers most streptococcal species; poor coverage for MRSA and anaerobes)

• Pediatric: 45-90 mg/kg/day divided q12h for 10-14 days
• Adult: 875 mg PO q12h for 10-14 days or

Cefpodoxime (covers most streptococcal species; poor coverage for MRSA and anaerobes)

• Pediatric: 10 mg/kg/day divided q12h for 10 days
• Adult: 200-400 mg PO q12h for 10-14 days or

Cefdinir (covers most streptococcal species; poor coverage for MRSA and anaerobes)

• Pediatric: 14 mg/kg/day PO divided q12h for 10 days (maximum of 600 mg/day)
• Adult: 600 mg PO daily for 10-14 days

Inpatient treatment recommendations

Initial inpatient therapy should cover the most causative organisms until clinical improvement occurs.

Inpatient regimens are as follows:

Piperacillin/tazobactam (covers S aureus, streptococci, H influenzae, and anaerobes)

• Age 2-9 months: 240 mg/kg/day IV divided q8h for 7-10 days
• Older than 9 months: 3.375 g IV q6h for 7-10 days or

​Amoxicillin-clavulanic acid (covers S aureus, streptococci, H influenzae, and anaerobes)

• Pediatric: 45 mg/kg/day divided q12h for 10-14 days
• Adult: 875 mg PO q12h for 10-14 days ^{[4, 5, 9]} or

Cefuroxime (covers S aureus, streptococci, H influenzae, and anaerobes)

• Age 3 months and older: 50-100 mg/kg/day IM/IV divided q8h for 10-14 days (maximum of 9 g/day)
• Adult: 1.5 g IV q8h for 10-14 days or

Ceftriaxone (covers S aureus, streptococci, H influenzae, and anaerobes)

• Pediatric: 50-100 mg/kg/day IM/IV
• Adult: 1-2 g IM/IV q24h ^[10]

​If MRSA is suspected, add vancomycin. Age-based vancomycin regimens are as follows:

• Age 1 month to 11 years: 10-15 mg/kg IV q6-8h (maximum of 1 g/dose)
• Older than 12 years: 1 g (15 mg/kg) q12h for 7-10 days