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Cellulitis, Preseptal: Treatment & Medication
Updated: Apr 4, 2008
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Treatment
Medical Care
Treatment involves management of predisposing conditions, antibiotic therapy, and close observation.
- Initial antibiotic therapy is empiric, and, in most cases, a pathogen will not be identified. Given the predisposing factors, antibiotic choice should be directed toward the organisms that cause upper respiratory infections, particularly sinusitis. Specific organisms include Streptococcus pneumoniae, nontypeable H influenzae, and Moraxella catarrhalis. In cases due to focal trauma, treatment should include coverage for S aureus.
- In older children or adults with mild preseptal cellulitis, outpatient treatment may be considered with amoxicillin/clavulanic acid or a first-generation cephalosporin. Outpatient management with intramuscular ceftriaxone also is possible. If the patient fails to respond within 48-72 hours, consider intravenous antibiotics.
- In younger children or in more severe cases, admission for close observation and intravenous antibiotics are standard. Many published regimens exist for empiric therapy, but no regimen has been tested in clinical trials. A second- or third-generation cephalosporin (eg, cefuroxime, ceftriaxone) provides adequate coverage, even with resistant S pneumoniae. If anaerobes or S aureus are suspected, then clindamycin with a cephalosporin provides coverage. Other primary antibiotics include penicillinase-resistant synthetic penicillins (eg, nafcillin, oxacillin), especially if S aureus is suspected.
- Clinical improvement should be seen within 24-48 hours. If the patient worsens, then consider an underlying orbital process or resistant organisms.
- After clinical improvement on 48-72 hours of intravenous antibiotics is demonstrated, a trial of oral antibiotics for 24 hours can be tried. If the clinical improvement continues, the patient can be observed on an outpatient basis. Oral antibiotics should be continued for 10 days. Such conservative treatment strategies are recommended, particularly for pediatric patients.
Surgical Care
Surgical drainage is indicated only for eyelid abscesses and usually is not needed for uncomplicated preseptal cellulitis.
Consultations
- Consultation should be considered in cases where the eye cannot be evaluated or if orbital spread is suspected. Ophthalmic consultation and evaluation is recommended for all pediatric patients.
- Otorhinolaryngology consultation is suggested for medical and surgical treatment of sinusitis.
Medication
The goal of pharmacotherapy is to reduce morbidity and to prevent complications. Drugs described below are antibiotics commonly used to treat preseptal cellulitis.
Antibiotics
Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin and clavulanate (Augmentin)
Third-generation aminopenicillin. Combined with the beta-lactam, clavulanic acid, is less susceptible to degradation by beta-lactamases produced by microorganisms.
Adult
250-500 mg PO tid
Pediatric
<3 months: 30 mg/kg PO divided q12h
>3 months: 45 mg/kg PO divided q12h or 40 mg/kg divided tid
Probenecid can decrease renal excretion of amoxicillin, but not clavulanic acid; pregnant women may have a transient decrease in plasma concentration of total conjugated estriol, estriol-glucuronide, conjugated estrone, and estradiol
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Pseudomembranous colitis is associated with amoxicillin; Augmentin is associated with cholestatic jaundice and hepatic dysfunction; high urine concentrations of ampicillin may result in false-positive reactions when testing for presence of glucose in urine using commercial tests
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV/IM qd or divided q12h
Pediatric
50-75 mg/kg IV/IM qd or divided q12h; not to exceed 2 g
Alterations in prothrombin times have occurred rarely in patients treated with ceftriaxone; patients with impaired vitamin K synthesis or low vitamin K stores may require monitoring of prothrombin time during ceftriaxone treatment; vitamin K (10 mg/wk) may be necessary if prothrombin time is prolonged before or during therapy; probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Nephrotoxic potential of ceftriaxone is similar to that of other cephalosporins; caution in history of gastrointestinal disease, especially colitis
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by a 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound lincomycin.
Adult
150-300 mg PO q6h
Pediatric
8-16 mg/kg/d PO divided tid/qid
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in history of gastrointestinal disease, particularly colitis; elderly persons may not tolerate colitis as well as younger individuals; caution in atopic individuals; hepatic and renal function should be monitored with chronic use
Nafcillin (Unipen)
For suspected penicillin G-resistant streptococcal or staphylococcal infections. Second-generation penicillinase penicillin.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Due to thrombophlebitis, particularly in elderly persons, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated.
Adult
0.5-1 g IV q4h
Pediatric
0-4 kg (neonates): 10 mg/kg IM bid
4-40 kg: 25 mg/kg IM bid
Alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses
PO dosing for children: 50 mg/kg/d PO divided qid
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives; when used with cyclosporine, subtherapeutic levels of cyclosporine are possible
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated; oral route of administration should not be relied upon in patients with severe illness, or with nausea, vomiting, gastric dilatation, cardiospasm, or intestinal hypermotility
Cephalexin (Keflex, Biocef)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.
Adult
1-4 g PO qd in divided doses; usual adult dose is 250 mg PO q6h; if qd doses of cephalexin >4 g required, parenteral cephalosporins, in appropriate doses, should be considered
Pediatric
25-50 mg/kg PO in divided doses
False-positive reaction for glucose in urine may occur; coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use may result in overgrowth of nonsusceptible organisms; caution in presence of markedly impaired renal function
More on Cellulitis, Preseptal |
| Overview: Cellulitis, Preseptal |
| Differential Diagnoses & Workup: Cellulitis, Preseptal |
 Treatment & Medication: Cellulitis, Preseptal |
| Follow-up: Cellulitis, Preseptal |
| Multimedia: Cellulitis, Preseptal |
| References |
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References
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Further Reading
Keywords
preseptal cellulitis, periorbital cellulitis, eyelid infection, eyelid erythema, eyelid edema, bacterial infection, upper respiratory tract infection, ocular infection, eyelid trauma, orbital cellulitis, postseptal cellulitis, orbital septum
