Periorbital Cellulitis (Preseptal Cellulitis) Organism-Specific Therapy

Updated: Sep 21, 2016

Author: T Amerson Pegram, MD; Chief Editor: Thomas E Herchline, MD

Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for the most common organisms responsible for periorbital cellulitis (also known as preseptal cellulitis), including those for Haemophilus influenzae, methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), streptococcal species, and anaerobes, are provided below.[1]

For empiric therapy, see Periorbital Cellulitis Empiric Therapy.

Haemophilus influenzae periorbital cellulitis

Therapeutic regimens for H influenzae periorbital cellulitis are listed below.

Amoxicillin-clavulanate (see age-based dosing regimens below)

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

Cefpodoxime (see age-based dosing regimens below)

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

Cefdinir (see age-based dosing regimens below)

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

Ceftriaxone (see age-based dosing regimens below)

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

Staphylococcus aureus, methicillin susceptible (MSSA) periorbital cellulitis

Therapeutic regimens for MSSA periorbital cellulitis are listed below.

Ampicillin-sulbactam 1.5-3 g IV q6h for 10-14 days or

Amoxicillin-clavulanic acid (see age-based dosing regimens below)

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

Cefuroxime (see age-based dosing regimens below)

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

Ceftriaxone (see age-based dosing regimens below)

Pediatric: 50-100 mg/kg/day IM/IV divided q12h (maximum 4 g/day)
Adult: 1 g IV daily for 10-14 days or

Clindamycin (see age-based dosing regimens below)

Pediatric: 30-40 mg/kg/day divided q8h for 10-14 days (maximum 1.8 g/day)
Adult: 600 mg IV/PO q8h for 10-14 days

Staphylococcus aureus, methicillin resistant (MRSA) periorbital cellulitis

Therapeutic regimens for MRSA periorbital cellulitis are listed below.

Vancomycin (see age-based dosing regimens below)

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

Daptomycin 4-6 mg/kg IV q24h[3] or

Clindamycin (see age-based dosing regimens below)

Pediatric: 30-40 mg/kg/day divided q8h for 10-14 days (maximum 1.8 g/day)
Adult: 600 mg IV/PO q8h for 10-14 days ^[4] or

Trimethoprim-sulfamethoxazole (see age-based dosing regimens below)

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 (see age-based dosing regimens below)

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

Streptococcal periorbital cellulitis

Therapeutic regimens for streptococcal periorbital cellulitis are listed below.

Vancomycin (see age-based dosing regimens below)

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

Trimethoprim-sulfamethoxazole (see age-based dosing regimens below)

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

Amoxicillin (see age-based dosing regimens below)

Pediatric: 80-100 mg/kg/day divided q12h for 10 days (maximum 500 mg/dose)
Adult: 875 mg PO q24h for 10-14 days or

Amoxicillin-clavulanic acid (see age-based dosing regimens below)

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

Ceftriaxone (see age-based dosing regimens below)

Pediatric: 50-100 mg/kg/day IM/IV divided q12h (maximum 4 g/day)
Adult: 1 g IV daily for 10-14 days or

Erythromycin (see age-based dosing regimens below)

Pediatric: 30-50 mg/kg/day divided q6-8h for 7-10 days (maximum 4 g/day)
Adult: 500 mg/day PO q6h for 10-14 days ^[5]

Anaerobic periorbital cellulitis

Therapeutic regimens for anaerobic periorbital cellulitis are listed below.

Piperacillin/tazobactam (see age-based dosing regimens below)

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 (see age-based dosing regimens below)

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

Metronidazole (see age-based dosing regimens below)

Pediatric: 30 mg/kg/day PO/IV divided q6h for 10-14 days (maximum 4 g/day)
Adult: 500 mg PO q6-8h for 10-14 days (maximum 1 g/dose) ^[6] or

Clindamycin (see age-based dosing regimens below)

Pediatric: 30-40 mg/kg/day divided q8h for 10-14 days (maximum 1.8 g/day)
Adult: 300 mg q8h for 10-14 days ^[7] or

Imipenem/cilastatin (see age-based dosing regimens below)

Pediatric: 60-100 mg/kg/day IV divided q6h (maximum 2-4 g/day)
Adult: 1 g IV q8h (maximum 50 mg/kg/day up to 3 g/day) or

Chloramphenicol (see age-based dosing regimens below)

Pediatric: 50-75 mg/kg/day IV divided q6h (maximum 4 g/day)
Adult: 50-100 mg/kg/day IV divided q6h (maximum 100 mg/kg/day)

Special considerations

Periorbital cellulitis is a common infection of the eyelid and periorbital soft tissues characterized by acute eyelid erythema and edema.

This bacterial infection usually results from the local spread of an adjacent upper respiratory tract infection, adjacent sinusitis, or an external ocular infection or following trauma to the eyelids.[6]

The most common organisms associated with periorbital cellulitis include Streptococcus pneumoniae, Staphylococcus aureus, other streptococcal species, and anaerobes.[8, 9]

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.

The condition should be treated initially as orbital cellulitis in children younger than one year, patients who are difficult to examine, and immunocompromised patients.

Surgical drainage is indicated only for abscesses and is usually unnecessary for uncomplicated periorbital cellulitis.[1, 10, 11, 12]

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Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004 Sep. 25(9):312-20. [Medline].
[Guideline] Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1. 52 (3):e18-55. [Medline]. [Full Text].
Koh E, Kim S. Decline in erythromycin resistance in group A Streptococci from acute pharyngitis due to changes in the emm Genotypes rather than restriction of antibiotic use. Korean J Lab Med. 2010 Oct. 30 (5):485-90. [Medline]. [Full Text].
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Brook I. Treatment of anaerobic infection. Expert Rev Anti Infect Ther. 2007 Dec. 5 (6):991-1006. [Medline]. [Full Text].
Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008 Mar. 72 (3):377-83. [Medline]. [Full Text].
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. 2008 Oct. 92 (10):1337-41. [Medline]. [Full Text].
Brook I. Microbiology of acute sinusitis of odontogenic origin presenting with periorbital cellulitis in children. Ann Otol Rhinol Laryngol. 2007 May. 116(5):386-8. [Medline].
Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotising fasciitis. Br J Ophthalmol. 2010 Dec. 94(12):1577-85. [Medline].
Mathew AV, Craig E, Al-Mahmoud R, Batty R, Raghavan A, Mordekar SR, et al. Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital. Br J Radiol. 2014 Jan. 87(1033):20130503. [Medline]. [Full Text].
Charalampidou S, Connell P, Fennell J, et al. Preseptal cellulitis caused by community acquired methicillin resistant Staphylococcus aureus (CAMRSA). Br J Ophthalmol. 2007 Dec. 91(12):1723-4. [Medline]. [Full Text].

Periorbital Cellulitis (Preseptal Cellulitis) Organism-Specific Therapy

Specific Organisms and Therapeutic Regimens

Haemophilus influenzae periorbital cellulitis

Staphylococcus aureus, methicillin susceptible (MSSA) periorbital cellulitis

Staphylococcus aureus, methicillin resistant (MRSA) periorbital cellulitis

Streptococcal periorbital cellulitis

Anaerobic periorbital cellulitis

Special considerations

Contributor Information and Disclosures

References