Periorbital Cellulitis (Preseptal Cellulitis) Organism-Specific Therapy

Updated: Jun 09, 2022

Author: Jonathan C Tsui, 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) are provided below.[1] Local antibiograms should be consulted in addition to the following guidelines below for methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), streptococcal species, Haemophilus influenzae, and anaerobes.

For empiric therapy, see Periorbital Cellulitis (Preseptal Cellulitis) Empiric Therapy.

Methicillin-susceptible Staphylococcus aureus (MSSA) periorbital cellulitis

Ampicillin-sulbactam

1.5-3 g IV q6h for 10-14 days

Pediatric

100-200mg/kg/dose IV of ampicillin component q6h (max: 2g/dose) OR

Amoxicillin-clavulanic acid

Pediatric

45-90 mg/kg/day PO divided q12h for 10-14 days

Adult

875 mg PO q12h for 10-14 days OR

Cefuroxime

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

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

Pediatric

IV: 20-40 mg/kg/day IV divided q6-8h; max 900 mg/dose given IV
PO: 20-30 mg/kg/day PO divided q6-8h; max 450 mg/dose given PO

Adult

600 mg IV/PO q8h for 10-14 days

Methicillin-resistant Staphylococcus aureus (MRSA) periorbital cellulitis

Vancomycin

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) IV q12h for 7-10 days OR

Daptomycin

4-6 mg/kg IV q24h ^[2] OR

Clindamycin

Pediatric

10–13 mg/kg/dose PO every 6–8 h, not to exceed 40 mg/kg/day ^[3]

Adult

600 mg IV/PO q8h for 10-14 days ^[4] OR

Trimethoprim-sulfamethoxazole

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

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

Vancomycin

Age 1 month to 11 years

10-15 mg/kg IV q6-8h (maximum 1 g/dose)

Older than 12 years

1 g (10-15 mg/kg) IV/PO q12h for 7-10 days OR

Trimethoprim-sulfamethoxazole

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

Pediatric

80-100 mg/kg/day PO divided q12h for 10 days (maximum 500 mg/dose)

Adult

875 mg PO q24h for 10-14 days OR

Amoxicillin-clavulanic acid

Pediatric

45 mg/kg/day PO divided q12h for 10-14 days

Adult

875 mg PO q12h for 10-14 days OR

Ceftriaxone

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

Pediatric

30-50 mg/kg/day PO divided q6-8h for 7-10 days (maximum 4 g/day)

Adult

500 mg/day PO q6h for 10-14 days ^[5]

Haemophilus influenzae periorbital cellulitis

Amoxicillin-clavulanate

Pediatric

45-90 mg/kg/day PO divided q12h for 10-14 days

Adult

875 mg PO q12h for 10-14 days OR

Cefpodoxime

Pediatric

10 mg/kg/day PO divided q12h for 10 days

Adult

200-400 mg PO q12h for 10-14 days OR

Cefdinir

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

Pediatric

50-100 mg/kg/day IM/IV

Adult

1-2 g IM/IV q24h ^[6]

Anaerobic periorbital cellulitis

Piperacillin/tazobactam

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-clavulanate

Pediatric

45 mg/kg/day PO divided q12h for 10-14 days

Adult

875 mg PO q12h for 10-14 days OR

Metronidazole

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) ^[7] OR

Clindamycin

Pediatric

30-40 mg/kg/day IV divided q8h for 10-14 days (maximum 1.8 g/day)

Adult

300 mg IV q8h for 10-14 days ^[8] OR

Imipenem/cilastatin

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

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.[7]

The most common organisms associated with periorbital cellulitis include Streptococcus pneumoniae, Staphylococcus aureus, other streptococcal species, and anaerobes.[9, 10]

Clinical improvement should occur within 24-48 hours with antibiotic therapy. If the patient worsens, consider an underlying orbital or sinus process, drug allergy, resistant organism(s), and need for hospitalization. In some cases, the treatment duration depends on disease severity.

The condition initially should be treated as orbital cellulitis in children younger than 1 year, patients who are difficult to examine, and patients who are immunocompromised.

Surgical drainage is indicated only for abscesses and is usually unnecessary for uncomplicated periorbital cellulitis. Drainage specimens should be sent for cultures.[1, 11, 12, 13]

There are no recommendations that steroids should be considered routinely in periorbital cellulitis.[14]

Author

Jonathan C Tsui, MD Fellow in Vitreoretinal Surgery, Scheie Eye Institute

Jonathan C Tsui, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ocular Trauma, American Society of Retina Specialists, Pennsylvania Academy of Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

Vivian Qin, MD Resident Physician, Department of Ophthalmology, Scheie Eye Institute

Vivian Qin, MD is a member of the following medical societies: American Medical Association, Asian Pacific American Medical Student Association, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

César A Briceño, MD Associate Professor of Clinical Ophthalmology, Advisory Dean, Perelman School of Medicine at the University of Pennsylvania; Attending Physician, Penn Presbyterian Medical Center, Hospital of the University of Pennsylvania, Corporal Michael J Crescenz VA Medical Center, and Delaware County Memorial Hospital

César A Briceño, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, Pan-American Association of Ophthalmology, Sociedad Panamericana de Oculoplastía (SOPANOP)

Disclosure: Nothing to disclose.

Specialty Editor Board

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Received research grant from: Regeneron.

Additional Contributors

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

T Amerson Pegram, MD Fellow in Ophthalmic Plastic and Reconstructive Surgery, Eyeplastx

T Amerson Pegram, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

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Periorbital Cellulitis (Preseptal Cellulitis) Organism-Specific Therapy

Specific Organisms and Therapeutic Regimens

Methicillin-susceptible Staphylococcus aureus (MSSA) periorbital cellulitis

Methicillin-resistant Staphylococcus aureus (MRSA) periorbital cellulitis

Streptococcal periorbital cellulitis

Haemophilus influenzae periorbital cellulitis

Anaerobic periorbital cellulitis

Special considerations

Contributor Information and Disclosures

References