Periorbital Cellulitis (Preseptal Cellulitis) Empiric Therapy 

Periorbital Cellulitis (Preseptal Cellulitis) Empiric Therapy 

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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.


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:

​​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)

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

​​​ 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)

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

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

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)

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

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

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

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

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].

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].

Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004 Sep. 25(9):312-20. [Medline].

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].

Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. 2007 Jun. 21(2):393-408, vi. [Medline].

Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotising fasciitis. Br J Ophthalmol. 2010 Dec. 94(12):1577-85. [Medline].

Brook I. Treatment of anaerobic infection. Expert Rev Anti Infect Ther. 2007 Dec. 5 (6):991-1006. [Medline].

Bell EA. Clindamycin: new look at an old drug. Infectious Diseases in Children. October 2009.

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].

Singleton R, Hammitt L, Hennessy T, Bulkow L, DeByle C, Parkinson A, et al. The Alaska Haemophilus influenzae type b experience: lessons in controlling a vaccine-preventable disease. Pediatrics. 2006 Aug. 118 (2):e421-9. [Medline].

Moore GH, Rootman DB, Roybal N, Goldberg RA. Orbital Relapsing Polychondritis: A Unique Presentation, Complication, and Treatment. Ophthal Plast Reconstr Surg. 2014 Jul 28. [Medline].

Pushker N, Tejwani LK, Bajaj MS, Khurana S, Velpandian T, Chandra M. Role of oral corticosteroids in orbital cellulitis. Am J Ophthalmol. 2013 Jul. 156(1):178-183.e1. [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].

Hirakata Y, Ohmori K, Mikuriya M, Saika T, Matsuzaki K, Hasegawa M, et al. Antimicrobial activities of piperacillin-tazobactam against Haemophilus influenzae isolates, including beta-lactamase-negative ampicillin-resistant and beta-lactamase-positive amoxicillin-clavulanate-resistant isolates, and mutations in their quinolone resistance-determining regions. Antimicrob Agents Chemother. 2009 Oct. 53 (10):4225-30. [Medline].

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.

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

Disclosure: Nothing to disclose.

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: Nothing to disclose.

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.

Periorbital Cellulitis (Preseptal Cellulitis) Empiric Therapy 

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