Preseptal or Orbital Cellulitis Clinical Pathway, All Settings – Common Pathogens and Antibiotic Recommendations

Preseptal or Orbital Cellulitis Clinical Pathway — All Settings

Common Pathogens and Antibiotic Recommendations

General Principles

  • Empiric treatment recommendations are based on local susceptibilities. Antibiotics should be tailored based on culture and susceptibility results when available.
  • MRSA is an uncommon cause of orbital cellulitis and abscess. MRSA directed therapy is not routinely required for most orbital cellulitis.
    • If vancomycin is started, either for recent history of MRSA infection or for sight-threatening infection, a MRSA nasal swab may help to determine whether to stop anti-MRSA antibiotics. Otherwise, MRSA nasal swabs are not routinely indicated.
  • The usual duration of therapy for preseptal cellulitis is 5-7 days.
  • The usual duration for orbital cellulitis is 10-14 days, though longer durations may be necessary for complicated infections or in children with undrained abscesses. ID consultation suggested in these cases.
  • Indications for ID consultation.

Pathogens and Antibiotic Recommendations

Diagnosis Pathogens
Preseptal Cellulitis
  • S. pyogenes
  • S. aureus (if purulent)
  • Less common (associated with sinusitis):
    • S. pneumoniae
    • H. influenzae
Orbital Cellulitis
  • Anginosus group Streptococci (Streptococcus anginosus, S. constellatus, and S. intermedius)
  • S. pneumoniae
  • S. pyogenes
  • Haemophilus influenzae
  • Oral anaerobes

Recommended Empiric Antibiotics

Diagnosis First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative
Preseptal Cellulitis
  • Cephalexin, PO
    • 60 mg/kg/day divided three times daily
      Max: 3,000 mg/day
  • or
  • Cefazolin, IV
    • 35 mg/kg/dose every 8 hours
      Max: 2,000 mg/dose
  • Clindamycin, PO
    • 10 mg/kg/dose three times daily
      Max: 600 mg/dose
  • or
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
      Max: 900 mg/dose
Orbital Cellulitis
  • Ampicillin-sulbactam, IV
    • 50 mg/kg/dose of ampicillin component every 6 hours
      Max: 2,000 mg/dose
  • Clindamycin, IV
    • 10 mg/kg/dose every 8 hours
      Max: 900 mg/dose
  • History of MRSA within the last 12 months
  • or
  • Concern for imminent sight threatening infection based upon exam by Ophthalmology:
    • Vancomycin, IV
      • Infants ≥ 1 month and children < 50 kg: 15 mg/kg/dose every 6 hours
        Max: 750 mg/dose
      • Children ≥ 50 kg, adolescents, and adults: 15 mg/kg/dose every 8 hours
        Max: 1,000 mg/dose
    • and
    • Ampicillin-sulbactam, IV
      • 50 mg/kg/dose of ampicillin component every 6 hours
        Max: 2,000 mg/dose
  • Concern for CNS extension based on imaging
    • Vancomycin, IV
      • Infants ≥ 1 month and children < 50 kg: 15 mg/kg/dose every 6 hours
        Max: 750 mg/dose
      • Children ≥ 50 kg, adolescents and Adults: 15 mg/kg/dose every 8 hours
        Max: 1,000 mg/dose
    • and
    • Ceftriaxone, IV
      • 50 mg/kg/dose every 12 hours
        Max: 2,000 mg/dose
    • and
    • Metronidazole, IV
      • Infants PMA > 44 weeks, children, adolescents, and adults: 10 mg/kg/dose every 8 hours
        Max: 1,500 mg/day
  • Concern for imminent sight threatening infection based upon exam by Ophthalmology:
    • Vancomycin, IV
      • Infants ≥ 1 month and children < 50 kg: 15 mg/kg/dose every 6 hours
        Max: 750 mg/dose
      • Children ≥ 50 kg, adolescents and adults:15 mg/kg/dose every 8 hours
        Max: 1,000 mg/dose
    • and
    • Ceftriaxone
      • Infants, Children and Adults:75 mg/kg/dose every 24 hours
        Max: 2,000 mg/dose