Contributor: Meghan Hurley MD

Educational Pearls:

What is Cellulitis?

A common and potentially serious bacterial skin infection.
Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.

What is Preseptal Cellulitis and why is it more serious than facial cellulitis?

Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.
This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.

How is Preseptal Cellulitis treated?

Oral antibiotics for five to seven days.
In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.
If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.
Check immunization status against H.influenzae and adjust appropriately.

What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?

Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.
Key features include:

Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.
Meningitis given that the meninges of the brain are continuous with optic nerve.
Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.

If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.

How is Orbital Cellulitis treated?

IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.
Add Metronidazole until intracranial involvement has been ruled out.
Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.
Admit to the hospital.

References

Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.
Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.
Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Podcast 872: Preseptal and Orbital Cellulitis

Emergency Medical Minute