(29) Opportunities for Stewardship in Pediatric Preseptal Cellulitis

Brennen J. Cooper, Medical College of Wisconsin, United States; Michelle Mitchell, Medical College of Wisconsin, Wauwatosa, WI, United States; Svetlana Melamed, Medical College of Wisconsin, United States; Amy Pan, Medical College of Wisconsin, United States; Melodee Liegl, Medical College of Wisconsin, WI, United States; Alina G. Burek, Medical College of Wisconsin, Milwaukee, WI, United States

Background: Preseptal cellulitis requires prompt identification and treatment due to the risk of infection extending to structures deep to the orbital septum, resulting in orbital cellulitis or abscess. The lack of clinical guidelines for pediatric preseptal cellulitis results in significant variation in evaluation and management. This contributes to antibiotic and testing overuse or misuse.

Objectives: In this study, we aimed to describe the pattern of antibiotic prescribing and resource utilization in the evaluation and management of pediatric preseptal cellulitis.

Design/Methods: Patients age 2 months to 17 years admitted to an academic children’s hospital for treatment of preseptal cellulitis between January 2013 and May 2021 were retrospectively reviewed. Patients were excluded if they had a diagnosis of orbital cellulitis/abscess, dacryocystitis, animal bite or viral infection (e.g., HSV); were immunocompromised; had a history of penetrating trauma or eye surgery within 30 days of hospitalization; or eye prosthetics.

Results: Of 182 patients included the median age was 4.9 years (IQR 1.9-8.4) and 47% were female. One or more risk factors for Methicillin-resistant Staphylococcus aureus (MRSA) infection was documented in 17% of patients, defined as history of MRSA or healthcare exposure within 30 days of admission. The most common empiric antibiotics used were clindamycin (82%) and ampicillin-sulbactam (52%), and 45% of patients received dual antibiotic therapy. Patients were most commonly discharged on oral clindamycin (73%) and amoxicillin/clavulanate (40%), and 20% of patients were discharged on two antibiotics. The median length of total antibiotic course was 10 days (IQR 10-10). Cultures were acquired in 46% of patients, with the majority from blood or eye drainage. Only 2 (3%) blood cultures were positive while 23 (85%) eye drainage cultures were positive. MRSA was detected in 44% (n=10) of positive eye drainage cultures and 5% of total patients. Additional labs were obtained in 75% of the patients, including complete blood count (74%), C-reactive protein (47%), erythrocyte sedimentation rate (26%), and procalcitonin ( < 1%). A computed tomography (CT) scan was obtained in 78% of patients.

Conclusion: The use of broad-spectrum and/or MRSA active antibiotics accounts for most empiric and discharge prescriptions for pediatric preseptal cellulitis. Resource utilization varies between providers. Interventions aimed to improve antibiotic prescribing and lab utilization in pediatric preseptal cellulitis are needed.