A 36-year-old Caucasian female was referred for pre-septal cellulitis unresponsive to oral antibiotics. The patient reported a “bump” in the middle of her eyelid that became tender and swollen over 3 days. Her optometrist started her on Augmentin 875mg bid but the condition continued to worsen even after 3 days of taking the medication and using hot compresses. She presented to me as a referral with a large, very tender area of cellulitis, concerning for an abscess, without lid margin involvement. Vision, EOMs, pupils, and examination of the globe were within normal limits. Given the presentation, a methicillin-resistant staph aureus (MRSA) periorbital, pre-septal cellulitis was suspected. The patient was questioned about a history of MRSA and reported that, although she had never had a MRSA infection herself, her husband had been diagnosed with a MRSA infection the previous year.

MRSA was historically a nosocomial infection that, over the last 2 decades, has also become a more common community-acquired infection. As its name implies, MRSA is resistant to the “cillin” class of antibiotics as well as cephalosporins, macrolide antibiotics such as azithromycin, and most fluoroquinolones. High-risk patients are those recently hospitalized or incarcerated, contact sports athletes or medical/daycare workers, and anyone with a history of a “hard to treat” infection themselves or in people with whom they live. Clinically, you should have an increased suspicion for MRSA when the infection doesn’t respond to your normal antibiotic regimen, the presentation is a very tender, fluid-filled cellulitis, and/or the patient reports a “spider bite” initial appearance. MRSA eyelid infections generally don’t start like a normal pre-septal cellulitis where there is an initial lid margin hordeolum that progresses across the lid. Oral agents most likely to be effective against MRSA include sulfamethoxazole-trimethoprim, clindamycin, and doxycycline.  Vancomycin is the most common intravenous antibiotic (IV) used to treat MRSA.

We sent the patient for a stat CT of the orbits to determine if the cellulitis was indeed confined to the pre-septal area and not orbital. The CT also told us the area did not look abcessed; which would have certainly required incision, drainage, and culture. The patient was started via home health on Vancomycin 1 gram q12h IV and Rocephin (third-generation cephalosporin to empirically cover other gram-positive/negative organisms) 1 gram q12h IV. After 3 days of IV therapy and hot compresses, the patient showed marked improvement in appearance and symptoms and we were able to stop the IV antibiotics and switch to oral Bactrim (Septra) DS and doxycycline 100mg, both bid po for 10 days.

Follow-up photo: