Cephalexin is a cephalosporin which puts another class of drug in the "little black bag" . . . so now we have a penicillin drug (dicloxacillin) and a cephalosporin drug (cephalexin).

Cephalexin penetrates the sinus cavity fairly well, so with a little stronger dosage, it can be used prophylactically for treating blowout fractures and preventing them from turning into orbital cellulitis in the first 7-10 days while the orbit is healing. It is also affective in afebrile adults with dacryocystitis.

Typical dosage for preseptal cellulitis is 500 mg BID for 7-10 days. In a case of significant cellulitis that raises Dr. Grogg's concern (especially patients with a large periauricular node and who seem really uncomfortable), she will go up to TID in dosage. QID dosage is appropriate for floor fractures.

Literature suggests that a cross sensitivity to penicillins exists with cephalexin although it is largely clinically ignored. There is about a 20% chance the patient will have cross sensitivity to cephalexin if the patient has had an anaphyllactic reaction to penicillin. If the patient has only had a simple rash from penicillin or is not sure of the response, cephalexin can probably be used, but stay away from cephalexin if the patient has had an anaphyllactic reaction to penicillin. Precautions in using cephalexin should be realized if the patient has a history of renal dysfunction or GI disease (especially colitis).

Occasional adverse reactions include GI upset and rash. Any antibiotic may cause some GI upset, but this one is very well tolerated. Cephalexin is inexpensive at $10 or $12 for a course of medicine.

Duricef is probably an under-used cephalosporin. It can be given as 500 mg BID or 1 gm QD, so it is good for compliance. And, it is now available generically, so it is inexpensive (1 gm x 7 days= approximately $15). Because this is a cephalosporin drug, the same cautions in penicillin allergies for cephalexin apply to Duricef.

In managing preseptal cellulitis secondary to hordeoli, let's not forget warm compresses and mechanical drainage.

This patient doesn't need an oral antibiotic. She doesn't have a preseptal cellulitis; she only has an isolated hordeoli which will do well with just warm compresses. Open it a bit, press on it, and drain it, and you'll be a hero in her book.

Some patients will get a concurrent conjunctivitis associated with preseptal cellulitis. If the patient has a concurrent conjunctivitis associated with the hordeoli, he/she can use a topical antibiotic. Consider Blephamide, Bacitracin ung, Polytrim, or Tobramycin. Any good broad-spectrum antibiotic works. Occasionally, patients have staph hypersensitivity associated with it, so a little bit of steroid on there goes a long way. If there is not an associated conjunctivitis and the infection is confined to the preseptal area, an oral antibiotic is the best treatment. Using a topical antibiotic for this soft tissue infection is a waste of the patient's money.

Orbital Blow-Out Fracture

This patient received a softball injury to the eye. She was hit hard enough that the stitches of softball were implanted on her skin around the eye.

CT scan of an orbital blow-out fracture. A CT scan is the test of choice to diagnose an orbital blow-out fracture. The CT scan enables better visualization of bone as compared to an MRI. In this image, you can see on the patient's left side the trap-door effect. Note the gray haze in the maxillary sinus. Blood and fluids filled in the maxillary sinus--creating a moist, warm, dark, and dirty environment next to the orbit which is perfect for bacteria to grow and develop into orbital cellulitis. Some oculoplastic surgeons are very liberal with not prescribing antibiotics for such patients, but it is not unreasonable to routinely put such patients on antibiotics for prophyllaxis.