What is the preferred treatment between cefuroxime and Augmentin (amoxicillin/clavulanate) for a skin infection caused by Methicillin-Sensitive Staphylococcus aureus (MSSA)?

Treatment of MSSA Skin Infections: Cefuroxime vs. Augmentin

For skin infections caused by Methicillin-Sensitive Staphylococcus aureus (MSSA), clindamycin is the preferred first-line oral therapy, but if choosing between cefuroxime and Augmentin (amoxicillin/clavulanate), Augmentin is the preferred option due to its broader coverage and established efficacy for MSSA skin infections.

First-Line Treatment Options for MSSA Skin Infections

According to the Infectious Diseases Society of America (IDSA) guidelines, the recommended oral antibiotics for MSSA skin infections include:

1. First-line options:

   • Clindamycin (A-I) 1
   • Trimethoprim-sulfamethoxazole (TMP-SMX) (A-II) 1
   • Tetracyclines (doxycycline or minocycline) (A-II) 1
   • Linezolid (A-II) 1

2. Beta-lactam options:

   • Amoxicillin/clavulanate (Augmentin) is specifically listed as an appropriate option for mild to moderate skin infections 1
   • Cephalexin (first-generation cephalosporin) 1

Cefuroxime vs. Augmentin for MSSA

When specifically comparing cefuroxime (a second-generation cephalosporin) and Augmentin:

Advantages of Augmentin:

• Explicitly recommended in guidelines for skin infections 1
• Provides coverage against both MSSA and beta-lactamase-producing strains
• Has additional anaerobic coverage which may be beneficial in polymicrobial skin infections

Considerations for Cefuroxime:

• While cefuroxime is mentioned as an option for diabetic foot infections 1 and can be used with metronidazole for complicated infections 1, it is not specifically highlighted for simple MSSA skin infections in the guidelines
• Recent research suggests cefuroxime has similar effectiveness to flucloxacillin (an antistaphylococcal penicillin) for MSSA bacteremia 2, but this study was not focused on skin infections

Treatment Algorithm

1. For uncomplicated MSSA skin infections:

   • First determine if incision and drainage is needed (primary treatment for abscesses) 1
   • For purulent cellulitis: Use clindamycin as first choice 1
   • If clindamycin cannot be used: Augmentin is preferred over cefuroxime based on guideline recommendations 1

2. For complicated MSSA skin infections requiring hospitalization:

   • Consider IV options: vancomycin, linezolid, daptomycin, or clindamycin 1
   • A beta-lactam like cefazolin may be considered for non-purulent cellulitis 1

3. Duration of therapy:

   • 5-10 days for uncomplicated infections
   • 7-14 days for complicated infections
   • Duration should be based on clinical response 1

Important Clinical Considerations

• Beta-lactamase production: Many MSSA strains produce beta-lactamases, which may affect treatment efficacy. Augmentin contains clavulanate, which inhibits beta-lactamases 3

• Allergies: In patients with non-anaphylactoid penicillin allergies, cefuroxime may be a reasonable alternative 1

• Monitoring: Assess response to therapy within 48-72 hours; lack of improvement may indicate need for drainage procedure, culture and susceptibility testing, or change in antibiotic 1

• Pitfall to avoid: Don't rely solely on cefuroxime for polymicrobial infections without anaerobic coverage; if using cefuroxime in such cases, consider adding metronidazole 1

In conclusion, while both antibiotics may be effective against MSSA, Augmentin has stronger guideline support for MSSA skin infections and provides broader coverage that may be beneficial in skin and soft tissue infections that are often polymicrobial.