What about using Augmentin (amoxicillin/clavulanate) with doxycycline for a patient with nasal cellulitis who has a sulfa allergy?

Treatment of Nasal Cellulitis with Sulfa Allergy: Augmentin with Doxycycline

For patients with nasal cellulitis who have a sulfa allergy, the combination of amoxicillin-clavulanate (Augmentin) with doxycycline is an appropriate and effective treatment option that provides broad-spectrum coverage against the most common pathogens.

Rationale for Combination Therapy

The combination of Augmentin with doxycycline offers several advantages:

1. Pathogen Coverage:

   • Augmentin provides coverage against most streptococcal species and methicillin-sensitive Staphylococcus aureus
   • Doxycycline adds coverage against resistant organisms including some MRSA strains and atypical pathogens
   • Together they cover the most common pathogens in nasal cellulitis

2. Sulfa Allergy Considerations:

   • Both medications are safe alternatives for patients with sulfa allergies
   • Avoids trimethoprim-sulfamethoxazole, which would be contraindicated

Evidence-Based Treatment Algorithm

First-Line Treatment for Nasal Cellulitis with Sulfa Allergy:

1. Augmentin (amoxicillin-clavulanate)

   • Dosage: 875/125 mg orally twice daily
   • Duration: 5-7 days
   • Rationale: Provides coverage against beta-lactamase producing organisms 1

2. Plus Doxycycline

   • Dosage: 100 mg orally twice daily
   • Duration: 5-7 days
   • Rationale: Recommended alternative for penicillin-allergic patients and provides additional coverage 1

Alternative Options (if Augmentin + Doxycycline not suitable):

1. For moderate-severe infection:

   • Respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1
   • OR Clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) 1

2. For mild infection:

   • Doxycycline monotherapy (100 mg twice daily) 1, 2

Clinical Considerations

• Monitoring: Reassess within 48-72 hours to evaluate treatment response

• Treatment Failure: If no improvement after 72 hours, consider:

  • Broadening antibiotic coverage
  • Obtaining cultures if possible
  • Imaging to rule out complications or abscess formation

• Adjunctive Therapies:

  • Saline nasal irrigation
  • Intranasal corticosteroids if significant inflammation
  • Analgesics for pain management

Potential Pitfalls and Caveats

1. Duration of Therapy: While 5-7 days is typically sufficient, more severe infections may require longer treatment courses

2. Antibiotic Resistance: Be aware of local resistance patterns that might affect treatment success

3. Distinguishing Bacterial vs. Viral Etiology: Bacterial infection is more likely with:

   • Symptoms persisting >10 days without improvement
   • Severe symptoms (fever >39°C, purulent discharge, facial pain for >3 consecutive days)
   • Worsening symptoms after initial improvement ("double sickening") 1

4. Complications: Watch for signs of orbital involvement or intracranial spread requiring immediate specialist referral 1

The combination of Augmentin with doxycycline provides excellent coverage for nasal cellulitis in patients with sulfa allergies while avoiding potentially harmful medications and minimizing the risk of treatment failure.