Is Augmentin (amoxicillin/clavulanate) with Doxycycline or Clindamycin preferred for nasal cellulitis?

Treatment of Nasal Cellulitis: Augmentin with Clindamycin vs. Doxycycline

For nasal cellulitis, Augmentin (amoxicillin/clavulanate) with clindamycin is preferred over Augmentin with doxycycline due to better coverage against the most common pathogens and higher clinical success rates.

Rationale for Combination Therapy

Nasal cellulitis requires coverage for both streptococci and Staphylococcus aureus, including potential MRSA. The choice between combination therapies should be guided by:

1. Pathogen Coverage:

   • Streptococci are the most common cause of typical cellulitis 1
   • S. aureus (including MRSA) may be involved, especially with purulent drainage

2. Clinical Efficacy:

   • Clindamycin has demonstrated higher success rates than cephalexin in culture-confirmed MRSA infections and in moderately severe cellulitis 2
   • Clindamycin provides excellent coverage against most oral anaerobes and aerobes 3

Recommended Treatment Approach

First-line Therapy:

• Augmentin (amoxicillin/clavulanate): 875/125 mg twice daily
  • Provides broad-spectrum coverage including beta-lactamase-producing pathogens 4
  • Recommended for facial/nasal infections due to coverage of common respiratory pathogens 1

When to Add Clindamycin:

• Add Clindamycin (300-450 mg orally 3 times daily) when:
  • Concern for MRSA exists
  • Moderate to severe infection is present
  • Previous antibiotic failure
  • Purulent drainage is present
  • Patient has risk factors for resistant organisms

When to Consider Doxycycline Instead:

• Consider Doxycycline when:
  • Patient has clindamycin allergy
  • Patient cannot tolerate clindamycin side effects
  • Less severe infection with lower risk of anaerobic involvement

Dosing Considerations

• Weight-based dosing is critical: Inadequate dosing of clindamycin (<10 mg/kg/day) is independently associated with clinical failure in cellulitis 5
• Duration: 5-7 days is typically sufficient if clinical improvement occurs 1
• Augmentin dosing: Higher doses (875/125 mg twice daily) are preferred over lower doses for better coverage of potentially resistant organisms 1, 4

Monitoring Response

• Assess clinical response after 72 hours of treatment
• If no improvement or worsening occurs after 72 hours:
  • Reevaluate diagnosis
  • Consider changing antibiotic therapy
  • Consider imaging or culture if available

Special Considerations

MRSA Risk Assessment:

• MRSA is an unusual cause of typical cellulitis but should be considered with:
  • Penetrating trauma
  • Purulent drainage
  • Previous MRSA infection
  • Failed prior beta-lactam therapy

Penicillin Allergy:

• For non-Type I hypersensitivity: Clindamycin alone or clindamycin plus a third-generation cephalosporin 1
• For Type I hypersensitivity: Clindamycin alone or a respiratory fluoroquinolone 1

Potential Adverse Effects

• Clindamycin: Gastrointestinal effects (diarrhea, C. difficile), rare allergic reactions including lip and nasal passage swelling 6
• Doxycycline: Photosensitivity, gastrointestinal effects, tooth discoloration (in children)
• Augmentin: Diarrhea, rash, nausea

Common Pitfalls to Avoid

1. Underestimating the severity of nasal cellulitis (proximity to central nervous system)
2. Inadequate dosing of antibiotics, particularly weight-based considerations
3. Failing to reassess after 72 hours of treatment
4. Not considering local resistance patterns
5. Overlooking signs of deeper infection requiring surgical intervention

By following this approach, you can provide optimal coverage for the most likely pathogens in nasal cellulitis while minimizing the risk of treatment failure.