What is the role of Augmentin (amoxicillin/clavulanate) and Levaquin (levofloxacin) in the treatment of cellulitis?

Role of Augmentin and Levaquin in the Treatment of Cellulitis

For typical cellulitis, Augmentin (amoxicillin/clavulanate) is recommended as first-line therapy, while Levaquin (levofloxacin) should be reserved for patients with specific indications such as beta-lactam allergies or when targeting gram-negative pathogens. 1, 2

Causative Organisms and Antibiotic Selection

Typical Cellulitis Pathogens

• Beta-hemolytic streptococci are the most common causative organisms in typical non-purulent cellulitis
• Staphylococcus aureus is the second most common pathogen
• MRSA is an unusual cause of typical cellulitis, with studies showing beta-lactams effective in 96% of cases 2

First-Line Treatment Options

1. Mild to Moderate Cellulitis (Outpatient):

   • Augmentin (amoxicillin/clavulanate) is highly effective and recommended as first-line therapy 1, 3
   • Alternative options include penicillin, dicloxacillin, or cephalexin 2

2. Severe Cellulitis (Requiring Hospitalization):

   • IV beta-lactams such as cefazolin or oxacillin are recommended 1
   • For severely compromised patients: vancomycin plus piperacillin-tazobactam or a carbapenem 1

When to Consider Levaquin (Levofloxacin)

Levofloxacin should be reserved for specific situations:

• Patients with severe beta-lactam allergies
• When targeting specific pathogens based on culture results
• Uncomplicated skin and skin structure infections due to methicillin-susceptible S. aureus or S. pyogenes 4

Treatment Algorithm Based on Severity

Mild Cellulitis (No Systemic Signs)

1. First Choice: Augmentin 875/125 mg twice daily for 5 days
2. If penicillin allergic: Clindamycin or doxycycline
3. Follow-up: Reassess within 48-72 hours

Moderate Cellulitis (With Systemic Signs)

1. First Choice: Augmentin 875/125 mg twice daily
2. If MRSA suspected: Add coverage with TMP-SMX or doxycycline
3. Duration: 5-7 days, extend if not improved
4. Consider hospitalization if no improvement within 48 hours

Severe Cellulitis (Requiring Hospitalization)

1. First Choice: IV beta-lactams (cefazolin)
2. If severely compromised: Vancomycin plus piperacillin-tazobactam
3. Duration: Until clinical improvement, then transition to oral therapy

Evidence Supporting Augmentin for Cellulitis

A 2019 study evaluating antibiotic treatment for erysipelas and bacterial cellulitis found that combination therapy with amoxicillin + clavulanic acid (Augmentin) was associated with the shortest hospital stay compared to cephalosporins or clindamycin. This therapy was also least often associated with the need to use other antibacterial agents 3.

Duration of Treatment

• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period 1
• Daily follow-up is essential until clear improvement is noted 2

Adjunctive Measures

1. Elevation of the affected area to reduce edema
2. Treatment of predisposing factors such as edema or underlying skin disorders
3. In lower-extremity cellulitis, careful examination of interdigital toe spaces 1
4. Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adult patients 1

Important Considerations

• Cultures: Not routinely recommended for typical cellulitis unless there are risk factors such as immunocompromise, animal bites, or malignancy 1
• Hospitalization: Recommended for patients with SIRS, altered mental status, hemodynamic instability, concern for deeper infection, poor adherence to therapy, severe immunocompromise, or failing outpatient treatment 1, 2
• Recurrent Cellulitis: Consider prophylactic antibiotics in patients with 3-4 episodes per year despite treatment of predisposing factors 1

Caution with Fluoroquinolones (Levaquin)

While levofloxacin is FDA-approved for uncomplicated skin and skin structure infections 4, fluoroquinolones are generally not recommended as first-line agents for cellulitis due to:

• Increasing resistance concerns
• Risk of adverse effects (tendinopathy, peripheral neuropathy)
• Need to preserve for more serious infections

Remember that appropriate antibiotic selection based on likely pathogens and severity of infection is key to successful treatment of cellulitis.