What's the next step for a patient with persistent swelling and warmth to the touch in their left leg after 2 weeks of treatment with Augmentin (amoxicillin/clavulanate) for cellulitis?

Management of Persistent Cellulitis After Initial Antibiotic Treatment

For a patient with persistent swelling and warmth in the left leg after 2 weeks of Augmentin treatment for cellulitis, further evaluation is needed with consideration for a longer course of antibiotics or alternative therapy, as well as addressing potential underlying factors contributing to delayed resolution.

Assessment of Persistent Symptoms

• Persistent symptoms after initial antibiotic therapy may indicate incomplete resolution rather than treatment failure, as some local inflammation can persist for 10 days or longer even with appropriate treatment 1
• Carefully examine the interdigital toe spaces, as treating fissuring, scaling, or maceration may eliminate pathogen colonization and reduce infection persistence 2
• Evaluate for deeper infection or underlying conditions such as diabetes, chronic venous insufficiency, or lymphedema that may contribute to slow response 2

Next Steps in Management

1. Extend Antibiotic Therapy

• If clinical improvement was initially noted but resolution is incomplete, extend the antibiotic course beyond the initial treatment period 2
• Continue with the same antibiotic (Augmentin) if there was partial improvement, as it likely covers the causative pathogens (typically streptococci and methicillin-sensitive S. aureus) 2, 3
• The recommended duration should be extended if the infection has not completely resolved within the initial treatment period 2

2. Consider Alternative Diagnoses

• If no improvement was seen at all, consider:
  • MRSA infection (though uncommon in typical cellulitis without purulent drainage) 2, 4
  • Deeper infection requiring surgical evaluation 2
  • Non-infectious mimickers of cellulitis such as venous stasis dermatitis, contact dermatitis, or lymphedema 4

3. Supportive Measures

• Elevation of the affected leg is crucial and often neglected; this promotes gravity drainage of edema and inflammatory substances 2
• Consider adding an anti-inflammatory agent (such as ibuprofen) to hasten resolution of inflammation, as some studies show more rapid improvement with combination therapy 5

4. Address Predisposing Factors

• Identify and treat underlying conditions such as edema, venous insufficiency, or toe web abnormalities 2, 6
• Keep skin well hydrated with emollients to avoid dryness and cracking 2
• Consider compression stockings if there is evidence of venous insufficiency or lymphedema 2, 6

When to Consider Hospitalization or Specialist Referral

• If there are signs of systemic illness (fever, tachycardia, confusion, hypotension) 2
• If there is concern for deeper or necrotizing infection 2
• If outpatient treatment is failing despite appropriate measures 2
• For patients with significant comorbidities or immunocompromise 2

Prevention of Recurrence

• For patients with multiple episodes of cellulitis, prophylactic antibiotics may be considered (such as penicillin V or erythromycin) 2, 6
• Treat predisposing factors such as tinea pedis, venous eczema, or trauma 2
• Regular skin care and maintenance of skin integrity is important to prevent recurrent episodes 6

Common Pitfalls to Avoid

• Assuming treatment failure too quickly - some local symptoms can persist for days after successful treatment 1
• Unnecessarily broadening antibiotic coverage when the initial agent is appropriate 2, 4
• Failing to address underlying conditions that predispose to persistent or recurrent infection 2, 6
• Neglecting elevation and other supportive measures that are crucial for resolution 2