What is the preferred oral antibiotic, Augmentin (amoxicillin/clavulanic acid) or Cefuroxime axetil, for treating cellulitis?

Amoxicillin-Clavulanate vs Cefuroxime Axetil for Cellulitis

Amoxicillin-clavulanate (Augmentin) is the preferred oral antibiotic for treating cellulitis compared to cefuroxime axetil, as it has been associated with shorter hospital stays and less need for additional antibiotics. 1

Pathogen Coverage and Recommendations

• Cellulitis is primarily caused by beta-hemolytic streptococci (most commonly Streptococcus pyogenes) and less frequently by Staphylococcus aureus 2, 3
• For typical cellulitis without purulence or MRSA risk factors, the Infectious Diseases Society of America (IDSA) recommends antibiotics active against streptococci, including amoxicillin-clavulanate 3
• Amoxicillin-clavulanate provides excellent coverage against both streptococci and beta-lactamase producing organisms that may be present in cellulitis 4, 1
• While cefuroxime axetil has activity against common skin infection pathogens, it has less optimal anaerobic coverage compared to amoxicillin-clavulanate 2

Efficacy Comparison

• A retrospective study of patients with erysipelas or bacterial cellulitis found that amoxicillin-clavulanate therapy was associated with the shortest hospital stay duration and least need for additional antibiotics compared to other regimens including cephalosporins 1
• Although an older comparative study showed similar clinical efficacy between cefuroxime axetil and amoxicillin-clavulanate in upper respiratory infections (97% vs 98% success rates), this was not specifically in cellulitis 5
• The IDSA guidelines specifically mention amoxicillin-clavulanate as a recommended agent for cellulitis, particularly when there are concerns about mixed infections 2, 3

Treatment Duration and Dosing

• A 5-day course of antimicrobial therapy is as effective as a 10-day course for uncomplicated cellulitis if clinical improvement has occurred by day 5 2, 3
• Elevation of the affected area should be recommended to hasten improvement by promoting drainage of edema 2, 3
• Standard dosing of amoxicillin-clavulanate for adults with cellulitis typically follows the conventional formulations used in clinical trials 6

Special Considerations

• MRSA is an unusual cause of typical cellulitis. A prospective study showed that treatment with beta-lactams such as cefazolin was successful in 96% of patients with cellulitis, suggesting MRSA coverage is usually unnecessary 2
• However, MRSA coverage may be prudent in cellulitis associated with:
  • Penetrating trauma, especially from illicit drug use
  • Presence of purulent drainage
  • Concurrent evidence of MRSA infection elsewhere 2, 3
• In patients with recurrent cellulitis (3-4 episodes per year), prophylactic antibiotics should be considered 3

Practical Approach

• For uncomplicated cellulitis without MRSA risk factors, amoxicillin-clavulanate is the preferred oral option 2, 3, 1
• For patients with penicillin allergy, cefuroxime axetil could be considered if the allergy is not severe (non-anaphylactic) 2
• For patients with severe penicillin allergy, clindamycin is an alternative option 2, 3
• Adjunctive measures should include elevation of the affected area and treatment of predisposing conditions (e.g., tinea pedis, venous insufficiency) 2, 3

Common Pitfalls to Avoid

• Failing to recognize when MRSA coverage is truly needed versus when standard streptococcal coverage is sufficient 2
• Not addressing underlying predisposing conditions that may lead to recurrent episodes 3
• Using unnecessarily broad-spectrum antibiotics for typical cellulitis cases 2
• Treating for longer than necessary (5 days is often sufficient if clinical improvement occurs) 2, 3