What is the recommended dosing of Augmentin (amoxicillin-clavulanate) for preseptal cellulitis?

Augmentin Dosing for Preseptal Cellulitis

For adults with preseptal cellulitis, high-dose amoxicillin-clavulanate at 4 g of amoxicillin with 250 mg of clavulanate per day divided into two doses is the recommended treatment. 1

Adult Dosing Recommendations

• High-dose amoxicillin-clavulanate (4 g amoxicillin/250 mg clavulanate per day divided into two doses) is the preferred regimen for preseptal cellulitis in adults 1
• Treatment duration should be 5-10 days, individualized based on clinical response 2, 1
• The shorter 5-6 day course is supported by recent evidence for nonpurulent cellulitis when patients can self-monitor and have close follow-up 2

Pediatric Dosing Recommendations

• For children with preseptal cellulitis, high-dose amoxicillin-clavulanate at 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate divided into two doses is recommended 1
• The pediatric formulation provides a 14:1 ratio of amoxicillin to clavulanate in an oral suspension 1
• Treatment duration for children is typically 10-14 days 1

Rationale for Amoxicillin-Clavulanate Selection

• Amoxicillin-clavulanate is preferred over amoxicillin alone due to better coverage against β-lactamase-producing organisms, including Streptococcus species and Staphylococcus aureus 1
• High-dose formulation overcomes potential resistance in Streptococcus pneumoniae with high MICs 1
• For nonpurulent cellulitis like preseptal cellulitis, empirical therapy for β-hemolytic streptococci is recommended, with consideration for MRSA coverage in patients who don't respond to β-lactam therapy 2

Treatment Considerations

• For mild cases of preseptal cellulitis, outpatient treatment with high-dose amoxicillin-clavulanate is appropriate with daily follow-up 1
• If no improvement occurs within 24-48 hours or if infection is progressive, hospitalization for intravenous antibiotics is warranted 1
• For patients with proptosis, impaired visual acuity, or impaired/painful extraocular mobility, immediate hospitalization and intravenous antibiotics are necessary 1
• Daily follow-up is recommended until definite improvement is noted for outpatient treatment 1

Alternative Regimens

• If no improvement occurs within 72 hours, consider switching to alternative antibiotics, such as clindamycin plus cefixime, linezolid plus cefixime, or levofloxacin 1
• For patients with MRSA concerns, options include clindamycin (300-450 mg PO TID for adults), trimethoprim-sulfamethoxazole, doxycycline, or linezolid 2
• Avoid first-generation cephalosporins like cephalexin as they may be ineffective for this condition 1

Potential Complications and Monitoring

• Complications of preseptal cellulitis can include progression to orbital cellulitis, which may lead to permanent blindness if not treated promptly 1, 3
• Laboratory findings such as elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein levels may be significantly higher in orbital cellulitis compared to preseptal cellulitis 4
• Clinical experience has shown that sulbactam-ampicillin (a similar β-lactam/β-lactamase inhibitor combination) has been effective in treating preseptal and orbital cellulitis 4