Is doxycycline (doxy) and ceftriaxone (Rocephin) a suitable treatment for toe cellulitis in a 58-year-old patient with a normal white blood cell (WBC) count and no diabetes?

Treatment Recommendation for Toe Cellulitis

For this 58-year-old patient with uncomplicated toe cellulitis, normal WBC, and no diabetes, the combination of doxycycline and ceftriaxone is NOT the recommended first-line therapy—a single agent targeting streptococci and methicillin-susceptible S. aureus (MSSA) is sufficient and preferred. 1

Appropriate First-Line Treatment

Outpatient Oral Therapy (Preferred)

For this patient without systemic signs of infection (SIRS), altered mental status, or hemodynamic instability, outpatient oral therapy is recommended 1:

• Cephalexin 500 mg every 6 hours PO 1
• Dicloxacillin (alternative) 1
• Clindamycin (if beta-lactam allergy) 1

Why Doxycycline + Ceftriaxone is Inappropriate

Doxycycline is not indicated for cellulitis 2:

• The FDA label for doxycycline does not list cellulitis or skin and soft tissue infections as approved indications 2
• Doxycycline is indicated for atypical pathogens (Mycoplasma, Chlamydia, Rickettsiae) and certain gram-negative infections, not the typical cellulitis pathogens 2

Ceftriaxone is unnecessarily broad-spectrum 1:

• Ceftriaxone is reserved for moderate-to-severe infections requiring parenteral therapy or when MRSA coverage plus streptococci is needed 1
• This patient has normal WBC and no systemic signs, indicating mild infection 1

Clinical Severity Assessment

This patient has MILD cellulitis based on 1:

• No SIRS (systemic inflammatory response syndrome)
• Normal WBC count
• No diabetes (lower risk for complications)
• No mention of hemodynamic instability or altered mental status

Treatment Duration and Adjunctive Measures

Duration: 5 days minimum, extending if not improved 1

Critical adjunctive measures for toe cellulitis 1:

• Examine interdigital toe spaces carefully for fissuring, scaling, or maceration 1
• Treat any toe web abnormalities (tinea pedis) as this eradicates pathogen colonization and reduces recurrence 1
• Elevate the affected extremity 1

When to Consider Broader Coverage

MRSA coverage (vancomycin or alternatives) is indicated ONLY if 1:

• Penetrating trauma to the toe
• Evidence of MRSA infection elsewhere
• Known MRSA nasal colonization
• Injection drug use
• Presence of SIRS

Parenteral therapy (including ceftriaxone) is indicated if 1:

• Systemic signs of infection develop
• Failed outpatient oral therapy
• Concern for deeper/necrotizing infection
• Poor adherence anticipated
• Severe immunocompromise

Common Pitfalls to Avoid

• Over-treatment with broad-spectrum antibiotics for uncomplicated cellulitis contributes to resistance without improving outcomes 1
• Ignoring toe web spaces: Failure to examine and treat interdigital fungal infection is a major cause of recurrent lower extremity cellulitis 1
• Unnecessary hospitalization: This patient meets criteria for outpatient management 1