Doxycycline with Augmentin for Cellulitis
For typical nonpurulent cellulitis, doxycycline plus Augmentin is unnecessary and represents overtreatment—beta-lactam monotherapy with Augmentin alone is sufficient and successful in 96% of cases. 1
When This Combination is Appropriate
The combination of doxycycline plus a beta-lactam (like Augmentin) is only indicated when cellulitis has specific MRSA risk factors requiring dual coverage for both streptococci and MRSA. 1
Specific indications for adding doxycycline to Augmentin include:
- Cellulitis associated with penetrating trauma 1
- Purulent drainage or exudate present 1
- Injection drug use history 1
- Known MRSA colonization or documented MRSA infection elsewhere 1
- Systemic inflammatory response syndrome (SIRS) present 1
Why This Combination is Usually Wrong
Beta-lactam monotherapy is the standard of care for typical uncomplicated cellulitis, with a 96% success rate, confirming that MRSA coverage is usually unnecessary. 1
The evidence strongly supports that:
- MRSA is an uncommon cause of typical nonpurulent cellulitis, even in high-prevalence settings 1, 2
- Adding MRSA coverage to beta-lactam therapy provides no additional benefit in typical cases 1
- Combination therapy with SMX-TMP plus cephalexin is no more efficacious than cephalexin alone in pure cellulitis without abscess, ulcer, or purulent drainage 1
The Correct Approach
For Typical Nonpurulent Cellulitis
Use Augmentin 875/125 mg twice daily as monotherapy for 5 days if clinical improvement occurs. 1
Augmentin alone provides:
- Single-agent coverage for both streptococci and common skin flora 1
- Adequate treatment without the need for additional MRSA coverage 1
When MRSA Coverage is Actually Needed
If MRSA risk factors are present, use doxycycline 100 mg orally twice daily PLUS a beta-lactam for 5 days. 1
However, a superior alternative is clindamycin monotherapy, which covers both streptococci and MRSA without requiring true combination therapy. 1
Critical Pitfalls to Avoid
Never use doxycycline as monotherapy for typical nonpurulent cellulitis, as tetracyclines lack reliable activity against beta-hemolytic streptococci. 1
Do not reflexively add MRSA coverage simply because the patient is hospitalized or because local MRSA prevalence is high—assess for specific risk factors first. 1
Augmentin lacks anti-MRSA activity and should not be used for purulent cellulitis requiring MRSA coverage. 1
Treatment Duration
Treat for 5 days if clinical improvement occurs; extend only if symptoms have not improved within this timeframe. 1
Traditional 7-14 day courses are no longer necessary for uncomplicated cases. 1
Adjunctive Measures
Elevate the affected extremity to hasten improvement by promoting drainage. 1
Treat predisposing conditions including edema, obesity, eczema, venous insufficiency, and toe web abnormalities. 1