Augmentin for Cellulitis
Augmentin (amoxicillin-clavulanate) is an appropriate and effective first-line antibiotic for uncomplicated cellulitis, providing single-agent coverage for both streptococci and methicillin-sensitive Staphylococcus aureus, with a recommended dose of 875/125 mg twice daily for 5 days if clinical improvement occurs. 1
Evidence Supporting Augmentin as First-Line Therapy
The Infectious Diseases Society of America explicitly lists amoxicillin-clavulanate among the recommended oral agents for typical uncomplicated cellulitis, alongside penicillin, dicloxacillin, cephalexin, and clindamycin. 1 This recommendation is supported by the fact that beta-lactam monotherapy achieves a 96% success rate in treating cellulitis, confirming that MRSA coverage is usually unnecessary. 1
Augmentin offers a distinct advantage over plain amoxicillin because the clavulanic acid component protects amoxicillin from destruction by beta-lactamases produced by Staphylococcus aureus, allowing effective coverage against both streptococci and staphylococci without waiting for culture results. 2 This is particularly valuable in mixed skin and soft tissue infections where beta-lactamase-producing organisms may be present. 2
Clinical Evidence of Effectiveness
A retrospective analysis of 59 hospitalized patients with erysipelas or bacterial cellulitis demonstrated that amoxicillin-clavulanate was associated with the shortest hospital stays compared to cephalosporins or clindamycin. 3 Additionally, patients receiving amoxicillin-clavulanate least often required switching to other antibacterial agents, suggesting superior clinical efficacy. 3
Historical data from 32 patients with various skin infections showed a 94% response rate to Augmentin, with the majority of cases caused by amoxicillin-resistant Staphylococcus aureus either alone or combined with Streptococcus pyogenes. 4 This demonstrates particular value when mixed infections of penicillin-resistant staphylococci and streptococci are present. 4
Dosing and Duration
- Standard dose: 875/125 mg orally twice daily 1
- Treatment duration: 5 days if clinical improvement occurs, extending only if symptoms have not improved within this timeframe 1
- High-dose regimen: 2000/125 mg twice daily can be considered for patients failing standard therapy or in regions with high antibiotic resistance 1
The 5-day duration is as effective as traditional 7-14 day courses for uncomplicated cases, based on high-quality randomized controlled trial evidence. 1
Specific Clinical Situations Where Augmentin Is Particularly Appropriate
Augmentin is the preferred choice for cellulitis associated with human or animal bites, dosed at 875/125 mg twice daily, because it provides single-agent coverage for polymicrobial oral flora. 1 The IDSA guidelines specifically recommend Augmentin as monotherapy for bite-associated cellulitis, and trimethoprim-sulfamethoxazole should NOT be added to this regimen. 1
Additional scenarios favoring Augmentin include: 2
- Recent use of plain amoxicillin
- Cellulitis associated with traumatic wounds
- Infections not responding to simple beta-lactams
- Cellulitis with purulent drainage (though MRSA coverage may still be needed)
When NOT to Use Augmentin
Augmentin lacks anti-MRSA activity and should not be used for purulent cellulitis requiring MRSA coverage. 1 Specific situations requiring MRSA-active agents instead include: 1
- Penetrating trauma or injection drug use
- Purulent drainage or exudate
- Evidence of MRSA infection elsewhere or known MRSA colonization
- Systemic inflammatory response syndrome (SIRS)
- Failure to respond to beta-lactam therapy after 48-72 hours
In these scenarios, use clindamycin monotherapy (300-450 mg four times daily) or combination therapy with trimethoprim-sulfamethoxazole plus a beta-lactam, or doxycycline plus a beta-lactam. 1
Safety Profile
Side effects are generally mild and limited to: 4
- Nausea (9%)
- Diarrhea (9%)
- Rash (3%)
No evidence of Clostridium difficile toxin production was found in patients experiencing diarrhea in clinical studies. 4
Essential Adjunctive Measures
Beyond antibiotic therapy, the following measures hasten improvement: 1
- Elevation of the affected extremity to promote gravitational drainage of edema and inflammatory substances
- Examination and treatment of interdigital toe spaces for tinea pedis, fissuring, or maceration to eradicate colonization
- Management of predisposing conditions including venous insufficiency, lymphedema, obesity, and eczema
Common Pitfalls to Avoid
- Do not extend treatment to 7-10 days automatically based on residual erythema alone, as some inflammation persists even after bacterial eradication 1
- Do not add MRSA coverage reflexively to Augmentin for typical nonpurulent cellulitis without specific risk factors 1
- Do not use Augmentin as monotherapy if MRSA risk factors are present—switch to clindamycin or add MRSA-active agents 1
- Reassess within 24-48 hours to verify clinical response; progression despite appropriate therapy indicates resistant organisms or deeper infection 1