Augmentin vs Cefuroxime for Skin Infections
Augmentin (amoxicillin-clavulanate) is the superior first-line choice for skin infections with unknown causative organisms, providing comprehensive coverage against the most common pathogens including both aerobic and anaerobic bacteria. 1, 2
Primary Recommendation
Augmentin 875/125 mg orally twice daily is the preferred empiric therapy for skin and soft tissue infections because it covers Staphylococcus aureus (including penicillinase-producing strains), Streptococcus pyogenes, gram-negative organisms, and anaerobes—the complete spectrum of bacteria commonly isolated from skin infections. 1, 2
The IDSA guidelines explicitly recommend amoxicillin-clavulanate as first-line therapy for animal bites, human bites, and contaminated wounds, noting its broad coverage of mixed aerobic-anaerobic infections. 1
Clinical studies demonstrate 94% response rates with Augmentin in primary skin sepsis, infected eczema, and infected trauma, with the majority of cases caused by amoxicillin-resistant S. aureus. 3
Why Cefuroxime is Inferior
Cefuroxime 500 mg orally twice daily has a critical gap in coverage: it misses anaerobes entirely, which are present in 60% of skin infections, particularly in bite wounds and contaminated injuries. 1
The IDSA guidelines list cefuroxime as requiring an additional agent active against anaerobes (metronidazole or clindamycin) for adequate coverage of skin infections. 1
Cefuroxime is FDA-approved for skin and skin-structure infections but only covers aerobic pathogens (S. aureus, S. pyogenes, E. coli, Klebsiella, Enterobacter), leaving significant therapeutic gaps. 4
Special Circumstances
For Penicillin Allergy
Mild penicillin allergy (non-anaphylactic): Cefuroxime 500 mg orally twice daily PLUS metronidazole 500 mg orally three times daily provides adequate coverage. 1, 2
Severe penicillin allergy (anaphylaxis history): Doxycycline 100 mg orally twice daily PLUS metronidazole 500 mg orally three times daily is recommended. 1, 2
Avoid cefuroxime monotherapy in severe penicillin allergy due to cross-reactivity risk (approximately 1-3% with second-generation cephalosporins). 2
For Impaired Renal Function
Augmentin requires dose adjustment: For CrCl 10-30 mL/min, reduce to 875/125 mg once daily or 500/125 mg twice daily; for CrCl <10 mL/min, reduce to 875/125 mg every 24 hours. 2
Cefuroxime also requires adjustment: For CrCl 10-20 mL/min, give 750 mg every 12 hours; for CrCl <10 mL/min, give 750 mg every 24 hours. 4
Both agents are dialyzable; administer supplemental doses after hemodialysis. 4
Critical Management Points
Start antibiotics immediately—delays beyond 3 hours significantly increase infection risk in contaminated wounds. 2
Duration is 3-5 days for uncomplicated skin infections without bone involvement. 2
Obtain cultures from purulent lesions to guide therapy, but do not delay treatment while awaiting results. 1, 2
Tetanus prophylaxis is mandatory if not current within 10 years; Tdap is preferred over Td if not previously given. 1, 2
Common Pitfalls to Avoid
Never use first-generation cephalosporins (cephalexin) for contaminated wounds or bite injuries—they lack adequate anaerobic and gram-negative coverage. 1, 2
Avoid clindamycin monotherapy—it misses Pasteurella multocida in animal bites and many environmental gram-negative organisms. 1
Do not use cefuroxime alone for mixed infections—it requires metronidazole for anaerobic coverage. 1
Augmentin loses potency if stored improperly in hot climates—counsel patients on proper refrigeration of reconstituted suspension. 5
When to Add MRSA Coverage
If MRSA is suspected (purulent infection, prior MRSA history, high local prevalence), add trimethoprim-sulfamethoxazole 160-800 mg orally twice daily to the base regimen. 1, 2
Alternatively, use doxycycline 100 mg orally twice daily or clindamycin 300 mg orally three times daily if local MRSA strains are susceptible. 1