What did I recommend?
I suggested that continuing with ceftriaxone was appropriate.
Despite the reports of it not improving, the overall look of this leg is of one that is improving. Bad cellulitis takes quite a long time to resolve and often the extent of the redness gets larger initially despite totally appropriate therapy. His leg is red but not BRIGHT red. You really need to look at a lot of cellulitic limbs through the course of their therapy to get a good feel for this.
The most important assessment is whether or not there was prompt improvement in systemic signs of infection after initiation of therapy. When this man was asked how he felt, in the overall sense, compared to when he first presented he responded “200% better!”. His fever had resolved, his appetite had improved and apart from a very uncomfortable leg he felt close to normal. I was convinced that he was responding well.
Why not go back to cefazolin?
A strong argument could be made for this as Group A Streptococci and S. aureus are well treated with cefazolin and it avoids the promotion of resistance in Gram- negative bacilli (in particular E. coli) by ceftriaxone. However, he appeared to be near ready for discharge and ceftriaxone facilitates home IV or OPAT therapy. Granted, cefazolin plus probenecid would be another option. I would not fault anyone for recommending going back to cefazolin.
At the start…
Four days later…
He was changed to oral therapy.
And 7 more days later (2 days after stopping antibiotics)…