A Cellulitis Case That Got Worse Under Treatment, and a $2,600 Antibiotic

The doctor says a patient he saw recently is a complex and interesting medical case, but that the health care system nearly killed this gentleman, and that this is what angers him. He says he is working a normal clinic shift when he sees a 39-year-old man on his schedule coming in for an emergency room follow-up.

According to the doctor, the man was seen in the emergency room a couple of days earlier for a rash on his right leg, which turned out to be cellulitis, and was prescribed a cephalosporin, a class of medications frequently used for skin and soft tissue infections.

The doctor explains that cellulitis is an infection of the superficial tissues caused by bacteria and requires antibiotic treatment. When the patient returned, he said the rash felt somewhat worse. The patient also reported that bearing weight on the leg caused a lot of discomfort, the leg was swelling, and the redness was starting to spread and streak, which the doctor describes as typical of cellulitis as it worsens.

The doctor says that antibiotics are chosen based on the bacteria suspected, and a culture would show the exact bacteria and which antibiotics work. No culture had been taken in this case, but the patient was worsening on oral antibiotics, so the doctor decided the cephalosporin was probably not covering the correct bacteria.

The doctor describes MRSA as a bacterium that lives on the skin and can occur in certain individuals. Some people have a higher risk of carrying it, while for others it may simply be part of their normal skin flora.

For this patient, the doctor felt MRSA was the one bug not being adequately covered by the cephalosporin, so he switched to oral Bactrim, an antibiotic used for skin and soft tissue infections with MRSA coverage for community-acquired MRSA.

The doctor says he told the patient clearly that he had to send a picture the next day to make sure the infection did not spread. He marked the border of the redness and told the patient that if the redness went outside that border while taking Bactrim, it meant the infection was getting worse and he would have to go to the ER.

When the patient reported on day seven that the infection was almost fully gone but some redness and discomfort remained, and asked whether the antibiotic could be extended, the doctor called the request totally reasonable. He said the guidelines for Bactrim in cellulitis allow 7 to 14 days of treatment, and the course could be expanded to 10 or 14 days depending on the severity of the infection.

The doctor then prescribed another seven days and followed up around day 10, when the patient said it was getting better and almost fully gone.

On day 13 the patient texted that he felt more discomfort in the leg and thought it might be getting worse. The doctor asked him to come in the next day, day 14, which was the last day of the antibiotic. At the visit the rash was clearly worse, with new red spots where there had been none, and the area was tender and warm, which the doctor said was what would be expected in a worsening cellulitis case.

The doctor told the patient he had to be sent back to the emergency room for IV antibiotics, and called ahead so he would be triaged faster. He also wrote a note asking the ER to rule out osteomyelitis, an infection of the bone, because the pain on pressing the area made it hard to tell whether the pain came from the skin or the bone.

At the ER the patient was started on IV vancomycin along with another antibiotic, which the doctor describes as the IV antibiotics of choice when the cause is unknown and the infection is severe. The doctor explains that broad-spectrum antibiotics cover many types of bacteria, and that using them indiscriminately can create multi-drug-resistant bacteria so that the strongest drugs later stop working. For that reason, the approach is to start with two strong drugs and narrow the spectrum once the causative bacteria is identified.

The ER checked the patient's blood for an elevated white blood cell count, which the doctor says was not reassuring, and checked inflammatory markers used for suspected osteomyelitis. One marker was only very mildly elevated by a few decimal points, which the doctor says is not very typical if the diagnosis is simple cellulitis. An X-ray of the right leg showed not much going on. The patient continued to do well on the two IV antibiotics.

The doctor reviewed the hospital course and found that on day three the patient was discharged on two oral antibiotics, Augmentin and doxycycline, to provide MRSA coverage, which he says was pretty broad coverage for take-home medications because improvement had been seen on IV treatment. Three days later the patient messaged the doctor with bad news.

The doctor says he went through possible causes, including hardware, outside exposure such as work around water in boots, and Pseudomonas infection. He also consulted a colleague, who was equally perplexed. He decided the patient needed IV treatment again. An MRI showed no osteomyelitis, and with the help of an infectious disease doctor the patient was given linezolid IV, which the doctor describes as a very rarely used antibiotic and a big gun.

At the follow-up two days later, the patient told the doctor there was bad news, saying it was more complicated than the antibiotic not working. The local pharmacy quoted $2,600 for a 10-day course. The patient said that even if he had to pay $400 or $500 he would pay, and the doctor called the price completely unreasonable and said insurance would not cover it.

The doctor says he then searched online for a reasonable price and found the drug through GoodRx for $38.

The doctor says the patient got better, which he calls the win of the story, and that through this advocacy the patient finally got the care he needed. He suspects many pharmacists are under gag orders that stop them from telling patients about cheaper options, because the pharmacy would then lose money. He says patients cannot be allowed to risk their health, with infection spreading into the blood and leading to sepsis, for the sake of pharmacy profit.

He says it is a shame that GoodRx has to exist in the US and calls the scenario absolutely terrible, adding that he is happy it worked out for his patient.