What should be done if a patient experiences diarrhea and abdominal cramps after taking 3 doses of Augmentin (amoxicillin/clavulanate) out of a 7-day course for a sinus infection?

Management of Diarrhea and Abdominal Cramps with Augmentin 875

The patient should discontinue Augmentin 875 immediately and contact their healthcare provider to switch to an alternative antibiotic while awaiting culture results for their sinus infection.

Rationale for Discontinuation

Diarrhea is a common adverse effect of amoxicillin-clavulanate (Augmentin) therapy. According to the European Position Paper on Rhinosinusitis (EPOS 2020), diarrhea was identified as the most common adverse event in patients receiving amoxicillin-clavulanate for sinusitis 1. The FDA drug label for amoxicillin-clavulanate specifically states that "diarrhea is a common problem caused by antibacterials" and advises that "if diarrhea is severe or lasts more than 2 or 3 days, patients should contact their physician" 2.

Management Algorithm

1. Immediate action:

   • Discontinue Augmentin 875 immediately
   • Stay hydrated with clear fluids
   • Monitor for worsening symptoms (fever, severe abdominal pain, bloody stools)

2. Contact healthcare provider for alternative therapy:

   • For patients with mild sinus infection:
     • Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1
     • If β-lactam allergic: TMP/SMX, doxycycline, azithromycin, or clarithromycin 1

3. Monitor for potential complications:

   • Watch for signs of C. difficile infection (watery, bloody diarrhea with fever)
   • If diarrhea persists after discontinuation, further evaluation may be needed

Evidence-Based Considerations

The 2015 Clinical Practice Guideline for Adult Sinusitis recommends that when a change in antibiotic therapy is needed due to adverse effects, "the clinician should consider the limitations in coverage of the initial agent" 1. Since the patient has only taken 3 pills of a 7-day course, switching to an alternative antibiotic is appropriate while awaiting culture results.

Studies have shown that diarrhea is a significant adverse effect of amoxicillin-clavulanate. A 2023 study comparing amoxicillin-clavulanate to amoxicillin alone found a higher risk of gastrointestinal symptoms with amoxicillin-clavulanate (RR, 1.15 [95% CI, 1.05-1.25]) 3.

Important Caveats

• Do not continue the medication despite symptoms: Continuing the medication despite gastrointestinal side effects may lead to dehydration, electrolyte imbalances, and potential development of C. difficile infection.

• Do not wait for culture results before acting: While culture results are pending, the patient should not continue taking a medication causing significant adverse effects when alternatives are available.

• Consider probiotics: Though not mentioned in the guidelines, probiotics may help reduce antibiotic-associated diarrhea, but this should not replace discontinuation of the offending antibiotic.

• Watch for C. difficile: Although less common with short-term antibiotic use, C. difficile infection can occur and presents with watery diarrhea, abdominal pain, and fever. If these symptoms develop, immediate medical attention is required 1.

The decision to discontinue Augmentin and switch to an alternative antibiotic balances the need to treat the sinus infection while preventing further gastrointestinal distress, which could lead to more serious complications if left unaddressed.