What is the next best antibiotic for a child with sinusitis who has failed Augmentin (amoxicillin-clavulanate)?

Antibiotic Selection for Pediatric Sinusitis After Augmentin Failure

For a child with sinusitis who has failed Augmentin therapy, levofloxacin is the recommended next-line antibiotic treatment due to its excellent coverage against resistant Streptococcus pneumoniae and high clinical success rates. 1

Treatment Algorithm

1. First-line failure assessment:

   • Ensure Augmentin (amoxicillin-clavulanate) was given at appropriate dose and duration
   • Confirm patient adherence to full course
   • Verify symptoms persisted despite 3-5 days of appropriate therapy

2. Next-line antibiotic options (in order of preference):

   • Levofloxacin:

     • First choice after Augmentin failure 1
     • Dosing: Weight-based dosing according to pediatric guidelines
     • Duration: 10-14 days
     • Advantage: Excellent coverage against resistant S. pneumoniae

   • Alternative options (if fluoroquinolones contraindicated):

     • Cefdinir, cefpodoxime, or cefuroxime 1
     • Note: These have less effectiveness against resistant pneumococci than fluoroquinolones

   • Azithromycin may be considered in specific cases:

     • Studies show high efficacy (90.6% complete recovery) in sinusitis 2
     • Dosing: 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5 3
     • Advantage: Once-daily dosing improves compliance

Important Clinical Considerations

• Monitoring response:

  • Reassess within 3-5 days of starting the new antibiotic 1
  • Look for improvement in nasal discharge, cough, and facial pain/pressure

• Treatment duration:

  • Continue until patient is symptom-free for 7 days 1
  • Typically 10-14 days for levofloxacin in treatment failures

• Adjunctive therapies:

  • Saline nasal irrigation to improve sinus drainage
  • Intranasal corticosteroids to reduce inflammation, especially if there's marked mucosal edema 1
  • Short-term oral corticosteroids may be considered in severe cases with significant inflammation

Cautions and Pitfalls

• Fluoroquinolone use in children:

  • While levofloxacin is recommended after Augmentin failure, be aware of potential risks with fluoroquinolones in pediatric patients
  • Reserve for treatment failures or complicated cases to minimize resistance development 1

• Common errors to avoid:

  • Switching antibiotics too early (before 3-5 days on initial therapy) 1
  • Not completing the full course of the new antibiotic even if symptoms improve
  • Failing to consider complications such as orbital involvement or intracranial spread

• Red flags requiring urgent evaluation:

  • Worsening symptoms despite appropriate antibiotic therapy
  • Development of severe headache, visual changes, or altered mental status
  • High fever that persists despite antibiotics
  • Periorbital swelling or erythema

Remember that completing the full course of antibiotics is crucial to prevent relapse, even if symptoms improve before completion 1. The selection of levofloxacin as the next-line therapy after Augmentin failure is supported by guidelines from the American Academy of Allergy, Asthma, and Immunology due to its effectiveness against resistant organisms commonly encountered in treatment failures.