If a patient attempting pregnancy has strep and has been on cefdinir (Cefdinir) for 2 weeks, should I escalate to amoxicillin (Amoxicillin) or Augmentin (Amoxicillin-Clavulanate)?

Management of Streptococcal Infection During Pregnancy Attempt

For a patient attempting pregnancy with strep infection who has been on cefdinir for 2 weeks without resolution, amoxicillin-clavulanate (Augmentin) is the recommended escalation therapy.

Assessment of Current Treatment Failure

When a patient with streptococcal infection has failed to respond to a 2-week course of cefdinir, this indicates treatment failure requiring a change in antibiotic strategy. Cefdinir is an oral third-generation cephalosporin with good activity against many respiratory pathogens 1, but persistent infection after 2 weeks suggests either:

• Resistant organism
• Inadequate drug penetration
• Non-compliance with medication
• Carrier state rather than active infection

Recommended Treatment Approach

Choice of Antibiotic

• Amoxicillin-clavulanate (Augmentin) is the preferred escalation option because:
  • It is classified as pregnancy category B by the FDA 2
  • The European Respiratory Society recommends it as a first-choice medication during pregnancy 2
  • It provides broader coverage than amoxicillin alone through the addition of a beta-lactamase inhibitor
  • It has demonstrated effectiveness against streptococcal infections that have failed other treatments 3

Dosing Recommendation

• Amoxicillin-clavulanate 500 mg twice daily for 10 days 3
  • This dosing regimen is supported by guidelines for treatment of recurrent streptococcal infections

Rationale for Choosing Augmentin Over Amoxicillin Alone

1. Enhanced Coverage: The clavulanic acid component inhibits beta-lactamases that may be contributing to treatment failure with cefdinir

2. Documented Efficacy: For recurrent or persistent streptococcal infections, amoxicillin-clavulanate has demonstrated superior eradication rates compared to single agents 3

3. Pregnancy Compatibility: Amoxicillin-clavulanate is considered compatible with pregnancy based on sufficient evidence of use in human pregnancies 2

Important Considerations

• Pregnancy Planning: Since the patient is attempting pregnancy, using a medication with established safety profile in pregnancy is crucial

• Monitoring: After initiating amoxicillin-clavulanate, follow up within 3-5 days to assess clinical response

• Potential Side Effects: Warn the patient about possible gastrointestinal effects (diarrhea is most common) 4

• Duration: Complete the full 10-day course even if symptoms improve earlier to ensure complete eradication

Special Precautions

• If the patient has a history of penicillin allergy, assess the risk for anaphylaxis (history of anaphylaxis, angioedema, respiratory distress, or urticaria) 3
• For patients with high risk of anaphylaxis to penicillin, alternative regimens would need to be considered with susceptibility testing

Follow-up Recommendations

• If symptoms persist after completing the 10-day course of amoxicillin-clavulanate, consider:
  • Throat culture to confirm persistent infection
  • Susceptibility testing
  • Evaluation for carrier state versus active infection
  • Consideration of clindamycin as an alternative for persistent cases 3

By escalating to amoxicillin-clavulanate, you provide broader coverage against potentially resistant streptococcal strains while maintaining a safety profile appropriate for a woman attempting pregnancy.