From the Guidelines
For a patient who has failed outpatient treatment with azithromycin and amoxicillin-clavulanate (Augmentin) for pneumonia, I recommend respiratory fluoroquinolones as the next line of therapy, specifically levofloxacin 750 mg orally once daily for 5 days or moxifloxacin 400 mg orally once daily for 7 days, as they provide excellent coverage against common respiratory pathogens and have a different mechanism of action compared to macrolides and beta-lactams. These agents are particularly useful in this scenario because they target bacterial DNA gyrase and topoisomerase IV, which is distinct from the mechanisms of azithromycin and amoxicillin-clavulanate 1. The American Thoracic Society and Infectious Diseases Society of America guideline recommends respiratory fluoroquinolones as a strong option for outpatient adults with comorbidities or risk factors for antibiotic-resistant pathogens, which may be applicable in this case given the patient's treatment failure 1.
Some key points to consider when prescribing fluoroquinolones include:
- Assessing for contraindications such as QT prolongation, tendon disorders, myasthenia gravis, or history of adverse reactions to fluoroquinolones
- Monitoring for signs of clinical deterioration, such as increased work of breathing, hypoxemia, or altered mental status, which may necessitate hospitalization for intravenous antibiotics and supportive care
- Ensuring the patient completes the full course of antibiotics, even if symptoms improve before completion, to minimize the risk of treatment failure and resistance development
- Considering the potential for drug interactions and adjusting the treatment plan accordingly, as fluoroquinolones can interact with various medications, including antacids, warfarin, and certain antiarrhythmics 1.
It is essential to note that the choice of antibiotic should be guided by local resistance patterns and susceptibility testing, when available, to ensure the most effective treatment and minimize the risk of resistance development 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Alternative Antibiotics for Pneumonia Treatment
In patients who have failed treatment with azithromycin and augmentin (amoxicillin-clavulanate) for pneumonia in an outpatient setting, alternative antibiotics may be considered.
- Levofloxacin is a potential alternative, as it has been shown to be effective in treating community-acquired pneumonia (CAP) in hospitalized patients 2, 3.
- A combination of a third-generation cephalosporin (such as ceftriaxone) and a macrolide (such as azithromycin or clarithromycin) may also be considered, as it has been found to be at least as efficacious as monotherapy with a fluoroquinolone for hospitalized patients with moderate to severe CAP 3, 4.
- For patients with lower respiratory tract infections, a 3-day course of azithromycin has been shown to be as effective as a 10-day course of amoxycillin-clavulanic acid (co-amoxiclav, Augmentin) 5.
Considerations for Antibiotic Selection
When selecting alternative antibiotics, it is essential to consider the patient's specific needs and the potential risks and benefits of each option.
- The use of azithromycin should be carefully considered, as inappropriate administration can incur unnecessary financial costs, exacerbate antimicrobial resistance, and risk QTc interval prolongation leading to cardiac arrhythmias 6.
- The choice of antibiotic should be guided by the patient's clinical presentation, the severity of their illness, and the likelihood of resistance to certain antibiotics.