If a patient with sinusitis, recently treated with Augmentin (amoxicillin/clavulanate), continues to report symptoms, should I change the antibiotic to Doxycycline (Doxy) after administering a steroid injection and Rocephin (ceftriaxone)?

Management of Persistent Sinusitis After Augmentin Treatment

For a patient with persistent sinusitis symptoms after Augmentin treatment, switching to doxycycline is appropriate after administering a steroid injection and Rocephin, especially if there's no improvement within 72 hours of the initial antibiotic therapy. 1

Assessment of Treatment Failure

When evaluating a patient with persistent sinusitis symptoms after Augmentin (amoxicillin/clavulanate) treatment:

1. Confirm bacterial sinusitis diagnosis - Look for:

   • Persistent symptoms (nasal discharge/cough >10 days without improvement)
   • Severe symptoms (fever >39°C/102.2°F with purulent nasal discharge or facial pain for ≥3 days)
   • Worsening symptoms after initial improvement ("double-sickening") 1

2. Consider possible reasons for treatment failure:

   • Inadequate antibiotic coverage (resistant organisms)
   • Inadequate duration of treatment
   • Poor medication adherence
   • Underlying conditions (nasal polyps, immunocompromise)
   • Non-bacterial causes (viral, allergic, fungal) 1

Treatment Algorithm for Persistent Sinusitis

Step 1: Antibiotic Change

• The current approach (steroid injection + Rocephin followed by doxycycline) aligns with guidelines for treatment failure
• Patients should be assessed for clinical improvement within 72 hours of starting antibiotics and considered for switching to a broader-spectrum antibiotic if no improvement is seen 1

Step 2: Antibiotic Selection

• Doxycycline is an appropriate choice after Augmentin failure:
  • Provides different mechanism of action
  • Covers common respiratory pathogens including resistant strains
  • Effective against beta-lactamase producing organisms 1, 2

Step 3: Adjunctive Treatments

• Steroid injection is beneficial to reduce inflammation and improve sinus drainage
• Consider additional adjunctive treatments:
  • Intranasal corticosteroids
  • Saline nasal irrigation
  • Oral or topical decongestants
  • Adequate hydration 1

Important Clinical Considerations

• One-time Rocephin (ceftriaxone) injection provides immediate broad-spectrum coverage while transitioning to oral therapy, particularly useful in treatment failures 3

• Duration of therapy: Continue doxycycline for 5-7 days 1

• Monitor for improvement: If symptoms persist despite this change in therapy, consider:

  • Referral to an otolaryngologist
  • Imaging studies
  • Evaluation for complications 1

Potential Pitfalls and Caveats

• Beware of complications: Watch for orbital involvement, severe pain, or persistent fever requiring immediate referral and possibly hospitalization 1

• Consider underlying conditions: Persistent symptoms may indicate allergic rhinitis, immunodeficiency, or anatomical issues requiring specific management 1

• Resistance concerns: In areas with high antimicrobial resistance, consider culture-guided therapy if available 1

• Patient education: Advise on completing the full course of antibiotics even if symptoms improve quickly

By following this approach, you provide comprehensive care addressing both the acute infection and the factors that may have contributed to the initial treatment failure.