What is the next step in treating sinusitis after Augmentin (amoxicillin-clavulanate) fails?

Treatment for Sinusitis After Augmentin Failure

When Augmentin (amoxicillin-clavulanate) fails in treating sinusitis, the next step should be switching to a respiratory fluoroquinolone such as levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily for 5-7 days. 1

Assessment After Augmentin Failure

Before switching antibiotics, it's important to:

• Confirm the patient has been evaluated after 3-5 days of appropriate Augmentin therapy 1
• Verify the patient received the correct dosage (875/125 mg twice daily for adults)
• Consider whether the patient might benefit from high-dose Augmentin (2000 mg amoxicillin component with 125 mg clavulanate twice daily) if not already tried 1
• Rule out complications requiring immediate specialist referral

Second-line Treatment Options

Recommended Options:

1. Respiratory Fluoroquinolones

   • Levofloxacin 500 mg once daily for 5-7 days 1, 2
   • Moxifloxacin 400 mg once daily for 5-7 days 1
   • Advantages: Once-daily dosing, excellent coverage against resistant S. pneumoniae, H. influenzae, and M. catarrhalis
   • Better tolerated than amoxicillin-clavulanate (7.4% vs 21.2% adverse events) 2

2. Alternative Cephalosporins

   • Cefuroxime 250-500 mg twice daily for 5-7 days 1, 3
   • Cefpodoxime 200-400 mg twice daily for 5-7 days 1, 3
   • Cefdinir 300-600 mg twice daily for 5-7 days 1, 3

3. For Penicillin-Allergic Patients

   • Clarithromycin or azithromycin may be considered, though they have lower efficacy against resistant pathogens 3
   • Clarithromycin has shown comparable efficacy to amoxicillin/clavulanate with fewer gastrointestinal side effects 4

Adjunctive Treatments

While changing antibiotics, also consider:

• Intranasal corticosteroids to reduce inflammation 1
• Saline nasal irrigation to improve mucus clearance 1
• Oral or topical decongestants (short-term use) 1
• Acetaminophen or ibuprofen for pain and fever 1
• Adequate hydration 1
• Avoidance of known allergens or irritants 1

When to Consider Referral

Consider referral to an otolaryngologist if:

• Symptoms persist despite appropriate second-line antibiotic therapy 1
• Signs of complications develop (orbital involvement, severe pain, persistent fever) 1, 5
• Symptoms persist beyond 3 weeks despite appropriate antibiotic therapy 1

Common Pitfalls to Avoid

• Failing to identify patients who need high-dose therapy initially (age <2 or >65 years, recent antibiotic use, immunocompromised state, etc.) 1
• Not addressing underlying conditions like allergic rhinitis or immunodeficiency 1
• Inadequate duration of treatment or poor patient adherence
• Missing complications that require immediate specialist attention
• Not considering resistant pathogens (penicillin-resistant S. pneumoniae, beta-lactamase-producing H. influenzae and M. catarrhalis) 6, 3

Remember that patients should show clinical improvement within 72 hours of starting the new antibiotic. If no improvement is seen, consider further antibiotic changes or immediate specialist referral 1.