What can be added to Augmentin (amoxicillin/clavulanate) for more coverage?

Antibiotic Options to Add to Augmentin for Enhanced Coverage

When additional coverage beyond Augmentin (amoxicillin/clavulanate) is needed, the most appropriate agent to add depends on the specific clinical scenario, with macrolides being the most commonly recommended addition for respiratory infections.

Understanding Augmentin's Coverage

• Augmentin provides broad-spectrum coverage against many common pathogens including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and beta-lactamase producing organisms 1
• It is effective against many respiratory, skin, and urinary tract infections as a standalone agent 2
• Despite its broad coverage, certain pathogens may require additional antimicrobial agents 3

When to Add Additional Coverage to Augmentin

For Community-Acquired Pneumonia:

• For outpatients with cardiopulmonary disease or other modifying factors, add a macrolide (azithromycin or clarithromycin) or doxycycline to Augmentin to cover atypical pathogens 3
• This combination provides coverage for both typical pathogens (via Augmentin) and atypical pathogens like Mycoplasma pneumoniae and Chlamydia pneumoniae (via macrolide/doxycycline) 3
• For hospitalized patients with CAP, a beta-lactam (like Augmentin) plus a macrolide is recommended to ensure adequate coverage 3

For COPD Exacerbations:

• In patients with severe COPD exacerbations (Group C patients), particularly those with risk factors for Pseudomonas aeruginosa or antibiotic resistance, consider adding agents with pseudomonal coverage 3
• For Group B COPD patients, respiratory fluoroquinolones (levofloxacin, moxifloxacin) can be considered as alternatives to Augmentin or added for broader coverage 3

For Acute Bacterial Rhinosinusitis:

• For patients with mild disease who fail initial therapy with Augmentin, consider adding or switching to a respiratory fluoroquinolone (gatifloxacin, levofloxacin, moxifloxacin) 3
• For moderate disease or recent antibiotic use, combination therapy with adequate gram-positive and gram-negative coverage may be appropriate 3

Specific Agents to Consider Adding

For Atypical Pathogen Coverage:

• Macrolides: Azithromycin or clarithromycin are preferred over erythromycin due to better tolerability and coverage of H. influenzae 3
• Doxycycline: An alternative to macrolides, particularly useful in patients with macrolide allergies 3

For Resistant Pathogens:

• Respiratory fluoroquinolones: Levofloxacin, moxifloxacin provide excellent coverage against resistant S. pneumoniae and H. influenzae 3
• Ceftriaxone: For parenteral therapy when oral agents are insufficient 3

For Anaerobic Coverage:

• Metronidazole: Can be added when anaerobic coverage is needed, particularly in aspiration pneumonia 3
• Clindamycin: Alternative for anaerobic coverage, particularly useful in lung abscess 3

Important Caveats and Considerations

• Avoid combining Augmentin with cefixime or other similar cephalosporins as this provides redundant coverage without additional benefit 4
• Consider local resistance patterns when selecting additional agents 3
• For patients with penicillin allergies, alternative regimens should be considered rather than adding to Augmentin 3
• When switching therapy due to treatment failure, consider the limitations in coverage of the initial agent 3

Dosing Considerations

• Augmentin can be dosed twice daily (875/125 mg) with similar efficacy to three-times-daily dosing, which may improve compliance when combined with other antibiotics 5
• For severe infections, high-dose Augmentin formulations (2000/125 mg twice daily for adults) may be more appropriate than adding another agent 1

Remember that antibiotic selection should always consider local resistance patterns, patient-specific factors, and the suspected pathogens based on the clinical presentation.