Next Best Antibiotic for Recurrent Tonsillitis After Augmentin Treatment
For recurrent tonsillitis after treatment with Augmentin (amoxicillin/clavulanate), clindamycin is the most effective next-line antibiotic therapy. 1, 2
Rationale for Clindamycin Selection
- Clindamycin has demonstrated superior clinical and microbiological efficacy in treating recurrent streptococcal pharyngotonsillitis compared to penicillin-based antibiotics 2
- The Infectious Diseases Society of America (IDSA) specifically recommends clindamycin as a strong, high-quality evidence option for treating chronic carriers of Group A Streptococci at a dosage of 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 1
- Clindamycin has excellent gram-positive coverage, making it particularly effective against Streptococcus pyogenes, the most common bacterial cause of tonsillitis 1
- Studies have shown that clindamycin can effectively eradicate bacteria from the tonsils and prevent future episodes of acute pharyngotonsillitis in patients with recurrent disease 2
Alternative Options Based on Patient Factors
If clindamycin cannot be used (due to allergy or other contraindications):
Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) - particularly effective for adults with moderate disease who have recently received antibiotics 1
Cefdinir - A good alternative with high patient acceptance, especially in cases of non-severe penicillin allergy (e.g., rash) 1, 3
Combination therapy options:
Special Considerations
For beta-lactam allergic patients: Clindamycin remains the preferred option. If clindamycin is contraindicated, macrolides like azithromycin can be considered, though they have lower efficacy rates (77-81% vs. 90-92% for respiratory fluoroquinolones) 1, 4
For children: High-dose amoxicillin/clavulanate (90 mg/6.4 mg per kg per day) may be tried at a different dosing schedule if the initial treatment failure was potentially due to compliance issues 1
Caution with rifampin combinations: Rifampin should not be used as monotherapy, should be limited to 10-14 days, and has significant drug interactions due to cytochrome p450 induction 1
Follow-up Recommendations
- Patients should be reassessed after 72 hours of new antibiotic therapy 1
- If symptoms persist despite appropriate second-line therapy, consider:
Common Pitfalls to Avoid
- Failing to distinguish between true recurrent infection and chronic carriage with intercurrent viral infection 1
- Using macrolides in areas with high clarithromycin resistance among Group A streptococci 5
- Continuing to use beta-lactam antibiotics after failure without considering alternative mechanisms of resistance 1
- Not considering the possibility of non-Group A streptococcal pathogens such as Staphylococcus aureus or anaerobes that may be beta-lactamase producers 6
By following this evidence-based approach, you can effectively manage recurrent tonsillitis after Augmentin failure while minimizing the risk of further treatment failures and complications.