Co-amoxiclav (Augmentin) as Alternative Treatment for Tonsillitis After Clarithromycin Failure
Co-amoxiclav (Augmentin) is the recommended alternative treatment when clarithromycin fails in treating tonsillitis, as it provides broader coverage against potential beta-lactamase producing organisms and is effective against resistant strains. 1
Rationale for Switching to Co-amoxiclav
- Co-amoxiclav is specifically recommended as a preferred alternative when macrolides (such as clarithromycin) are ineffective for respiratory tract infections including tonsillitis 1
- Co-amoxiclav provides broader antimicrobial coverage than clarithromycin, particularly against beta-lactamase producing organisms that may be causing treatment failure 1
- The beta-lactamase inhibitor component (clavulanate) in co-amoxiclav addresses potential resistance mechanisms that might have caused clarithromycin failure 1
Dosing Recommendations
- For adults with tonsillitis after clarithromycin failure, co-amoxiclav 625 mg three times daily orally is the recommended dosage 1
- For children with tonsillitis after clarithromycin failure, co-amoxiclav should be dosed according to weight and age-appropriate guidelines 1
- The typical treatment duration for co-amoxiclav in tonsillitis is 7-10 days to ensure complete eradication of the causative organism 1
Evidence Supporting Co-amoxiclav Use
- Clinical studies have demonstrated that co-amoxiclav has superior clinical efficacy compared to penicillin alone in recurrent or persistent pharyngotonsillitis 2, 3
- Co-amoxiclav achieved a 95.7% clinical cure rate at 3-month follow-up in patients with recurrent pharyngotonsillitis 3
- Co-amoxiclav has shown excellent bacteriological eradication rates (94.4% at 12 days and 99.6% at 3 months) in patients with streptococcal pharyngotonsillitis 3
Alternative Options if Co-amoxiclav is Not Suitable
- If the patient has a penicillin allergy or co-amoxiclav is contraindicated, a tetracycline such as doxycycline (200 mg initially, then 100 mg once daily) is recommended for adults 1
- For patients who cannot tolerate either co-amoxiclav or tetracyclines, a fluoroquinolone with enhanced pneumococcal activity (e.g., levofloxacin 500 mg daily) may be considered 1
- Clindamycin has shown superior efficacy in recurrent streptococcal pharyngotonsillitis and can be considered as another alternative when other options are not suitable 2, 3
Clinical Considerations When Switching Antibiotics
- When switching from clarithromycin to co-amoxiclav, ensure there has been an adequate trial of clarithromycin (typically 5-7 days) before determining treatment failure 1, 4
- Consider obtaining throat cultures before switching antibiotics to confirm the presence of resistant organisms and guide therapy 1, 2
- Be aware that treatment failure with clarithromycin may be due to macrolide-resistant strains of Streptococcus pyogenes, which are increasingly common in some regions 5, 2
Monitoring After Switching to Co-amoxiclav
- Patients should show clinical improvement within 48-72 hours after starting co-amoxiclav 1
- If symptoms persist or worsen after 48-72 hours of co-amoxiclav therapy, reevaluation is necessary to consider other diagnoses or complications 1
- Monitor for common side effects of co-amoxiclav, particularly diarrhea, which occurs in approximately 5.6% of patients 3
By following these evidence-based recommendations, co-amoxiclav provides an effective alternative treatment option for patients with tonsillitis who have failed clarithromycin therapy.