What are the contraindications for using clavulanate (Augmentin)?

Contraindications to Using Clavulanate (Augmentin)

Clavulanate is contraindicated in patients with a history of serious hypersensitivity reactions to amoxicillin, clavulanate, or other beta-lactam antibiotics, and in patients with previous cholestatic jaundice/hepatic dysfunction associated with amoxicillin-clavulanate. 1

Absolute Contraindications

• Serious hypersensitivity reactions to amoxicillin, clavulanate, or other beta-lactam antibiotics (including penicillins and cephalosporins) 1

  • Includes anaphylaxis and Stevens-Johnson syndrome 1
  • Recent data implicate amoxicillin-clavulanate in up to 80% of beta-lactam allergy cases 2
  • Clavulanate itself can be the specific allergen in approximately 32.7% of immediate allergic reactions to amoxicillin-clavulanate combinations 2

• Previous cholestatic jaundice or hepatic dysfunction associated with amoxicillin-clavulanate use 1

  • Amoxicillin-clavulanate can cause a predominantly cholestatic syndrome 3
  • This hepatic adverse effect appears to be reversible upon discontinuation of the drug 3
  • Fever and eosinophilia may be present, suggesting a hypersensitivity phenomenon contributing to hepatic dysfunction 3

Relative Contraindications and Precautions

• Gastrointestinal sensitivity: The clavulanate component limits the maximum daily dose due to its gastrointestinal adverse effects 4

  • Diarrhea or loose stools are the most common side effects 5
  • Nausea and vomiting may also occur but can be lessened by taking the medication with food 5

• Delayed hypersensitivity reactions: Non-immediate reactions to clavulanate can occur even in patients who previously tolerated it 6

  • These reactions may present as generalized itchy erythema days after completing therapy 6
  • May be T-cell mediated rather than IgE-mediated 6

Special Considerations

• Selective reactions: Patients may have selective reactions to clavulanate while tolerating amoxicillin 2

  • Diagnostic testing may be necessary to determine the specific component causing the reaction 2
  • Skin test sensitivity for clavulanate reactions is below 50%, making diagnosis challenging 2

• Co-sensitization: Some patients may be co-sensitized to both amoxicillin and clavulanate, requiring avoidance of both components 2

• Appropriate use: Amoxicillin-clavulanate should be reserved for infections with suspected beta-lactamase-producing bacteria 7

  • Using amoxicillin-clavulanate when amoxicillin alone would be effective exposes patients to unnecessary risks 7
  • Inappropriate use may contribute to bacterial resistance development 7

Clinical Implications

• For patients with contraindications to clavulanate but requiring antibiotic therapy, alternative options include:

  • For adults with penicillin allergy: doxycycline or respiratory fluoroquinolones (levofloxacin or moxifloxacin) 8
  • For children with non-type I penicillin allergy: clindamycin plus a third-generation oral cephalosporin 9

• When evaluating a patient with a history of reaction to amoxicillin-clavulanate, it's important to determine whether the reaction was to the amoxicillin component, the clavulanate component, or both 2