What is the next step for a patient who has failed oral Augmentin (amoxicillin/clavulanate)?

Next Steps After Augmentin Failure

For patients who have failed oral Augmentin (amoxicillin/clavulanate), the next step should be treatment with a respiratory fluoroquinolone such as levofloxacin or moxifloxacin for 5-7 days. 1

Assessment of Treatment Failure

• Treatment failure is defined as worsening of symptoms or lack of clinical improvement within 7 days after diagnosis and initiation of antibiotic therapy 2, 1
• Before changing antibiotics, confirm the original diagnosis by reviewing presenting symptoms and ensuring they match the clinical picture of the suspected infection 2
• Consider potential causes of treatment failure, including resistant bacterial pathogens, poor medication adherence, or incorrect diagnosis 1, 3

Antibiotic Options After Augmentin Failure

First Choice:

• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) for 5-7 days provide excellent coverage against resistant strains of common pathogens 1, 2
• These agents are particularly effective for respiratory infections where S. pneumoniae or H. influenzae with reduced susceptibility are suspected 2, 1

Alternative Options:

• High-dose amoxicillin-clavulanate (2g every 12 hours) may be considered if fluoroquinolones are contraindicated 1, 4
• For penicillin-allergic patients with non-type I hypersensitivity, consider combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) 2

Specific Recommendations by Infection Type

For Sinusitis:

• Respiratory fluoroquinolones are recommended for patients who fail initial therapy with amoxicillin-clavulanate 2, 1
• Consider adding intranasal corticosteroids to reduce mucosal inflammation and improve sinus drainage 1

For Respiratory Tract Infections:

• For community-acquired pneumonia after Augmentin failure, an intravenous combination of a broad-spectrum β-lactamase stable antibiotic (such as cefuroxime or ceftriaxone) together with a macrolide is preferred 2
• For COPD exacerbations, respiratory fluoroquinolones are recommended after failure of first-line therapy 2

For Streptococcal Infections:

• For patients with streptococcal pharyngitis who fail penicillin therapy, options include narrow-spectrum cephalosporins, clindamycin, or amoxicillin-clavulanate 2

Monitoring Response to New Treatment

• Clinical improvement should be expected within 3-5 days of starting appropriate therapy 1
• If symptoms worsen after 48-72 hours or fail to improve after 3-5 days on the new antibiotic, further evaluation is needed 2, 1
• Consider imaging studies if there is no response to second-line therapy to rule out complications or alternative diagnoses 2

When to Consider Specialist Referral

• If the patient fails to respond to second-line therapy (respiratory fluoroquinolone) 1
• For recurrent infections (typically 3 or more episodes per year) 1
• When complications such as orbital or intracranial spread of infection are suspected 2

Important Caveats and Pitfalls

• Avoid macrolides (azithromycin, clarithromycin) as second-line agents due to their relatively weak activity against penicillin-resistant H. influenzae and S. pneumoniae 1
• Older fluoroquinolones (e.g., ciprofloxacin) have limited activity against S. pneumoniae and should not be used for respiratory infections 2
• Cefixime and ceftibuten have poor activity against S. pneumoniae and should not be used as monotherapy 1
• Remember that some treatment failures may be due to non-infectious causes or viral infections that will not respond to antibiotics 3