Cefuroxime with Clindamycin After Augmentin Failure
Yes, cefuroxime (a second-generation cephalosporin) with clindamycin is an appropriate alternative for acute sinusitis that has failed to respond to Augmentin, particularly when anaerobic pathogens or resistant organisms are suspected. 1
When to Use This Combination
The 2005 Joint Task Force guidelines specifically recommend this approach for sinusitis that fails to improve after 21-28 days of initial antibiotic treatment. 1 The rationale is:
- Cefuroxime provides coverage against β-lactamase-producing H. influenzae (present in ~50% of cases), M. catarrhalis (90-100% β-lactamase producers), and penicillin-resistant S. pneumoniae 1
- Clindamycin adds anaerobic coverage for Prevotella species and other anaerobes that may emerge in protracted or severe cases 1
Specific Dosing Recommendations
- Cefuroxime axetil: 250-500 mg twice daily for 10-14 days 1, 2
- Clindamycin: Added when anaerobic pathogens are suspected (typical adult dose 300-450 mg three times daily) 1
Clinical Decision Algorithm
Use cefuroxime alone if:
- Patient has failed initial amoxicillin therapy after 3-5 days 1
- You suspect β-lactamase-producing organisms 1
- Patient is in a region with high antibiotic resistance 1
Add clindamycin to cefuroxime if:
- Symptoms persist beyond 21-28 days despite initial antibiotics 1
- Severe or protracted disease suggests anaerobic involvement 1
- Patient has dental-related sinusitis (higher anaerobic likelihood) 1
Evidence Supporting This Approach
Cefuroxime axetil has been extensively studied in sinusitis with clinical cure rates of 79-100% and bacteriologic eradication rates of 84-100% across 18 clinical trials involving 1,516 patients. 2 Direct comparative studies show cefuroxime achieves 85% clinical success versus 82% with amoxicillin-clavulanate, with significantly fewer adverse events (3% vs 13%, particularly less diarrhea). 3
Important Caveats
Warn patients about clindamycin risks: Patients must be instructed to contact you immediately for any diarrhea or bloody stools due to risk of pseudomembranous colitis (C. difficile infection). 1 This is the most critical safety consideration with this regimen.
Consider respiratory fluoroquinolones instead (levofloxacin 500 mg daily or moxifloxacin 400 mg daily) if you suspect frontal, fronto-ethmoidal, or sphenoidal involvement where complications are more likely. 4 These provide broader coverage without needing combination therapy, though they should be reserved for treatment failures or complicated disease. 4
Alternative to Combination Therapy
If you want to avoid combination therapy, high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, maximum 2 g every 12 hours) is the preferred single-agent alternative for Augmentin failure, as it overcomes most penicillin-resistant S. pneumoniae. 1, 5 This may be simpler than cefuroxime plus clindamycin unless you have strong clinical suspicion for anaerobes.
Treatment Duration and Follow-Up
Continue treatment for 10-14 days total, or until the patient is symptom-free for 7 days. 1 If no improvement occurs within 3-5 days of the new regimen, obtain sinus CT imaging and consider ENT referral for possible structural abnormalities or complications. 1, 4