What is the next step for a patient with worsening condition on Augmentin (amoxicillin/clavulanate)?

Management of Worsening Condition on Augmentin

If a patient worsens or fails to improve on Augmentin within 7 days of diagnosis, you must reassess to confirm the diagnosis, exclude other causes, detect complications, and change the antibiotic regimen. 1

Immediate Assessment Steps

When a patient deteriorates on Augmentin, perform the following evaluation:

• Confirm the original diagnosis by verifying the patient meets diagnostic criteria for acute bacterial rhinosinusitis (ABRS): purulent nasal drainage with nasal obstruction, facial pain/pressure/fullness, or both, persisting ≥10 days or worsening within 10 days after initial improvement 1
• Exclude alternative diagnoses including migraines, tension headaches, cluster headaches, temporomandibular joint disorder, allergic rhinitis, vasomotor rhinitis, deviated nasal septum, or nasal valve collapse 1
• Detect complications by examining for proptosis, visual changes, severe headache, abnormal extraocular movements, mental status changes, periorbital inflammation, edema, or erythema suggesting orbital or intracranial spread 1

Timing of Reassessment

• The 7-day cutpoint is evidence-based: 73-85% of ABRS patients show clinical improvement by 7-12 days, making earlier assessment premature and later assessment potentially dangerous 1
• Worsening at any time (progression of presenting symptoms or new symptoms) requires immediate reassessment regardless of the 7-day window 1

Antibiotic Change Strategy

For Patients Initially on Standard-Dose Amoxicillin/Clavulanate:

Switch to one of the following options:

• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) - these provide the best coverage for both S. pneumoniae and H. influenzae with 92% clinical efficacy and 100% bacteriologic efficacy 1
• High-dose amoxicillin/clavulanate (4g/250mg daily for adults; 90mg/6.4mg/kg/day for children) if not already used 1
• Ceftriaxone (91% clinical efficacy, 99% bacteriologic efficacy) 1
• Combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) for penicillin-allergic patients 1

For Penicillin-Allergic Patients:

• Doxycycline or respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1
• Avoid fluoroquinolones if the patient was on fluoroquinolone prophylaxis 1

Rationale for Treatment Failure

Treatment failures on Augmentin typically involve:

• Beta-lactamase-producing organisms with resistance to the initial antibiotic regimen 1
• Drug-resistant S. pneumoniae (DRSP) requiring higher amoxicillin doses or alternative agents 1, 2
• Misdiagnosis requiring imaging (CT scan) or nasal endoscopy if diagnosis remains uncertain after clinical reassessment 1

Critical Pitfalls to Avoid

• Do not wait beyond 7 days if the patient shows no improvement, as this delays effective therapy and risks complications 1
• Do not obtain routine imaging for uncomplicated ABRS unless complications or alternative diagnoses are suspected 1
• Do not continue the same antibiotic hoping for delayed response - bacterial resistance is the likely cause of failure 1
• Do not use macrolides (azithromycin, clarithromycin) as second-line agents due to poor coverage (77% clinical efficacy, 73% bacteriologic efficacy) 1

When to Consider Hospitalization or Specialty Referral

• Severe complications including orbital cellulitis, intracranial extension, or sepsis require immediate hospitalization 1
• Persistent treatment failure after appropriate antibiotic change warrants otolaryngology consultation, sinus aspiration for culture, or CT imaging 1
• Immunocompromised patients or those with prior sinus surgery require specialist evaluation 1