Is Augmentin (amoxicillin/clavulanate) for 10 days an appropriate treatment choice for a patient with Haemophilus influenzae type B (HiB) infection presenting with a cough and a sensation of something stuck in the throat?

Treatment of Haemophilus influenzae Type B (HiB) Infection

Augmentin (amoxicillin-clavulanate) for 10 days is NOT the appropriate first-line treatment for confirmed Haemophilus influenzae type B infection presenting with respiratory symptoms; third-generation cephalosporins (ceftriaxone or cefotaxime) are the guideline-recommended first-line agents for invasive HiB disease. 1, 2

Why Augmentin is Suboptimal for This Case

Guideline-recommended therapy for HiB infections:

• Ceftriaxone 2g IV every 12 hours for 10 days is the first-line treatment for H. influenzae type b infections, including meningitis and other invasive disease 1, 2
• Cefotaxime 2g IV every 6 hours for 10 days is an equally acceptable alternative 1, 2
• Third-generation cephalosporins are preferred due to excellent CSF penetration and activity against both β-lactamase-producing and non-producing strains 2

Augmentin's role is limited:

• Amoxicillin-clavulanate is FDA-approved for lower respiratory tract infections caused by beta-lactamase-producing H. influenzae, but this indication is for non-typeable strains in less severe infections 3
• The FDA label does not specifically address invasive HiB disease 3
• While Augmentin has activity against beta-lactamase-producing H. influenzae, it is not the guideline-recommended agent for confirmed HiB 3

Critical Clinical Considerations

Assess disease severity immediately:

• The presentation of "cough and feeling of something stuck in throat" raises concern for epiglottitis or supraglottitis, which can be life-threatening 4, 5
• Look for stridor, respiratory distress, tachycardia, tachypnea, rapid symptom onset, or shortness of breath—these predict need for airway intervention 5
• Odynophagia (100%), dysphagia (85%), and voice change (75%) are the most common presenting symptoms in supraglottitis 5
• 21% of supraglottitis patients require airway intervention (intubation or tracheotomy) 5

If this is invasive HiB disease:

• Switch immediately to ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours for 10 days 1, 2
• Consider ICU admission if any signs of airway compromise are present 5
• Add corticosteroids—associated with shorter ICU and overall length of stay in supraglottitis 5

If this is non-invasive respiratory colonization/infection:

• Augmentin may be acceptable for mild lower respiratory tract infection caused by beta-lactamase-producing H. influenzae 3
• However, the 10-day duration is appropriate 1, 2

Chemoprophylaxis Considerations

Index patient management:

• If the patient was treated with Augmentin (not ceftriaxone/cefotaxime) and is aged <2 years, rifampin prophylaxis should be given prior to discharge 1, 2
• Ceftriaxone and cefotaxime eradicate HiB colonization, so prophylaxis is not needed if these agents are used 1

Household contact prophylaxis:

• Rifampin chemoprophylaxis (20 mg/kg once daily, maximum 600 mg, for 4 days) is recommended for all household contacts if there are members aged <4 years who are not fully vaccinated 1, 2
• This also applies to immunocompromised household members aged <18 years regardless of vaccination status 1
• Family carriers should be identified, as they may be a source of reinfection 6

Common Pitfalls to Avoid

Do not miss invasive disease:

• HiB can cause meningitis, epiglottitis, and other life-threatening invasive infections 1, 2
• Brain abscess is a rare but serious complication that can occur even after apparently successful treatment of meningitis 7
• If clinical improvement does not occur within 48-72 hours, evaluate for antibiotic resistance or alternative diagnoses 2

Do not forget contact prophylaxis:

• Failure to provide appropriate chemoprophylaxis to close contacts can result in secondary cases 2
• Secondary attack rates are highest among household contacts aged <12 months (6%) and <24 months (3%) 1

Vaccination status matters:

• In the post-Hib vaccine era, the mean age of epiglottitis patients has increased from 5.8 years (1992-1997) to 11.6 years (1998-2002) 4
• H. influenzae was cultured in patients with up-to-date immunizations, suggesting vaccine failure or non-type b strains 4