What are alternative antibiotics to Augmentin (amoxicillin-clavulanate) for patients with a hypersensitivity reaction to penicillin?

From the Guidelines

For patients with a penicillin allergy who cannot take Augmentin, doxycycline or a respiratory fluoroquinolone, such as levofloxacin or moxifloxacin, are recommended as alternative agents for empiric antimicrobial therapy. When considering alternatives to Augmentin for patients allergic to penicillin, it's crucial to weigh the severity of the allergy, the type of infection, and local resistance patterns.

• Doxycycline [ 1 ] is a viable option for many infections, given its broad-spectrum activity.
• Respiratory fluoroquinolones like levofloxacin or moxifloxacin [ 1 ] are also effective, especially for more severe infections, but their use should be judicious due to concerns about resistance and side effects.
• Combination therapy with clindamycin plus a third-generation oral cephalosporin (cefixime or cefpodoxime) [ 1 ] can be considered in adults with a history of non–type I hypersensitivity to penicillin.
• Macrolides and trimethoprim-sulfamethoxazole are generally not recommended for initial therapy of acute bacterial rhinosinusitis (ABRS) due to high resistance rates among common pathogens [ 1 ]. The choice of alternative antibiotic should prioritize coverage for the suspected pathogens while considering the patient's allergy history, comorbidities, and the infection site, always aiming to minimize morbidity, mortality, and improve quality of life.

From the FDA Drug Label

Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days). In a randomized, double blind, double-dummy controlled clinical trial of acute bacterial sinusitis, azithromycin (500 mg once daily for 3 days) was compared with amoxicillin/clavulanate (500/125 mg tid for 10 days).

Alternative to Augmentin: Azithromycin is a potential alternative to Augmentin for patients with a penicillin allergy.

• Key points:
  • Azithromycin has been shown to be effective in treating various bacterial infections, including pharyngitis, sinusitis, and chronic bronchitis.
  • It has been compared to penicillin and amoxicillin/clavulanate in clinical trials, demonstrating similar or superior efficacy in some cases.
  • The most common side effects of azithromycin are gastrointestinal, including diarrhea, vomiting, and abdominal pain. 2

From the Research

Alternatives to Augmentin for Patients with Penicillin Allergy

• For patients with a penicillin allergy, alternative antibiotics can be used, depending on the type of reaction and the specific condition being treated 3, 4.
• Azithromycin has been shown to be a safe alternative to penicillin and cephalosporin in patients allergic to these drugs 5.
• Other antibiotics that may be used as alternatives to Augmentin include fluoroquinolones and macrolides, although the choice of antibiotic will depend on the specific condition being treated and the patient's medical history 6, 7.
• It is essential to evaluate the patient's allergy history and determine the best course of treatment, as many patients who report a penicillin allergy may not have a clinically significant reaction 4, 6.

Considerations for Antibiotic Selection

• The selection of an alternative antibiotic should be based on the patient's medical history, the type of reaction they experienced, and the specific condition being treated 3, 4.
• Clinicians should consider the potential for cross-reactivity between penicillins and other beta-lactam antibiotics, such as cephalosporins 4, 7.
• Patients with a history of anaphylaxis or other severe reactions to penicillin should be treated with caution, and alternative antibiotics should be chosen carefully 4, 7.

Evaluation and Management of Penicillin Allergy

• Patients with a reported penicillin allergy should be evaluated to determine the likelihood of a clinically significant reaction 4, 6.
• Penicillin skin testing and graded challenge can be used to evaluate patients with a reported penicillin allergy 4, 7.
• Desensitization may be used in some cases where treatment with penicillins is essential 7.