What antibiotic can be added to Augmentin (amoxicillin-clavulanate) for the treatment of mild community-acquired pneumonia?

From the Guidelines

For mild pneumonia, adding a macrolide such as azithromycin to Augmentin (amoxicillin-clavulanate) is recommended, as it provides coverage against atypical pathogens like Mycoplasma pneumoniae and Chlamydophila pneumoniae. According to the American Thoracic Society and Infectious Diseases Society of America guidelines 1, combination therapy with a macrolide is a strong recommendation for outpatient adults with comorbidities. Azithromycin is typically given as 500mg on day 1, followed by 250mg daily for 4 more days. This combination therapy ensures broader coverage of potential respiratory pathogens, which is particularly valuable when the specific causative organism is unknown.

When taking these medications, patients should complete the full course even if symptoms improve, take azithromycin on an empty stomach or at least 1 hour before or 2 hours after meals. The guidelines also suggest that doxycycline 100mg twice daily can be used as an alternative, but the quality of evidence is lower compared to macrolides 1.

The choice of antibiotic add-on to Augmentin should be based on the patient's comorbidities, risk factors for antibiotic-resistant pathogens, and local resistance patterns. However, based on the most recent and highest quality study 1, adding a macrolide such as azithromycin to Augmentin is the recommended approach for mild pneumonia. Key points to consider when prescribing this combination include:

• Completing the full course of antibiotics even if symptoms improve
• Taking azithromycin on an empty stomach or at least 1 hour before or 2 hours after meals
• Taking doxycycline with food to minimize stomach upset
• Advising patients to use sun protection when taking doxycycline due to increased sun sensitivity.

From the FDA Drug Label

DOSAGE & ADMINISTRATION SECTION Adults Infection *Recommended Dose/Duration of Therapy *DUE TO THE INDICATED ORGANISMS (See INDICATIONS AND USAGE.) Community-acquired pneumonia (mild severity) Treatment of pneumonia In the treatment of pneumonia, azithromycin has only been shown to be safe and effective in the treatment of community-acquired pneumonia due to Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy

Antibiotic Add-on to Augmentin for Mild Pneumonia:

• Azithromycin can be used as an add-on to augmentin for mild pneumonia, as it has been shown to be safe and effective in the treatment of community-acquired pneumonia due to certain organisms.
• The recommended dose of azithromycin for adults with community-acquired pneumonia (mild severity) is 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2.
• However, it is essential to note that azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia) 2.

From the Research

Antibiotic Add-on to Augmentin for Mild Pneumonia

• The efficacy of adding an antibiotic to Augmentin (amoxicillin-clavulanate) for the treatment of mild pneumonia has been studied in several clinical trials 3, 4, 5, 6, 7.
• A study published in 2008 compared the efficacy of azithromycin 1g once daily for 3 days with amoxicillin-clavulanate 875/125 mg twice daily for 7 days in the treatment of community-acquired pneumonia, and found that azithromycin was at least as effective as amoxicillin-clavulanate 3.
• Another study published in 2007 compared the efficacy of levofloxacin with a combination of amoxicillin-clavulanate and clarithromycin in the treatment of hospitalized patients with community-acquired pneumonia, and found that levofloxacin was at least as effective as the combination therapy 4.
• A study published in 1999 compared the efficacy of twice-daily amoxycillin/clavulanate with three times daily amoxycillin/clavulanate in the treatment of community-acquired pneumonia, and found that the twice-daily regimen was as effective as the three times daily regimen 5.
• A study published in 2011 evaluated the efficacy and safety of amoxicillin-clavulanic acid 1000/125mg twice daily extended release (XR) tablet for the treatment of bacterial community-acquired pneumonia in adults, and found that it was clinically effective and safe 6.
• A study published in 2003 compared the safety and efficacy of clarithromycin and amoxicillin/clavulanic acid in patients with community-acquired pneumonia due to penicillin-resistant and/or macrolide-resistant Streptococcus pneumoniae, and found that clarithromycin was similar to amoxicillin/clavulanic acid in terms of clinical cure rates and pathogen eradication rates 7.

Potential Add-on Antibiotics

• Azithromycin: may be considered as an add-on to Augmentin for the treatment of mild pneumonia, based on the study published in 2008 3.
• Levofloxacin: may be considered as an add-on to Augmentin for the treatment of mild pneumonia, based on the study published in 2007 4.
• Clarithromycin: may be considered as an add-on to Augmentin for the treatment of mild pneumonia, based on the study published in 2003 7.