What should be done for an 89-year-old female patient with acute bacterial sinusitis, who was prescribed Amoxicillin (amoxicillin) one week ago, and has developed severe diarrhea and persistent symptoms?

From the Guidelines

The patient should be reassessed and the antibiotic changed due to lack of improvement and development of severe diarrhea.

Reassessment and Antibiotic Change

• The patient was initially prescribed Amoxicillin one week ago and has not shown improvement, indicating treatment failure 1.
• The development of severe diarrhea may be a sign of Clostridioides difficile infection, a potential complication of antibiotic use, and warrants further evaluation.
• According to the clinical practice guideline, if the patient fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm acute bacterial rhinosinusitis (ABRS), exclude other causes of illness, and detect complications 1.
• If ABRS is confirmed, the clinician should change the antibiotic 1.
• The new antibiotic should be chosen based on its effectiveness against the most likely pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1.

Considerations for Antibiotic Choice

• Narrow-spectrum agents, such as amoxicillin-clavulanate, doxycycline, or trimethoprim-sulfamethoxazole, may be considered for initial antibiotic therapy 1.
• However, given the patient's recent use of amoxicillin and development of diarrhea, an alternative antibiotic with a different mechanism of action and spectrum of activity may be preferred.
• The patient's age, comorbidities, and potential allergies or intolerances should also be taken into account when selecting a new antibiotic.

From the FDA Drug Label

1. 3 Clostridioides difficile-Associated Diarrhea (CDAD) Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including amoxicillin, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile. C difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial use Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

The patient has developed severe diarrhea while being treated with amoxicillin for acute bacterial sinusitis. Given the development of diarrhea, CDAD must be considered.

• The amoxicillin may need to be discontinued if CDAD is suspected or confirmed.
• Appropriate fluid and electrolyte management and antibacterial treatment of C. difficile should be instituted as clinically indicated 2. The patient's persistent symptoms of sinusitis also need to be addressed, but the primary concern is the potential for CDAD.

From the Research

Patient Assessment

The patient is an 89-year-old female with acute bacterial sinusitis, who was prescribed Amoxicillin one week ago and has developed severe diarrhea and persistent symptoms.

• The patient's symptoms and age should be taken into consideration when determining the best course of action 3, 4, 5, 6, 7.
• The development of severe diarrhea may be a side effect of the Amoxicillin or a sign of a more serious infection 3, 6.

Treatment Options

• The initial treatment with Amoxicillin may not be effective, and alternative antibiotics may be necessary 3, 5, 7.
• Considering the patient's age and symptoms, a switch to a second-line antibiotic such as amoxicillin-clavulanate, cefuroxime, cefpodoxime, or cefdinir may be appropriate 3, 5.
• For patients with severe diarrhea, it may be necessary to consider alternative treatments that are less likely to cause gastrointestinal side effects 6.

Management of Symptoms

• Supportive care, including saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 7.
• The patient's symptoms and response to treatment should be closely monitored, and adjustments to the treatment plan made as necessary 4, 6.

Further Evaluation

• If the patient's symptoms persist or worsen, further evaluation, including imaging studies, may be necessary to rule out complications such as orbital cellulitis, meningitis, or abscess 7.
• Referral to an otolaryngologist may be considered if the patient's symptoms are severe or persistent 7.