Management of a 32-Month-Old Child Vomiting After Augmentin
Give a single dose of ceftriaxone 50 mg/kg intramuscularly or intravenously, then reassess at 24 hours to determine if oral therapy can be resumed or if additional parenteral doses are needed. 1
Immediate Management Strategy
Administer ceftriaxone as rescue therapy when a child cannot tolerate oral antibiotics due to vomiting. The American Academy of Pediatrics specifically recommends ceftriaxone 50 mg/kg (single dose, IM or IV) for children who are vomiting, unable to tolerate oral medication, or unlikely to be adherent to initial antibiotic doses 1, 2. This provides excellent coverage against the three major bacterial pathogens in pediatric sinusitis (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) with 95-100% susceptibility 2.
Dosing Calculation
For a 32-month-old child (approximately 13-15 kg average weight), the dose would be:
- Ceftriaxone 650-750 mg as a single IM or IV dose 1, 2
- Maximum dose is 2 grams, but this ceiling is not relevant for toddlers 2
24-Hour Reassessment Protocol
Evaluate clinical response at 24 hours to determine next steps 1, 2:
If clinical improvement occurs: Switch to oral high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses) to complete a 10-14 day total course 1, 2, 3
If still significantly febrile or symptomatic: Administer additional parenteral ceftriaxone doses before transitioning to oral therapy 1, 2
Critical Considerations for Augmentin Intolerance
Distinguish Between Allergy and GI Side Effects
The vomiting may represent:
Gastrointestinal intolerance (most common): The clavulanate component causes diarrhea and GI upset in a significant proportion of children 4, 5. This is not an allergy and does not preclude future use of amoxicillin or other beta-lactams.
True hypersensitivity reaction: Immediate Type I reactions (anaphylaxis, urticaria, angioedema) would contraindicate all penicillins 1. However, isolated vomiting without other allergic symptoms is almost never a true allergy 4.
Reducing GI Side Effects When Resuming Oral Therapy
Take medication with food or a meal to minimize gastrointestinal upset 4. The FDA label explicitly states that each dose should be taken with a meal or snack to reduce the possibility of GI disturbance 4.
Use the high-dose formulation (14:1 ratio) rather than conventional formulations when resuming oral therapy. The 90/6.4 mg/kg/day formulation (Augmentin ES-600) provides the same total daily clavulanate dose as lower-dose formulations but with higher amoxicillin, resulting in less diarrhea and better tolerability 5, 6, 7.
Alternative Oral Antibiotics If Augmentin Cannot Be Resumed
If the child continues to vomit with attempts to resume Augmentin after ceftriaxone:
Second-line option: Cefdinir, cefpodoxime, or cefuroxime 1, 8, 2
- These third-generation cephalosporins provide excellent coverage and are better tolerated in children with GI sensitivity to clavulanate 1, 8
- Cefdinir is preferred due to high patient acceptance 1
Do NOT use: Azithromycin or other macrolides have 20-25% resistance rates and are explicitly contraindicated as first-line therapy 1, 8
Treatment Duration and Follow-Up
- Total treatment duration: 10-14 days or until symptom-free for 7 days 1, 8
- Reassess at 72 hours if no improvement to avoid treatment failure 1, 2, 3
- Red flags requiring immediate imaging/specialist consultation: Periorbital swelling, impaired extraocular movements, severe headache with photophobia, seizures, or focal neurologic findings 2
Common Pitfall to Avoid
Do not assume vomiting equals penicillin allergy. The vast majority of children who vomit with Augmentin have GI intolerance from clavulanate, not true allergy 4, 5. Mislabeling this as "penicillin allergy" unnecessarily restricts future antibiotic options and leads to use of broader-spectrum, less effective alternatives 1, 8. If there are no other signs of allergic reaction (rash, urticaria, angioedema, bronchospasm), this is GI intolerance, not allergy 1, 4.