What is a suitable oral (PO) alternative to Augmentin (amoxicillin/clavulanate)?

Oral Alternatives to Augmentin (Amoxicillin/Clavulanate)

The best oral alternative to Augmentin depends on the specific infection and patient allergy status: for respiratory tract infections, use cefuroxime axetil, cefpodoxime proxetil, or respiratory fluoroquinolones (levofloxacin/moxifloxacin); for penicillin-allergic patients without anaphylaxis history, second or third-generation cephalosporins are appropriate; for true Type I hypersensitivity, use respiratory fluoroquinolones or macrolides depending on the infection site.

Algorithm for Selecting Augmentin Alternatives

Step 1: Identify the Infection Type

Respiratory Tract Infections (Sinusitis, Pneumonia, Bronchitis):

• Second-generation cephalosporins are guideline-recommended first-line alternatives 1:

  • Cefuroxime axetil 1.5g IV q8h or appropriate oral dosing 1
  • Demonstrated equivalent efficacy to Augmentin in upper respiratory infections with 97% success rate 2

• Third-generation cephalosporins (excluding cefixime) 1:

  • Cefpodoxime proxetil: 8-10 mg/kg/day in 2 divided doses for pediatrics, adult dosing per indication 3
  • Cefotiam-hexetil 1
  • Critical caveat: Cefixime is specifically contraindicated for sinusitis due to poor pneumococcal coverage 4

• Respiratory fluoroquinolones for moderate-severe disease or treatment failure 1:

  • Levofloxacin 750 mg PO daily 1
  • Moxifloxacin 400 mg PO daily 1
  • Reserve for complicated sinusitis (frontal, ethmoidal, sphenoidal) or first-line treatment failure 1

Pediatric Respiratory Infections:

• High-dose amoxicillin alone (90 mg/kg/day in 2 doses) if no beta-lactamase producers suspected 1
• Cefdinir, cefpodoxime proxetil, or cefuroxime axetil for penicillin-intolerant children 1
• Azithromycin (10 mg/kg day 1, then 5 mg/kg days 2-5) for atypical pathogens or beta-lactam allergy 1

Step 2: Assess Penicillin Allergy Status

Non-Type I Hypersensitivity (rash without anaphylaxis):

• Cephalosporins are safe and appropriate 5
• First-generation cephalosporins acceptable for streptococcal/staphylococcal infections 5
• Second/third-generation cephalosporins preferred for respiratory pathogens 1

Type I Hypersensitivity (anaphylaxis, angioedema, urticaria):

• Avoid all cephalosporins due to up to 10% cross-reactivity risk 6, 5
• Use respiratory fluoroquinolones (levofloxacin 750 mg or moxifloxacin 400 mg daily) 1
• Macrolides (azithromycin, clarithromycin) for atypical coverage 1
• Pristinamycin for beta-lactam allergic patients in sinusitis 1

Step 3: Consider Pathogen-Specific Coverage

For Beta-Lactamase Producers (H. influenzae, M. catarrhalis):

• Augmentin specifically targets these organisms 7, 8, 9
• Alternatives must maintain this coverage:
  • Cefuroxime axetil 1, 2
  • Cefpodoxime proxetil 3
  • Respiratory fluoroquinolones 1

For Penicillin-Resistant S. pneumoniae:

• High-dose formulations required 1, 9
• Respiratory fluoroquinolones provide reliable coverage 1
• Ceftriaxone or cefotaxime for severe infections 1

For MRSA (if suspected):

• Add vancomycin, linezolid, or clindamycin to any regimen 1
• Levofloxacin or moxifloxacin have some MRSA activity 1

Step 4: Match Duration to Infection

Standard durations:

• Sinusitis: 7-10 days (cefuroxime/cefpodoxime can be 5 days) 1
• Community-acquired pneumonia: 5-7 days if clinical stability achieved 1
• Pharyngitis: 10 days for first-generation cephalosporins, 5 days for cefpodoxime 5, 3

Critical Pitfalls to Avoid

Do not use these alternatives:

• Cefixime for any respiratory infection—lacks pneumococcal coverage 4
• Macrolides alone for suspected pneumococcal pneumonia—41% erythromycin resistance in community settings 6
• TMP/SMX for respiratory infections—20-25% bacterial failure rate 1
• First-generation cephalosporins for H. influenzae or M. catarrhalis infections—inadequate coverage 5

Fluoroquinolone stewardship concerns:

• May delay tuberculosis diagnosis in endemic areas 1
• Reserve for treatment failure or severe disease 1
• Consider local resistance patterns before empiric use 4

Dental infections require different approach:

• Phenoxymethylpenicillin or amoxicillin alone are first-line, not cephalosporins 6
• Surgical drainage is mandatory; antibiotics without source control fail 6

Specific Dosing Recommendations

Adults:

• Cefuroxime axetil: 250-500 mg PO q12h 1
• Cefpodoxime proxetil: 200-400 mg PO q12h 1
• Levofloxacin: 750 mg PO daily 1
• Moxifloxacin: 400 mg PO daily 1

Pediatrics:

• Cefpodoxime: 8-10 mg/kg/day divided q12h (max 400 mg/dose) 3
• Cefuroxime axetil: age-appropriate dosing per guidelines 1
• Azithromycin: 10 mg/kg day 1, then 5 mg/kg days 2-5 (max 500 mg day 1,250 mg days 2-5) 1