What is an alternative to Augmentin (amoxicillin-clavulanate) for a dog bite in a patient with a penicillin allergy?

From the Guidelines

For a dog bite in a patient with penicillin allergy, doxycycline is the recommended alternative to Augmentin, with a typical adult dosage of 100 mg twice daily for 5-7 days. This recommendation is based on the guidelines for the diagnosis and management of skin and soft tissue infections, which suggest doxycycline as an effective option for animal bites, particularly due to its excellent activity against Pasteurella multocida, a common pathogen in dog bites 1.

Key Considerations

• The choice of antibiotic should cover a broad spectrum of pathogens, including aerobic and anaerobic bacteria, as dog bites can introduce a mix of these into the wound.
• Doxycycline is specifically noted for its good activity against Pasteurella multocida, as well as some streptococci, although resistance can vary 1.
• Other alternatives, such as trimethoprim-sulfamethoxazole (TMP-SMX) combined with clindamycin, or a fluoroquinolone (like ciprofloxacin or levofloxacin) combined with clindamycin, can be considered based on the specific circumstances of the bite and the patient's health status.
• It's crucial to initiate antibiotic therapy as soon as possible after the bite, ideally within 24 hours, to prevent infection.
• Wound care, including thorough cleaning with soap and water, and consideration of tetanus prophylaxis if the patient's immunization status is not up to date, are also important aspects of management.

Management Approach

• For severe bites, or those involving the face, hands, or joints, or if the patient is immunocompromised, intravenous antibiotics may be necessary, and prompt evaluation in an emergency setting is recommended.
• The guidelines from the Infectious Diseases Society of America provide a comprehensive approach to managing skin and soft tissue infections, including those resulting from animal bites, emphasizing the importance of appropriate antibiotic selection based on the likely pathogens involved 1.

From the FDA Drug Label

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections. Staphylococci: Serious respiratory tract infections; serious skin and soft tissue infections.

For a dog bite in a patient with a penicillin allergy, clindamycin can be considered as an alternative to Augmentin, as it is effective against susceptible strains of streptococci, staphylococci, and anaerobic bacteria, which may be involved in dog bite infections 2.

• Key considerations:
  • Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin.
  • The use of clindamycin should be reserved for penicillin-allergic patients or other patients for whom a penicillin is inappropriate.
• Doxycycline may also be considered as an alternative for the treatment of dog bites, especially for infections caused by susceptible strains of bacteria, but the provided label does not directly address its use for this specific indication 3.

From the Research

Alternatives to Augmentin for Dog Bites in Patients with Penicillin Allergy

• For patients with a penicillin allergy, alternative antibiotics to Augmentin (amoxicillin-clavulanate) for dog bites can be considered based on the severity of the allergy and the patient's medical history 4, 5.
• Patients with a low-risk allergy history may be suitable for an oral rechallenge with low-dose penicillin or alternative beta-lactam antibiotics, such as cephalosporins, under supervised medical care 6, 7.
• Cephalosporins are a relatively safe treatment option for patients with a low risk of severe allergic reactions, with a cross-reactivity rate of approximately 1-2% 8, 7.
• Other alternative antibiotics, such as clindamycin, doxycycline, or azithromycin, may also be considered for patients with a penicillin allergy, depending on the severity of the infection and the patient's medical history 5.

Evaluation of Penicillin Allergy

• A thorough evaluation of the patient's penicillin allergy history is essential to determine the best course of treatment 4, 8.
• Penicillin skin testing and graded-dose challenge can be used to assess the patient's allergy and determine their tolerance to penicillin or alternative beta-lactam antibiotics 6, 8.
• Patients with a high-risk allergy history, such as anaphylaxis or positive penicillin skin testing, should be avoided from penicillin and alternative beta-lactam antibiotics 4, 5.