In an 11‑month‑old infant with a few days of cough and cold, a one‑day fever, started on oral amoxicillin‑clavulanate but with poor compliance, now has a night‑time fever after five days and persistent cold symptoms while awaiting complete blood count and C‑reactive protein results, should we continue the current amoxicillin‑clavulanate course or switch to a different antibiotic?

Management of Recurrent Fever in an 11-Month-Old with Poor Antibiotic Compliance

Continue the current amoxicillin-clavulanate course and ensure proper administration rather than switching antibiotics, since the initial fever resolved within 24 hours, indicating likely bacterial susceptibility, and the recurrent fever after 5 days with poor compliance suggests inadequate drug exposure rather than treatment failure. 1

Clinical Assessment Framework

The clinical presentation fits a "worsening course" pattern—initial improvement followed by new fever—which is one of three diagnostic criteria for acute bacterial sinusitis in children according to the American Academy of Pediatrics 1. The key diagnostic features include:

• Persistent illness (>10 days of nasal discharge or cough without improvement) 1
• Worsening course (new or worsening symptoms after initial improvement) 1
• Severe onset (fever ≥39°C with purulent nasal discharge for ≥3 consecutive days) 1

Your patient demonstrates a worsening course, which mandates antibiotic therapy 1.

Why Continue Current Antibiotic Rather Than Switch

The rapid initial fever resolution within 24 hours strongly suggests the causative organism is susceptible to amoxicillin-clavulanate 2. The recurrence after 5 days with documented poor compliance indicates inadequate antibiotic exposure rather than bacterial resistance 1.

• Therapeutic efficacy should be reassessed at 48-72 hours of adequate antibiotic therapy 1, 2
• Fever typically resolves within 24-48 hours in susceptible bacterial infections 2
• Treatment failure is defined as lack of improvement after 72 hours of compliant therapy, not sporadic dosing 1

Ensuring Adequate Antibiotic Administration

Critical pitfall: Non-compliance is the most common reason for apparent treatment failure in pediatric respiratory infections 3. Address this immediately:

• Consider a single dose of intramuscular ceftriaxone (50 mg/kg) if oral compliance cannot be ensured, then transition back to oral therapy after clinical improvement 1
• Use palatability-enhancing strategies (mixing with food, using flavored suspensions) 3
• Simplify dosing to twice daily if using high-dose amoxicillin-clavulanate formulation 3

Antibiotic Selection Rationale

Amoxicillin-clavulanate remains the first-line agent for this clinical scenario 1:

• Covers Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 3
• The clavulanate component addresses β-lactamase-producing organisms 3
• Recommended dosing: 90 mg/kg/day of amoxicillin component divided into 2-3 doses 1, 2

When to Consider Switching Antibiotics

Switch antibiotics only if the following criteria are met after ensuring 72 hours of compliant therapy 1:

• Persistent fever despite adequate dosing 1
• Clinical deterioration (increased respiratory distress, toxic appearance) 1
• Development of complications (orbital cellulitis, meningitis) 1

If switching becomes necessary after documented compliance failure, consider 1:

• Ceftriaxone 50 mg/kg IM/IV daily for 3-5 days 1
• High-dose amoxicillin-clavulanate (90 mg/6.4 mg/kg/day) if not already using this formulation 1

Role of Pending Laboratory Studies

While awaiting CBC and CRP results 4:

• CRP >10 mg/L supports bacterial infection and need for continued antibiotics 4
• CRP <10 mg/L after 24-48 hours of therapy suggests infection is controlled 4
• However, do not delay antibiotic continuation while awaiting results given the worsening clinical course 1
• Use CRP primarily to guide treatment duration once compliance is established 4

Treatment Duration

Complete a 10-day course of antibiotics for acute bacterial sinusitis 1:

• The American Academy of Pediatrics recommends 10-14 days for bacterial sinusitis 1
• Shorter courses (5-7 days) may be adequate for uncomplicated cases, but given the worsening course and compliance issues, err toward the longer duration 1
• Restart the day count from when compliant dosing begins, not from the original start date 1

Red Flags Requiring Immediate Escalation

Reassess urgently if any of the following develop 1:

• Periorbital swelling, proptosis, or impaired extraocular movements (orbital complications) 1
• Severe headache, photophobia, seizures, or focal neurologic signs (intracranial complications) 1
• Respiratory rate >70 breaths/min (infants) or oxygen saturation ≤92% 2
• Inability to feed or signs of dehydration 2

These complications mandate immediate imaging (contrast-enhanced CT) and hospitalization with IV antibiotics 1.