How should I manage a 68-year-old man with persistent fever and worsening productive cough after three days of amoxicillin‑clavulanate for cough and nasal congestion?

Reassess Immediately and Switch Antibiotics

This patient requires urgent clinical reassessment with chest radiography to evaluate for pneumonia, and you should switch from Augmentin to a respiratory fluoroquinolone or continue high-dose amoxicillin-clavulanate if pneumonia is confirmed. 1, 2

Immediate Clinical Actions

Perform Focused Reassessment

• Examine for signs of pneumonia: tachycardia (>100 bpm), tachypnea (>24 breaths/min), abnormal chest auscultation findings, and persistent fever >38°C beyond 3 days 3
• Order chest radiography immediately – persistent fever on day 3-5 of antibiotic therapy mandates imaging to identify pneumonia, pleural effusion, or abscess 1, 3
• Assess for complications: facial swelling/erythema, visual changes, periorbital inflammation, or any neurologic signs suggesting spread beyond the respiratory tract 4

Why This Patient Represents Treatment Failure

• Fever persisting beyond day 3 of appropriate antibiotic therapy indicates treatment failure and requires intervention, not continuation of the same regimen 1, 2
• The combination of persistent fever AND worsening productive cough meets criteria for clinical deterioration, which demands immediate antibiotic change 2
• Do not wait longer – symptoms should decrease within 48-72 hours of effective treatment 2

Antibiotic Management Algorithm

If Chest X-Ray Confirms Pneumonia

• Switch to a respiratory fluoroquinolone (levofloxacin or moxifloxacin) for community-acquired pneumonia with treatment failure 5, 6
• Alternative: Continue amoxicillin-clavulanate but escalate to high-dose formulation (2000/125 mg twice daily) to cover drug-resistant S. pneumoniae 7, 6
• Duration: 5-10 days total from the start of effective therapy, with reassessment at 48-72 hours after the switch 1

If No Pneumonia But Severe Acute Bacterial Sinusitis

• The "severe symptoms" presentation (high fever for >3 consecutive days with purulent discharge) warrants antibiotics even without the 10-day persistence criterion 3, 8
• High-dose amoxicillin-clavulanate remains appropriate for acute bacterial sinusitis, but ensure adequate dosing (90 mg/kg amoxicillin component, not to exceed 2g every 12 hours) 4, 8
• If already on standard-dose Augmentin, escalate to the high-dose formulation rather than switching drug classes 4

If Acute Exacerbation of Chronic Bronchitis (AECB)

• This diagnosis applies if the patient has underlying chronic bronchitis with increased dyspnea, sputum production, and sputum purulence 5
• For severe exacerbation with risk factors (age 68 years, persistent fever), switch to high-dose amoxicillin-clavulanate or a respiratory fluoroquinolone 5

Critical Pitfalls to Avoid

Do Not Continue Failing Therapy

• Continuing Augmentin when fever recurs on day 3-5 represents the most common management error – this is treatment failure requiring immediate intervention 1, 2
• The presence of productive cough alone does not indicate bacterial superinfection, but persistent fever does 2, 3

Do Not Assume All Respiratory Infections Need Antibiotics

• However, this patient's persistent fever beyond 3 days on antibiotics distinguishes him from simple viral URTI and mandates escalation 3
• Purulent sputum color (green/yellow) does not by itself indicate bacterial infection, but the clinical context (fever >3 days on antibiotics) does 3

Do Not Underestimate Drug-Resistant Pathogens

• Standard-dose amoxicillin-clavulanate may fail against penicillin-resistant S. pneumoniae, which has increasing prevalence 7, 8
• High-dose formulations were specifically developed to overcome this resistance pattern 7, 6

Symptomatic Management Adjuncts

• Add inhaled ipratropium bromide for the persistent productive cough – this has the best evidence for postinfectious cough relief 2
• Consider short-term oral corticosteroids if marked mucosal edema is present on examination, particularly if sinusitis is confirmed 4
• Ensure adequate hydration, bronchodilators if wheezing is present, and chest physiotherapy for secretion clearance 5

Follow-Up Timeline

• Reassess within 48-72 hours after changing antibiotics to confirm clinical improvement (defervescence, reduced cough, improved general condition) 1
• If no improvement after the antibiotic switch, consider hospital admission for intravenous antibiotics, repeat cultures, and investigation for complications 1
• Complete the full antibiotic course (typically 10-14 days total for pneumonia or sinusitis) even after symptoms resolve 4, 8