How to Decrease Diarrhea with Augmentin
Immediate Dosing Strategy
Switch to twice-daily dosing of amoxicillin-clavulanate instead of three-times-daily dosing to reduce gastrointestinal side effects while maintaining therapeutic efficacy. 1
- The clavulanate component causes dose-dependent gastrointestinal toxicity, so reducing the frequency of clavulanate exposure (by using twice-daily instead of three-times-daily formulations) decreases diarrhea rates without compromising antimicrobial coverage 1
- Take each dose with a meal or snack, as the FDA label specifically recommends this to reduce gastrointestinal upset 2
- Limit treatment duration to the minimum effective period for your specific infection 1
When to Continue vs. Discontinue
For mild, non-bloody diarrhea, continue the antibiotic if clinically necessary while monitoring symptoms, as most cases are self-limited. 1, 3
- Diarrhea occurs in 44-52% of patients on high-dose amoxicillin-clavulanate compared to 14-36% with placebo, so some degree of loose stools is expected and tolerable 1
- The FDA label confirms that diarrhea is a common problem that usually ends when the antibacterial is discontinued 2
Immediately discontinue amoxicillin-clavulanate and test for C. difficile toxin if you develop:
- Moderate to severe diarrhea 1, 3
- Watery and bloody stools 2
- Stomach cramps with fever 2
- Diarrhea lasting more than 2-3 days 2
This is critical because 13-27% of children on amoxicillin-clavulanate develop toxigenic C. difficile colonization, with significantly higher rates in those experiencing diarrhea 4
Alternative Antibiotics if Diarrhea is Intolerable
Switch to clindamycin 300 mg twice daily for 10 days if treating tonsillitis or pharyngitis, as it achieves 92.6% clinical cure rates with only 8.6% diarrhea rates. 3
For respiratory infections like sinusitis, consider cefuroxime 375 mg twice daily, which shows similar efficacy but lower gastrointestinal side effects. 1, 3
Avoid azithromycin as a replacement—it provides inadequate coverage for common respiratory pathogens and carries QT prolongation risk. 1, 3
Probiotic Supplementation
Consider adding Enterococcus faecium strain SF68 (FortiFlora) during and after antibiotic therapy, as research shows it reduces total diarrhea scores (P = 0.0058) and prevents the most severe diarrhea (fecal scores of 7 occurred only in the placebo group) 5
Common Pitfalls to Avoid
- Do not use empiric antibiotics for the diarrhea itself while awaiting C. difficile results, unless you show signs of sepsis 1
- Do not ignore bloody diarrhea or fever—these warrant immediate discontinuation and C. difficile testing, as the toxin can appear up to 2 months after the last antibiotic dose 2
- Do not switch to shorter antibiotic courses (3-5 days) as alternatives, since 7-10 day courses are superior for complete symptom resolution 3
Mechanism Explanation
Amoxicillin-clavulanate causes diarrhea through two distinct pathways: direct dose-dependent gastrointestinal toxicity from the clavulanate component itself, and disruption of normal intestinal flora leading to potential C. difficile overgrowth 1, 3. This explains why twice-daily dosing (which reduces clavulanate exposure) is more tolerable than three-times-daily dosing.