What is the recommended treatment for recurrent streptococcal pharyngitis in a 6-year-old despite treatment with amoxicillin (Amoxil)?

From the Guidelines

For recurrent strep pharyngitis in a 6-year-old who has failed amoxicillin treatment, I recommend switching to clindamycin at 20-30 mg/kg/day divided into three doses for 10 days, as supported by the most recent and highest quality study 1. This recommendation is based on the consideration of several factors, including efficacy, safety, and potential resistance patterns. The Infectious Diseases Society of America guidelines 2 suggest that clindamycin is a reasonable alternative for patients who have failed first-line treatment with amoxicillin. Additionally, the 2019 clinical practice guideline for tonsillectomy in children 3, 1 provides guidance on the management of recurrent throat infections, including the consideration of tonsillectomy for patients with frequent and severe episodes.

Some key points to consider in the management of recurrent strep pharyngitis include:

• The potential for beta-lactamase producing organisms, which may contribute to treatment failure with amoxicillin 2
• The importance of documenting the frequency and clinical features of throat infection episodes to ensure clinical benefits consistent with those achieved in randomized controlled trials 1
• The consideration of tonsillectomy for patients with frequent and severe episodes, particularly if the child has had at least 7 episodes in one year or 5 episodes per year for two consecutive years 3, 1
• The potential for strep carriage and the need to test family members and possibly treat them simultaneously if the child continues to get reinfected from household contacts 2

Overall, the management of recurrent strep pharyngitis requires a comprehensive approach that takes into account the individual patient's needs and circumstances, as well as the latest evidence-based guidelines and recommendations.

From the FDA Drug Label

Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS): Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)

The recommended treatment for strep pharyngitis that is recurrent despite treatment with amoxicillin in a 6-year-old is azithromycin.

• Dosage: 12 mg/kg once a day for 5 days
• Efficacy: Azithromycin has been shown to be clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30
• Side effects: The most common side effects were diarrhea/loose stools, vomiting, and abdominal pain 4

From the Research

Treatment Options for Recurrent Strep Pharyngitis

• The recommended treatment for strep pharyngitis is penicillin or amoxicillin for 10 days 5, 6.
• For patients with a non-anaphylactic allergy to penicillin, first-generation cephalosporins are recommended 6.
• There is limited evidence to support the use of other antibiotics, such as azithromycin or clarithromycin, due to significant resistance in some parts of the United States 6.
• A study comparing different antibiotics found that cephalosporins may be more effective than penicillin in reducing clinical relapse, but the evidence is uncertain 7.
• Another study found that carbacephem may be more effective than penicillin in symptom resolution, but the evidence is limited to adults and children 7.

Considerations for Recurrent Infections

• Chronic group A beta-hemolytic streptococcal (GABHS) colonization is common despite appropriate antibiotic therapy, and treatment of carriers is generally not recommended 5.
• Tonsillectomy is rarely recommended as a preventive measure, and is typically considered for patients with recurrent infections (seven episodes in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years) 6.

Management of Treatment Failure

• Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 6.
• There is no clear evidence to support a specific treatment approach for recurrent strep pharyngitis despite treatment with amoxicillin, and further evaluation and consideration of alternative treatments may be necessary 5, 6, 7.