Should a patient with a negative throat swab continue antibiotics for strep throat?

From the Guidelines

A patient with a negative throat swab for strep throat should generally discontinue antibiotics unless there are compelling clinical reasons to continue, as the risk of contributing to antibiotic resistance and disrupting normal gut flora outweighs any potential benefits in the absence of a confirmed Group A Streptococcus infection. The decision to continue antibiotics should be based on a comprehensive clinical evaluation, including the patient's symptoms, medical history, and the results of any diagnostic tests. According to the clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis 1, antimicrobial therapy is not indicated for the large majority of chronic streptococcal carriers, and treatment should only be considered in special situations, such as during a community outbreak of acute rheumatic fever or in patients with a family or personal history of acute rheumatic fever.

Some key points to consider when deciding whether to continue antibiotics include:

• The patient's symptoms and medical history, including any history of rheumatic fever or other conditions that may increase the risk of complications from strep throat
• The results of any diagnostic tests, including throat cultures or rapid strep tests
• The potential risks and benefits of continuing antibiotics, including the risk of contributing to antibiotic resistance and disrupting normal gut flora
• The presence of any compelling clinical reasons to continue treatment, such as a high clinical suspicion of strep throat despite a negative test result

It's also important to note that repeated courses of antibiotic therapy are rarely indicated in asymptomatic patients who continue to harbor Group A Streptococcus after appropriate therapy, as stated in the scientific statement from the American Heart Association 1. In general, patients should discuss their specific situation with their healthcare provider rather than stopping prescribed antibiotics without consultation, as the decision to continue or discontinue treatment should be based on a comprehensive clinical evaluation and a consideration of the potential risks and benefits.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Cultures should be taken following completion of treatment to determine whether streptococci have been eradicated.

The patient should continue antibiotics for the full recommended course, even with a negative throat swab, as the treatment course is intended to eliminate the organism and prevent sequelae of streptococcal disease. The ten-day minimum therapy is recommended, and cultures should be taken after completion to confirm eradication of streptococci 2.

From the Research

Patient Treatment for Strep Throat with Negative Throat Swab

• The decision to continue antibiotics for a patient with a negative throat swab should be based on clinical judgment and guidelines, as the presence of group A beta-hemolytic streptococcal pharyngitis cannot be ruled out solely by a negative rapid antigen test result 3.
• According to the American Family Physician, guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics 3.
• A study published in The Pediatric Infectious Disease Journal found that penicillin failure in streptococcal tonsillopharyngitis can be caused by various factors, including lack of compliance, reexposure to infected family members, and antibiotic-associated eradication of normal protective pharyngeal flora 4.
• Another study published in The Journal of Antimicrobial Chemotherapy compared azithromycin and penicillin V in the treatment of acute streptococcal pharyngitis and tonsillitis in children, and found that both drugs were effective in achieving clinical cure and bacterial eradication 5.
• A Cochrane review of different antibiotic treatments for group A streptococcal pharyngitis found that there is uncertainty regarding the comparative efficacy of different antibiotics in alleviating symptoms, shortening the duration of illness, and preventing clinical relapse and complications 6.
• A retrospective study published in Anales de Pediatria found that a shortened 5- to 7-day antibiotic regimen for acute streptococcal pharyngotonsillitis was not less effective or more unsafe than the traditional 10-day course 7.

Considerations for Continuing Antibiotics

• The patient's clinical presentation, medical history, and risk factors for complications should be taken into account when deciding whether to continue antibiotics 3, 4.
• The potential benefits and risks of continuing antibiotics, including the risk of antibiotic resistance and side effects, should be weighed against the potential benefits of treating the infection 6, 7.
• Clinical guidelines and evidence-based recommendations should be consulted to inform the decision-making process 3, 6.