What's the next best antibiotic for a patient with recurrent strep (streptococcal) infections, who has not improved on penicillin and cephalexin (Cefalexin), with leukocytosis (WBC 11)?

From the Guidelines

For a patient with recurrent strep infections who hasn't responded to penicillin and cephalexin, with leukocytosis (WBC 11), clindamycin would be the next best antibiotic option, as recommended by the Infectious Diseases Society of America 1. The recommended dosage is 20-30 mg/kg/day divided into three or four doses for children, and 300-450 mg orally every 6-8 hours for adults for 10 days. Before starting clindamycin, it's essential to confirm the diagnosis with a throat culture and sensitivity testing to ensure the organism is susceptible, as noted in the guidelines 1. Clindamycin works by inhibiting bacterial protein synthesis and is effective against many strains of Streptococcus, including those that may have developed resistance to beta-lactam antibiotics like penicillin and cephalexin. The elevated white blood cell count indicates ongoing infection, supporting the need for a different antibiotic approach. Some key points to consider when treating recurrent strep infections include:

• The importance of accurate diagnosis to prevent unnecessary antibiotic use and the development of antibiotic resistance 1.
• The need to distinguish between persistent carriage and recurrent episodes of acute GAS pharyngitis, as this can inform treatment decisions 1.
• The potential for clindamycin to cause side effects such as diarrhea, nausea, and abdominal pain, and the importance of monitoring for these effects 1. Patients should complete the full course of antibiotics even if symptoms improve before completion. If severe diarrhea occurs, the patient should contact their healthcare provider immediately as this could indicate Clostridioides difficile infection, a serious potential complication of clindamycin therapy.

From the FDA Drug Label

Clindamycin is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections. Bacteriologic studies should be performed to determine the causative organisms and their susceptibility to clindamycin

The next best antibiotic for a patient with recurrent strep infections who has not improved on penicillin and cephalexin, with leukocytosis (WBC 11), could be clindamycin 2, considering the patient's lack of response to initial treatments and the drug's indication for treating serious infections caused by susceptible strains of streptococci. However, bacteriologic studies should be performed to confirm the susceptibility of the causative organisms to clindamycin. It's crucial to weigh the benefits against the risks, including the potential for colitis, and consider less toxic alternatives when appropriate.

From the Research

Next Best Antibiotic for Recurrent Strep Infections

Given the patient's lack of improvement on penicillin and cephalexin, the next best antibiotic option can be considered based on the available evidence:

• Clindamycin has been shown to be effective in treating recurrent group A streptococcal pharyngotonsillitis, particularly in cases where penicillin treatment has failed 3.
• Amoxicillin/clavulanate has also been demonstrated to be effective in eradicating group A beta-haemolytic streptococci and preventing recurrent infections 4.
• Carbacephem may provide better symptom resolution compared to penicillin, although the evidence is of low certainty 5.

Considerations for Antibiotic Selection

When selecting an antibiotic, it is essential to consider the following factors:

• The patient's previous treatment history and response to antibiotics
• The presence of beta-lactamase producing bacteria, which may affect the efficacy of certain antibiotics
• The potential for antibiotic resistance and the need to choose an antibiotic with a suitable spectrum of activity
• The patient's clinical presentation, including the presence of leukocytosis (WBC 11) and the absence of PTA

Potential Antibiotic Options

Based on the available evidence, potential antibiotic options for the patient could include:

• Clindamycin
• Amoxicillin/clavulanate
• Carbacephem It is crucial to consult the latest clinical guidelines and consider the patient's individual circumstances before making a final decision on the next best antibiotic option 5, 4, 3.