What is the recommended treatment for a 14-year-old patient weighing 128 pounds with strep throat and an ear infection?

Treatment for 14-Year-Old with Strep Throat and Ear Infection

Amoxicillin is the recommended first-line treatment for this 14-year-old patient weighing 128 pounds (58 kg) with strep throat and ear infection, at a dose of 50 mg/kg once daily (maximum 1000 mg) for a full 10-day course. 1, 2

Antibiotic Selection and Dosing

First-Line Treatment:

• Amoxicillin:
  • Dosage: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose)
  • For this 58 kg patient: 1000 mg once daily or 500 mg twice daily
  • Duration: 10 days (mandatory to prevent acute rheumatic fever)
  • Strong, high-quality evidence supports this recommendation 1

Amoxicillin is preferred over penicillin V due to:

• Better taste (improving compliance)
• Once-daily dosing option (improving compliance)
• Equivalent efficacy to twice-daily dosing 3
• FDA approval for upper respiratory tract infections including ear infections and strep throat 2

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy: Cephalexin 20 mg/kg twice daily (max 500 mg/dose) for 10 days
• Anaphylactic allergy: Azithromycin 12 mg/kg once daily (max 500 mg) for 5 days 1, 4

Treatment Algorithm

1. Confirm diagnosis: Both strep throat and ear infection are present, requiring treatment
2. Check for penicillin allergy:
   • If no allergy → Amoxicillin
   • If non-anaphylactic allergy → Cephalexin
   • If anaphylactic allergy → Azithromycin
3. Calculate weight-based dosing: For this 58 kg patient, use maximum doses
4. Emphasize importance of completing full course: 10 days for beta-lactams, 5 days for azithromycin

Adjunctive Therapy

• Pain management:
  • Acetaminophen or ibuprofen for pain and fever
  • Throat lozenges (if age-appropriate) for symptomatic relief
  • Warm salt water gargles
• Hydration: Cold liquids or ice chips may provide relief
• Return to school: After completing at least 24 hours of antibiotics 1

Important Considerations

• A full 10-day course of antibiotics is mandatory to prevent acute rheumatic fever, with the exception of azithromycin (5-day course) 1
• Treatment failures with penicillin have increased over time, reaching approximately 30% in some studies 5
• If symptoms persist after 48-72 hours of antibiotic therapy, reevaluation is necessary 1
• Routine post-treatment cultures are not indicated unless symptoms persist 1

Monitoring

• Assess for clinical improvement within 48-72 hours
• Monitor for potential side effects (gastrointestinal symptoms most common)
• Ensure completion of the full antibiotic course

The combination of strep throat and ear infection in this adolescent patient requires effective treatment with a beta-lactam antibiotic, with amoxicillin being the optimal choice due to its efficacy, convenient dosing, and established safety profile.