What to do if strep throat symptoms persist despite amoxicillin (amoxicillin) treatment?

Management of Persistent Strep Throat Symptoms Despite Amoxicillin Treatment

For patients with persistent strep throat symptoms despite amoxicillin treatment, the clinician should change the antibiotic to amoxicillin-clavulanate, clindamycin, or a respiratory fluoroquinolone after reassessing to confirm the diagnosis. 1, 2

Reassessment of Diagnosis

When strep throat symptoms persist despite amoxicillin treatment, the first step is to reassess and confirm the diagnosis:

• Evaluate for treatment failure (symptoms worsening or not improving after 48-72 hours of antibiotic therapy) 2
• Consider whether the patient is:
  • Non-compliant with the prescribed regimen 2
  • A streptococcal carrier with concurrent viral infection 2
  • Experiencing a new infection with Group A Streptococcus 2
  • Having true treatment failure (rare) 2

Antibiotic Management

First-line Change in Therapy

If the patient was initially treated with amoxicillin and failed to improve:

• Switch to amoxicillin-clavulanate 2
  • This addresses potential beta-lactamase producing organisms that may be causing treatment failure

Alternative Options

For patients with penicillin allergy or continued failure:

• Clindamycin: 20-30 mg/kg/day in 3 divided doses for children; 600 mg/day in 2-4 divided doses for adults (10 days) 2
• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) for adults 2
• Cephalosporins (if not anaphylactically sensitive to penicillin): cefdinir, cefpodoxime, or cefuroxime 1

Special Considerations

Streptococcal Carriers

• Streptococcal carriers (positive throat culture but no immune response to the organism) generally do not require further antimicrobial therapy 2, 1
• They are at low risk for developing complications and unlikely to spread the organism 1
• More difficult to eradicate Group A streptococci from carriers than from patients with acute infections 2

Recurrent Episodes

For patients with multiple recurrent episodes of confirmed streptococcal pharyngitis:

• Consider clindamycin or amoxicillin-clavulanate for eradication 2
• Tonsillectomy may be considered for severe recurrent cases (≥7 episodes in the past year, or ≥5 episodes per year for 2 consecutive years) 1

Monitoring and Follow-up

• Clinical improvement should be noted within 48-72 hours of starting the new antibiotic 2
• During the first 24 hours after changing antibiotics, symptoms may worsen slightly 2
• In the next 24 hours, symptoms should begin to improve 2
• If febrile, temperature should decline within 48-72 hours 2

Common Pitfalls and Caveats

1. Failure to distinguish carriers from acute infection: Carriers may have positive throat cultures during viral illnesses but don't require antibiotic changes 2

2. Not considering alternative diagnoses: Persistent symptoms may indicate another condition such as infectious mononucleosis, peritonsillar abscess, or non-infectious causes 2

3. Inadequate duration of therapy: Ensure patients complete the full course of antibiotics (typically 10 days) to prevent rheumatic fever 1

4. Unnecessary testing of asymptomatic household contacts: Routine testing or treatment of asymptomatic household contacts is not recommended 2

By following this approach, clinicians can effectively manage persistent strep throat symptoms while minimizing unnecessary antibiotic use and preventing complications.