What is the treatment for recurrent streptococcal pharyngitis after a course of Augmentin (amoxicillin-clavulanate)?

Treatment for Recurrent Streptococcal Pharyngitis After Augmentin

For recurrent streptococcal pharyngitis after a course of Augmentin (amoxicillin-clavulanate), clindamycin is the recommended treatment of choice at a dosage of 20-30 mg/kg/day in 3 divided doses for children or 600 mg/day in 2-4 divided doses for adults for 10 days. 1

Treatment Algorithm for Recurrent Strep Pharyngitis

First-line Options

1. Oral Clindamycin

   • Children: 20-30 mg/kg/day in 3 equally divided doses for 10 days
   • Adults: 600 mg/day in 2-4 equally divided doses for 10 days 1

2. Alternative: Benzathine Penicillin G with Rifampin

   • Benzathine penicillin G (intramuscular injection)
   • Plus rifampin: 20 mg/kg/day orally in 2 equally divided doses for 4 days
   • Maximum daily dose of rifampin: 600 mg 1

3. Alternative: Amoxicillin-clavulanate (different dosage than initial treatment)

   • Children: 40 mg/kg/day in 3 equally divided doses for 10 days
   • Adults: 500 mg twice daily for 10 days 1

Evidence-Based Rationale

The Infectious Diseases Society of America (IDSA) guidelines specifically address treatment for recurrent streptococcal pharyngitis after initial antibiotic failure. Since the patient has already failed a course of Augmentin (amoxicillin-clavulanate), clindamycin is particularly effective in this scenario.

Research supports this approach, with one study showing that in patients with GAS pharyngotonsillitis who failed penicillin treatment, a 10-day course of clindamycin protected patients from recurrence for at least 3 months and might be an alternative to tonsillectomy 2. In this study, only 3/26 patients in the clindamycin group had positive cultures for GAS during follow-up (all were new infections), compared to 15/22 in the penicillin group (p<0.001) 2.

Important Considerations

Diagnostic Confirmation

Before initiating treatment for recurrent streptococcal pharyngitis:

• Confirm the diagnosis with a throat culture or rapid antigen detection test (RADT) 3
• Distinguish between true recurrent infection versus carrier state with intercurrent viral infection 1

Carrier State vs. True Recurrence

It's important to differentiate between:

• Streptococcal carrier with viral infection: Patient may have GAS in throat but symptoms are due to a viral infection
• True recurrent streptococcal infection: Actual infection with GAS causing symptoms 1

Family Considerations

• When multiple recurrences occur within a family, consider "ping-pong" spread
• Performing simultaneous cultures for all family contacts and treating those with positive cultures may be helpful 1

Treatment Pitfalls to Avoid

1. Avoid macrolides (e.g., erythromycin) and cephalosporins for recurrent streptococcal pharyngitis after initial treatment failure, as there are insufficient data to support their efficacy in this specific circumstance 1

2. Don't prescribe continuous long-term antimicrobial prophylaxis to prevent recurrent episodes of acute pharyngitis (except for patients with a history of rheumatic fever) 1

3. Avoid routine follow-up cultures after treatment unless the patient remains or becomes symptomatic 1

4. Don't test or treat asymptomatic household contacts routinely 3

Surgical Considerations

Tonsillectomy may be considered for patients whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation for recurrent pharyngitis is evident. However, this should be reserved as a last resort when medical management fails 1, 3.

Conclusion on Treatment Approach

When treating recurrent streptococcal pharyngitis after Augmentin failure, clindamycin offers the best evidence-based option with high rates of bacterial eradication. The full 10-day course must be completed to ensure adequate treatment and prevent complications like rheumatic fever.