What to do if a patient with strep throat, already on amoxicillin (amox) 1 capsule three times a day (tDS) for 7 days, shows no improvement after 2 days?

Management of Strep Throat After 2 Days on Amoxicillin

If a patient tests positive for strep throat after already being on amoxicillin 1 capsule TDS for 7 days (meaning they've completed 2 days of treatment when the result returns), continue the current amoxicillin regimen to complete the full 10-day course, as this is the standard first-line treatment for streptococcal pharyngitis. 1

Understanding the Clinical Scenario

This situation represents a common clinical challenge where treatment was initiated empirically before culture confirmation. The key question is whether to continue or change therapy.

Continue Current Amoxicillin Therapy

• Complete the full 10-day course of amoxicillin as originally prescribed, since this is the guideline-recommended first-line treatment for Group A streptococcal pharyngitis 1, 2
• The standard adult dosing is 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate infections, or 875 mg every 12 hours or 500 mg every 8 hours for severe infections 2
• At least 10 days of treatment is required to prevent acute rheumatic fever when treating Streptococcus pyogenes infections 2

When to Reassess and Change Therapy

Change antibiotics only if the patient worsens after 48-72 hours or fails to improve after 3-5 days of initial therapy 1

If treatment failure occurs, consider these alternatives:

• Amoxicillin-clavulanate (amoxicillin 40 mg/kg/day in 3 doses, max 2000 mg/day for 10 days) 1
• Narrow-spectrum cephalosporin 1
• Clindamycin (20-30 mg/kg/day in 3 doses, max 300 mg/dose for 10 days) 1
• Intramuscular benzathine penicillin G if compliance is a concern 1

Important Clinical Distinctions

Carrier State vs. Active Infection

This scenario may represent a chronic streptococcal carrier with an intercurrent viral infection rather than true treatment failure 1:

• Carriers have persistent positive cultures without clinical findings or immunologic response to GAS antigens 1
• Carriers do not ordinarily require further antimicrobial therapy and are unlikely to spread the organism or develop complications 1
• Helpful clues to distinguish carriers from active infection include: patient age, season, local epidemiological characteristics, and the precise nature of presenting signs and symptoms 1

When Carrier Treatment Is Indicated

Antimicrobial therapy for carriers is only recommended in special situations 1:

• During a community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive GAS infection
• During an outbreak of GAS pharyngitis in a closed or partially closed community
• In the presence of a family or personal history of acute rheumatic fever
• In a family with excessive anxiety about GAS infections
• When tonsillectomy is being considered only because of carriage

Common Pitfalls to Avoid

Do Not Routinely Obtain Post-Treatment Cultures

• Post-treatment throat cultures are NOT indicated for asymptomatic patients who have completed appropriate therapy 1
• Follow-up cultures are only indicated for patients who remain symptomatic, have recurrent symptoms, or have had rheumatic fever 1

Do Not Prematurely Switch Antibiotics

• Wait at least 48-72 hours before declaring treatment failure 1
• Many patients will show clinical improvement within this timeframe
• Premature switching contributes to antibiotic resistance without clear benefit

Avoid Shorter Courses of Penicillin/Amoxicillin

• Short-course penicillin (3-5 days) is less effective than the standard 10-day course for both clinical cure and bacteriological eradication 3, 4
• While short-course cephalosporins and macrolides may be effective, they are "Highest Priority Critically Important Antimicrobials" and should be reserved for specific indications 3
• Penicillin V for 10 days remains the gold standard despite the availability of shorter-course alternatives 1

Monitoring and Follow-Up

• Assess clinical response at 48-72 hours: Look for reduction in fever, throat pain, and ability to swallow 1
• If symptoms worsen or fail to improve by day 3-5: Reassess to confirm diagnosis, exclude complications (peritonsillar abscess, cervical lymphadenitis), and consider alternative antibiotics 1
• Ensure compliance: Consider intramuscular benzathine penicillin G if adherence to oral therapy is questionable 1