What to do with an adult patient who shows improvement on amoxicillin (amoxicillin) despite a negative streptococcal (strep) test, with symptoms of ear pressure and dull ear drum?

Management of Adult Patient Improving on Amoxicillin Despite Negative Strep Test

Complete the current course of amoxicillin for a total of 10-14 days, as the patient's clinical improvement with dull ear drum and ear pressure suggests acute bacterial rhinosinusitis with associated eustachian tube dysfunction, not streptococcal pharyngitis. 1

Clinical Reasoning

The Diagnosis is Likely Acute Bacterial Rhinosinusitis, Not Strep Pharyngitis

• The negative streptococcal test definitively rules out group A streptococcal pharyngitis as the primary diagnosis 1
• Ear examination findings of dull ear drum and pressure are classic for middle ear effusion and eustachian tube dysfunction associated with acute sinusitis 1
• The patient's symptomatic improvement on amoxicillin strongly suggests a bacterial etiology responsive to beta-lactam therapy 1

Why the Patient is Improving on Amoxicillin

• Amoxicillin is the first-line antibiotic for acute bacterial rhinosinusitis in adults, effective against common pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
• The guideline recommendation is to continue amoxicillin for 3-5 days to assess improvement; if improving, continue until the patient is well for 7 days (generally 10-14 days total) 1
• Clinical improvement typically occurs within the first few days, with complete resolution requiring 10-14 days 1

Specific Management Algorithm

Continue Current Therapy

• Complete a full 10-14 day course of amoxicillin since the patient is demonstrating clinical response 1
• Treatment should continue until the patient is well for 7 days after symptom resolution 1
• The typical effective dosage for adults is 500 mg three times daily or 875 mg twice daily 2

If Patient Fails to Improve by Day 7

• Reassess the diagnosis to confirm acute bacterial rhinosinusitis criteria 1
• Switch to high-dose amoxicillin-clavulanate (2g every 12 hours) if the patient was on amoxicillin alone 1
• Alternative agents include respiratory fluoroquinolones (levofloxacin or moxifloxacin) or doxycycline for penicillin-allergic patients 1

Monitor for Complications

• Watch for warning signs including periorbital edema, visual changes, severe headache, or mental status changes that would indicate orbital or intracranial extension 1
• The presence of facial swelling, erythema over involved sinuses, or abnormal extraocular movements requires urgent evaluation 1

Common Pitfalls to Avoid

Do Not Discontinue Antibiotics Prematurely

• Even though strep was negative, stopping antibiotics when the patient is improving from bacterial sinusitis would be inappropriate 1
• Premature discontinuation risks treatment failure and potential complications 1

Do Not Confuse Carrier State with Active Infection

• The negative strep test eliminates concern about streptococcal pharyngitis or carrier state 1
• No follow-up strep testing is needed for asymptomatic patients after completing therapy 1

Recognize the Sinusitis-Otitis Connection

• Ear findings (dull tympanic membrane, pressure) are frequently present in acute sinusitis due to eustachian tube dysfunction 1
• This does not represent acute otitis media requiring different management, but rather a manifestation of the underlying sinusitis 1

Adjunctive Therapies to Consider

• Intranasal saline irrigation may alleviate symptoms and potentially decrease antibiotic duration 1
• Intranasal corticosteroids can be helpful, particularly if marked mucosal edema is present 1
• Analgesics for pain and antipyretics for fever provide symptomatic relief 1