Treatment After Augmentin for Strep Throat
If the patient has completed a full course of Augmentin and still has symptoms or positive strep testing, you should treat with clindamycin 300 mg three times daily for 10 days, as this agent achieves high pharyngeal eradication rates even in chronic streptococcal carriers. 1
Understanding the Clinical Scenario
The question implies treatment failure or recurrence after Augmentin therapy. This is an important distinction because:
Augmentin (amoxicillin-clavulanate) is NOT first-line therapy for uncomplicated strep pharyngitis - penicillin or plain amoxicillin remain the drugs of choice due to proven efficacy, narrow spectrum, safety, and low cost 1, 2
Augmentin is specifically reserved for recurrent streptococcal pharyngitis or chronic carriers who have multiple symptomatic episodes, as it achieves high pharyngeal eradication rates in these difficult-to-treat situations 1, 3
Treatment Algorithm for Post-Augmentin Management
Step 1: Determine if Retreatment is Needed
Do NOT routinely retest asymptomatic patients who completed therapy - repeat cultures or rapid antigen tests are not recommended except in special circumstances such as patients with history of rheumatic fever 1, 4
Step 2: If Symptomatic Recurrence Occurs
For patients with recurrent acute pharyngitis and positive strep testing shortly after completing Augmentin:
First-line retreatment: Clindamycin 300 mg (7 mg/kg) three times daily for 10 days 1, 4
Alternative option: Intramuscular benzathine penicillin G if compliance with oral agents is questionable 1
Step 3: Distinguish True Infection from Carrier State
When multiple episodes occur over months or years, differentiate viral infections in a streptococcal carrier from true Group A streptococcal infections 1
- Chronic carriers generally do not require antimicrobial therapy as they are unlikely to spread infection or develop complications 4
- True recurrent infections warrant the clindamycin regimen described above 1, 4
Why Augmentin Was Likely Inappropriate Initially
Plain amoxicillin (not Augmentin) is first-line for uncomplicated streptococcal pharyngitis at 1000 mg once daily or 500 mg twice daily for 10 days in adults 2
Augmentin should only be used for:
- Chronic streptococcal carriers with recurrent symptomatic episodes at 500 mg twice daily for 10 days 3
- Pediatric chronic carriers at 40 mg/kg/day of amoxicillin component divided into three doses for 10 days 3
The broader spectrum and added cost of Augmentin are unnecessary for standard acute strep pharyngitis 1
Critical Treatment Principles
Complete the full 10-day course of any antibiotic (except azithromycin which requires 5 days) to prevent acute rheumatic fever - this is essential regardless of symptom improvement 1, 4, 2, 5
Patients are no longer contagious after 24 hours of appropriate antibiotic therapy, but treatment must continue for the full duration to prevent complications 2
Common Pitfalls to Avoid
Do not prescribe shorter courses than recommended - even shortening by a few days results in appreciable increases in treatment failure rates 4
Do not use macrolides (azithromycin, clarithromycin) after Augmentin failure - macrolide resistance is 5-8% in the United States and may be higher in treatment failures 4
Do not retreat with another beta-lactam if Augmentin failed - the addition of clavulanate already addresses beta-lactamase producing organisms, so switching to clindamycin provides a different mechanism of action 1, 4
Do not assume the patient needs treatment if asymptomatic - routine post-treatment testing is not indicated 1, 4