What should be done for a patient with a recent streptococcal (strep) infection, initially treated with amoxicillin and then transitioned to Augmentin (amoxicillin-clavulanate), who now reports their tonsils are touching?

Immediate Evaluation for Peritonsillar Abscess

This patient requires urgent evaluation for peritonsillar abscess given the acute worsening with "tonsils touching" despite appropriate antibiotic therapy, and if confirmed, needs immediate drainage plus antibiotic escalation to clindamycin or a respiratory fluoroquinolone. 1

Critical First Step: Rule Out Suppurative Complications

Before changing antibiotics, you must immediately assess for:

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and severe unilateral throat pain 1
• Ability to swallow: Drooling or inability to tolerate oral intake suggests airway compromise requiring immediate ENT consultation 1
• Systemic toxicity: High fever, severe pain, or respiratory distress 1

This clinical picture of acute worsening with "tonsils touching" after appropriate antibiotic therapy strongly suggests either peritonsillar abscess formation or severe tonsillar hypertrophy from treatment failure, not simple antibiotic resistance 1.

If Peritonsillar Abscess is Present

• Immediate needle aspiration or incision and drainage is required 1
• Continue antibiotics but this is now a surgical problem first 1

If No Abscess: Antibiotic Escalation Strategy

Since this patient has failed both amoxicillin and Augmentin (amoxicillin-clavulanate), the next step depends on age:

For Adults:

Switch to a respiratory fluoroquinolone (levofloxacin or moxifloxacin) as the single most effective option with 92% clinical efficacy and 100% bacteriologic efficacy in treatment failures 2, 3

Alternative options if fluoroquinolones are contraindicated:

• Clindamycin 300 mg three times daily for 10 days 2, 3
• Intramuscular ceftriaxone 1g daily for 5 days 2

For Pediatric Patients:

Clindamycin 20-30 mg/kg/day divided into 3 doses (maximum 300 mg/dose) for 10 days is the preferred option 2, 3

Alternative:

• Intramuscular ceftriaxone if compliance is a concern 1, 3

Why This Patient Failed Augmentin

The failure of Augmentin after amoxicillin suggests:

• Beta-lactamase producing organisms were already covered by clavulanate, so this is likely true treatment failure rather than resistance 4, 5
• Possible chronic carrier state with intercurrent viral infection, though the acute worsening makes active infection more likely 2
• Inadequate dosing or compliance - verify the patient received high-dose Augmentin (4g/250mg daily for adults or 90mg/6.4mg/kg/day for children) 2, 6

Critical Pitfalls to Avoid

• Do NOT use macrolides (azithromycin, clarithromycin) as they have only 77% clinical efficacy compared to 92% for fluoroquinolones, and resistance is common 2, 7
• Do NOT continue beta-lactam antibiotics after two failures - this suggests either abscess formation or a mechanism beyond simple bacterial resistance 1, 3
• Do NOT delay evaluation for abscess - "tonsils touching" with treatment failure is a red flag for suppurative complication 1

Mandatory 48-72 Hour Reassessment

• Patient must return if no improvement within 48-72 hours on new antibiotic 2, 1
• Immediate return if develops difficulty breathing, inability to swallow, severe unilateral pain, or drooling 1
• Consider ENT referral if second antibiotic fails, as this may represent chronic carrier state or need for tonsillectomy 2, 3

Symptomatic Management

• Continue acetaminophen or ibuprofen for pain control throughout therapy 1
• Ensure adequate hydration 1
• Complete full 10-day course even if symptoms improve earlier 2, 8