What to do for fever, white spots, sore throat, and swallowing pain after finishing Amoxicillin for strep, with allergy to Tylenol and high dose of Advil?

Immediate Evaluation and Management for Recurrent Strep Symptoms After Amoxicillin

This patient requires urgent clinical evaluation for possible treatment failure, peritonsillar abscess, or other suppurative complication, with immediate pain control using ibuprofen (which is already being taken) and consideration of alternative antibiotic therapy if Group A Streptococcus is confirmed. 1

Immediate Pain Management

• Continue ibuprofen for fever and throat pain, as NSAIDs have demonstrated superior efficacy in reducing fever and pain in pharyngitis with strong, high-quality evidence 1, 2
• The 1600 mg dose mentioned is concerning if taken as a single dose (standard adult dosing is 400-600 mg every 6-8 hours, maximum 3200 mg/day) - clarify dosing to avoid toxicity
• Since the patient has a Tylenol (acetaminophen) allergy, ibuprofen remains the primary analgesic option 1
• Aspirin must be avoided if this is a child due to Reye syndrome risk 1

Critical Assessment Needed

White spots in the mouth with severe pain on swallowing 3 days after completing amoxicillin suggests several possibilities:

• Treatment failure - the amoxicillin course may not have eradicated the Group A Streptococcus 1
• Suppurative complication - peritonsillar abscess or other bacterial complication requiring urgent evaluation 3
• New viral infection - the patient may be a chronic GAS carrier experiencing a concurrent viral pharyngitis 1
• Candidiasis (thrush) - white spots could represent oral candidiasis, though this would be unusual after only 10 days of amoxicillin

Diagnostic Approach

Obtain a throat culture or rapid antigen detection test immediately to determine if Group A Streptococcus is still present 1, 4

• If positive, this represents either treatment failure or the patient being a chronic carrier with a new infection 1
• Physical examination must assess for:
  • Peritonsillar swelling or asymmetry (suggests abscess) 3
  • Trismus (difficulty opening mouth) - indicates possible abscess
  • Cervical lymphadenopathy
  • Ability to handle secretions

Antibiotic Management if GAS Confirmed

If Group A Streptococcus is confirmed and treatment failure is suspected, DO NOT repeat amoxicillin 1, 4

For Non-Anaphylactic Penicillin/Amoxicillin Allergy:

• First-generation cephalosporin is preferred: Cephalexin 500 mg orally twice daily for 10 days 4, 3
• Cross-reactivity risk is only 0.1% in non-immediate reactions 4

For Immediate/Anaphylactic Penicillin Allergy (or if cephalosporins contraindicated):

• Clindamycin is the preferred choice: 300 mg orally three times daily for 10 days 1, 4
• Clindamycin has only ~1% resistance among GAS in the United States and is particularly effective in chronic carriers and treatment failures 1, 4
• Alternative: Azithromycin 500 mg once daily for 5 days, though macrolide resistance is 5-8% in the US 1, 4

Critical Pitfalls to Avoid

• Do NOT assume this is simple treatment failure without ruling out suppurative complications - peritonsillar abscess requires drainage, not just antibiotics 2, 3
• Do NOT use cephalosporins if the original amoxicillin reaction was anaphylactic (hives, angioedema, bronchospasm within 1 hour) - up to 10% cross-reactivity risk 1, 4
• Do NOT prescribe macrolides (azithromycin, clarithromycin) without considering local resistance patterns - treatment failure rates can be significant 1, 5
• Do NOT give corticosteroids - they provide minimal benefit (only ~5 hours symptom reduction) and are not recommended 1

When to Refer for Emergency Evaluation

Immediate emergency department evaluation is needed if:

• Severe dysphagia with inability to swallow secretions (drooling)
• Respiratory distress or stridor
• Trismus (inability to open mouth)
• Unilateral tonsillar swelling suggesting peritonsillar abscess
• High fever unresponsive to ibuprofen
• Signs of dehydration from inability to drink

Chronic Carrier Consideration

If this patient has "Hx of strep++" (recurrent infections), consider that they may be a chronic pharyngeal GAS carrier experiencing repeated viral infections rather than true recurrent streptococcal pharyngitis 1, 4

• Chronic carriers generally do not require treatment as they are unlikely to spread GAS or develop complications 1, 4
• However, if treatment of a carrier state is desired (e.g., recurrent tonsillitis), clindamycin is most effective at eradicating carriage 4

Duration of Therapy

All antibiotics except azithromycin require a full 10-day course to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 4, 3

• Azithromycin requires only 5 days due to prolonged tissue half-life 1, 4
• Do not shorten courses despite clinical improvement - this dramatically increases treatment failure and complication risk 4