What is the best course of treatment for a patient with persistent sore throat and hoarseness despite 10 days of clindamycin (clindamycin) 450mg for suspected streptococcal pharyngitis (strep throat) and ear infection?

Treatment of Persistent Sore Throat and Hoarseness After Clindamycin Failure

The patient needs re-evaluation to confirm the diagnosis before prescribing additional antibiotics, as clindamycin is highly effective for Group A Streptococcus with only 1% resistance rates, suggesting either treatment failure, non-compliance, incorrect diagnosis, or a non-bacterial cause for persistent symptoms. 1, 2

Critical First Step: Reassess the Diagnosis

Before prescribing more antibiotics, confirm whether this is truly bacterial pharyngitis:

• Obtain a rapid antigen detection test (RADT) or throat culture now to determine if Group A Streptococcus is still present, as routine post-treatment cultures are not recommended for asymptomatic patients, but are appropriate when symptoms persist 1, 3
• If the RADT is positive, this represents true treatment failure with clindamycin, which is extremely rare given clindamycin's approximately 1% resistance rate among Group A Streptococcus in the United States 2, 4
• Consider that persistent hoarseness and sore throat after 10 days of appropriate antibiotics suggests either viral laryngitis, gastroesophageal reflux, or that the patient may be a chronic carrier experiencing a concurrent viral infection rather than active bacterial infection 1, 4

If Confirmed Bacterial Treatment Failure (Positive RADT/Culture)

Switch to a different antibiotic class with proven efficacy:

• First-line choice: Penicillin V 500 mg orally twice daily for 10 days - This is the gold standard with zero documented resistance worldwide and proven efficacy in preventing rheumatic fever 1, 4, 3
• Alternative: Amoxicillin 500 mg twice daily (or 1000 mg once daily) for 10 days - Equally effective as penicillin with the advantage of once-daily dosing to enhance adherence 1, 4, 3
• If penicillin allergy exists: First-generation cephalosporin (cephalexin 500 mg twice daily for 10 days) - Only if the patient has non-anaphylactic penicillin allergy, as cross-reactivity is only 0.1% in delayed reactions 2, 3

Why not continue clindamycin or increase the dose? Clindamycin has already been given for the full 10-day course at an appropriate dose (450 mg is within the recommended 300 mg three times daily range for adults), and repeating it is unlikely to be more effective unless there was a compliance issue 2, 5

If Negative RADT/Culture or Viral Etiology Suspected

Focus on symptomatic management only:

• Ibuprofen 400-600 mg every 6-8 hours or acetaminophen 650-1000 mg every 6 hours for pain relief and fever control - These are the recommended first-line symptomatic treatments 4, 3
• Warm salt water gargles may provide temporary relief 4
• Do not prescribe additional antibiotics if testing is negative, as this leads to unnecessary antibiotic exposure, resistance, and adverse effects without benefit 3

Critical Considerations for Hoarseness

Persistent hoarseness after 10 days suggests laryngeal involvement, which is typically viral:

• Viral laryngitis commonly causes hoarseness and can persist for 1-2 weeks beyond pharyngitis resolution 3
• Consider gastroesophageal reflux disease (GERD) as a cause of persistent throat symptoms and hoarseness, especially if symptoms worsen at night or after meals
• Voice rest and adequate hydration are important for laryngeal recovery

Common Pitfalls to Avoid

• Never prescribe antibiotics without confirming bacterial infection - Clinical features alone cannot reliably distinguish bacterial from viral pharyngitis, and most sore throats are viral 3, 6
• Do not assume treatment failure means antibiotic resistance - Consider non-compliance, incorrect diagnosis, or chronic carrier state with concurrent viral infection 1, 4
• Avoid prescribing broad-spectrum antibiotics when narrow-spectrum options like penicillin are effective and have zero resistance 1, 4
• Do not treat chronic carriers - They are unlikely to spread infection or develop complications and generally do not require antimicrobial therapy 2

When to Consider Alternative Diagnoses

If symptoms persist despite appropriate antibiotic therapy and negative cultures, consider:

• Peritonsillar abscess or other suppurative complications requiring imaging and possible drainage
• Infectious mononucleosis (Epstein-Barr virus) - presents with severe pharyngitis, fatigue, and lymphadenopathy
• Gonococcal pharyngitis in sexually active patients with appropriate exposure history
• Non-infectious causes: GERD, allergic rhinitis with post-nasal drip, vocal cord pathology