Management of Recurrent Fever and Sore Throat After Completing Amoxicillin for Strep Throat
This patient most likely has a viral upper respiratory infection superimposed on a Group A Streptococcus (GAS) carrier state, and antibiotics should be discontinued with supportive care only. 1
Understanding the Clinical Scenario
This presentation is extremely common and represents a diagnostic pitfall. The key facts are:
- True treatment failure with amoxicillin for strep pharyngitis is rare 1
- Up to 20% of school-aged children are chronic GAS carriers during winter and spring months, and these carriers can experience intercurrent viral infections that produce new symptoms while still harboring streptococci in their pharynx 1
- The patient had been asymptomatic for 7-8 days, which strongly suggests successful treatment of the initial strep infection 1
- Carriers are at very low risk for complications, including rheumatic fever, and are unlikely to spread infection to contacts 1
Recommended Management Approach
Primary Recommendation: Discontinue Antibiotics and Provide Supportive Care
- Discontinue any consideration of additional antibiotics, as continuing antibiotics for what is likely a viral infection provides no benefit and increases adverse effects and resistance 1
- Cough, congestion, and similar respiratory symptoms suggest a viral cause rather than bacterial infection 1
Symptomatic Treatment
- Ibuprofen or acetaminophen for fever and discomfort, with ibuprofen providing superior pain relief 1
- Avoid aspirin due to Reye syndrome risk in children 1
- Provide supportive care for viral upper respiratory symptoms 1
- Warm salt water gargles can provide symptom relief for patients old enough to gargle 2
- Topical agents containing anesthetics (ambroxol, lidocaine, benzocaine) may provide temporary symptomatic relief 2
When to Consider Alternative Antibiotic Therapy
Only consider retreatment if 1:
- Symptoms clearly worsen after initial improvement (not just new symptoms after being well)
- Fever and pharyngeal symptoms persist beyond 10 days without improvement
- The patient develops severe symptoms (difficulty swallowing, drooling, neck tenderness, or swelling)
If Retreatment is Necessary
- Any agent from standard treatment protocols is appropriate 1
- Intramuscular benzathine penicillin G can be considered if compliance with oral therapy is questionable 1
- For documented multiple recurrences, clindamycin or amoxicillin-clavulanate can be considered as these achieve higher carrier eradication rates 1
Common Pitfalls to Avoid
- Do not reflexively prescribe antibiotics for new symptoms after completing treatment for confirmed strep throat 1
- Do not routinely test asymptomatic patients who have successfully completed a course of antimicrobial therapy 3
- Do not confuse bacteriologic failure with clinical failure - while bacteriologic failure rates can be 20-30%, many represent carrier states rather than true treatment failures 4
- Clinical features alone cannot distinguish between viral pharyngitis in a GAS carrier versus true recurrent GAS infection 1
Patient Education
- Reassure parents that the typical course of a viral sore throat is less than 1 week 3
- Explain that antibiotics are not needed for viral infections and may cause harm 3, 2
- The patient should return if symptoms clearly worsen after initial improvement, persist beyond 10 days, or severe symptoms develop 1