What is the next step in managing an 18-year-old male with persistent sore throat despite completing a course of Augmentin (amoxicillin/clavulanate) and having a negative throat culture?

Management of Persistent Sore Throat After Negative Strep Test

Stop antibiotics immediately and provide symptomatic treatment only, as the negative throat culture effectively rules out group A streptococcal pharyngitis and continued antibiotic use provides no benefit while increasing risk of adverse effects. 1, 2

Immediate Management Steps

• Discontinue antimicrobial therapy - A negative throat culture is sufficient to rule out streptococcal pharyngitis, and withholding or discontinuing antibiotics for culture-negative patients is a key quality indicator 2
• Provide symptomatic relief with ibuprofen or acetaminophen for pain control, which have moderate evidence for effectiveness in acute sore throat 2
• Reassure the patient that most pharyngitis cases are viral and self-limiting, typically resolving within one week 2

Understanding the Clinical Picture

The persistent symptoms despite Augmentin treatment strongly suggest a viral etiology rather than treatment failure. Here's why:

• Viral pharyngitis accounts for 70-80% of all sore throat cases in this age group, and antibiotics provide no benefit 2
• The negative throat culture has 95% specificity, making false negatives extremely rare 1
• Switching from one antibiotic to another without microbiological indication increases adverse effects without clinical benefit 2

Key Diagnostic Considerations

Consider infectious mononucleosis if the following features are present:

• Severe pharyngitis with tonsillar exudate
• Generalized lymphadenopathy (not just anterior cervical)
• Significant fatigue or malaise
• Prolonged symptom duration (>1 week) 3

Evaluate for non-infectious causes if symptoms persist beyond 3-4 weeks:

• Gastroesophageal reflux disease (GERD)
• Chronic postnasal drip from allergies
• Environmental irritants 3

When to Reassess

• If symptoms worsen significantly or persist beyond 3-4 days, consider suppurative complications (peritonsillar abscess, retropharyngeal abscess) or alternative diagnoses 2
• Red flag symptoms requiring urgent evaluation include:
  • Difficulty swallowing saliva (drooling)
  • Severe difficulty breathing
  • Muffled "hot potato" voice
  • Trismus (inability to open mouth)
  • These may indicate epiglottitis or peritonsillar abscess 4, 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical appearance alone - even severe exudate and white patches occur commonly with viral infections and cannot reliably distinguish bacterial from viral causes 2
• Do not test or treat asymptomatic household contacts - this is not recommended even with recurrent infections, as up to one-third of households include asymptomatic GAS carriers 2
• Avoid repeated courses of antibiotics without confirming bacterial etiology - this contributes to antimicrobial resistance without clinical benefit 3

The Carrier State Consideration

The patient may be a chronic GAS carrier (15% prevalence in this age group during winter/spring) experiencing a viral pharyngitis superimposed on colonization 1. This explains why:

• The initial culture may have been falsely interpreted as negative if not properly obtained
• Antibiotics failed to resolve symptoms (treating colonization, not infection)
• Symptoms persist (due to ongoing viral infection) 1

However, since the throat culture was negative, this is less likely, and viral pharyngitis remains the most probable diagnosis 2.

Follow-Up Strategy

• No routine follow-up testing is needed if symptoms resolve with symptomatic treatment 2
• If symptoms persist beyond one month despite appropriate management, consider referral to otolaryngology for direct visualization and possible tissue sampling to evaluate for less common causes 3
• Monospot testing should be performed if infectious mononucleosis features develop 3