Can we give amoxicillin (amoxicillin-clavulanic acid) TID (three times a day) for 5 days to a 15-year-old patient with pharyngitis, cold, and cough in a setting where Group A Streptococcus (GAS) testing is not available?

No, Amoxicillin-Clavulanate TID for 5 Days is Not Appropriate for Pharyngitis Without GAS Testing

In settings without GAS testing, you should not prescribe antibiotics at all for pharyngitis in a 15-year-old with cough and cold symptoms, as these features strongly suggest viral etiology that does not require antibiotic treatment. 1

Why Testing is Essential Before Treatment

The presence of cough, rhinorrhea, and cold symptoms in this patient are classic viral features that make GAS pharyngitis unlikely 1. The IDSA guidelines explicitly state that testing for GAS pharyngitis is not recommended for patients with clinical features that strongly suggest viral etiology, including cough and rhinorrhea 1.

• Clinical features alone cannot reliably discriminate between GAS and viral pharyngitis, which is precisely why testing is required before prescribing antibiotics 1
• In adolescents, negative rapid antigen tests should be backed up by throat culture due to the risk of acute rheumatic fever in this age group 1
• Only 10% of adults seeking care for sore throat actually have GAS pharyngitis, yet 60% or more are prescribed antibiotics inappropriately 2

The Specific Problems with Your Proposed Regimen

Amoxicillin-clavulanate is not a first-line agent for GAS pharyngitis and should be reserved for treatment failures or chronic carriers 3. Even if GAS were confirmed, the correct regimen would be:

• Plain amoxicillin (not amoxicillin-clavulanate) at 50 mg/kg once daily for 10 days (not 5 days) 1, 4
• The clavulanate component adds unnecessary cost, broader spectrum activity, and increased gastrointestinal side effects without improving efficacy for uncomplicated GAS pharyngitis 1
• A 5-day course is inadequate for GAS pharyngitis—all antibiotics except azithromycin require a full 10-day course to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 5

What You Should Do Instead

If Testing is Truly Unavailable:

Provide symptomatic treatment only with acetaminophen or NSAIDs for moderate to severe symptoms or fever 1, 4. The viral features (cough, cold symptoms) make bacterial infection highly unlikely, and GAS pharyngitis is self-limited even without treatment 1.

If You Can Arrange Testing:

1. Use a rapid antigen detection test (RADT) if available—positive results are highly specific and do not require backup culture 1
2. Back up negative RADTs with throat culture in this 15-year-old adolescent, as the risk of acute rheumatic fever remains relevant in this age group 1
3. Only prescribe antibiotics if testing confirms GAS 1, 4

The Correct Treatment if GAS is Confirmed

If testing were to confirm GAS pharyngitis (unlikely given the viral features), the appropriate regimen would be:

• Amoxicillin 50 mg/kg once daily (maximum 1,000 mg) for 10 days 4
• Alternative: Penicillin V 500 mg twice daily for 10 days 4
• Never shorten the course below 10 days—this dramatically increases treatment failure rates and rheumatic fever risk 1, 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical features alone when viral symptoms (cough, rhinorrhea) are present 1
• Do not use amoxicillin-clavulanate as first-line therapy—it is reserved for treatment failures 3
• Do not prescribe 5-day courses of amoxicillin or amoxicillin-clavulanate—only azithromycin has evidence for a 5-day regimen due to its unique pharmacokinetics 1, 5
• Do not assume all sore throats need antibiotics—the majority are viral and resolve spontaneously in 3-4 days 1, 2