Restart Augmentin After Premature Discontinuation for Strep Throat
You should restart a full 10-day course of amoxicillin-clavulanate (Augmentin) immediately, as stopping at 6 days has allowed the infection to relapse and incomplete treatment markedly increases the risk of acute rheumatic fever and treatment failure. 1, 2
Why Symptoms Returned After Stopping Early
- Premature discontinuation at 6 days fails to achieve maximal pharyngeal eradication of Group A Streptococcus, even though symptoms typically improve within 3–4 days of starting therapy. 1, 2
- The primary goal of treating strep throat is preventing acute rheumatic fever and suppurative complications through complete bacterial eradication, not merely symptom relief; shortening the course by even a few days results in appreciable increases in treatment failure rates and rheumatic fever risk. 1, 2
- Bacteriologic failure occurs in approximately 20–30% of cases when treatment duration is inadequate, and many of these failures manifest as clinical recurrence within days to weeks. 2, 3
Recommended Management
Restart Full Antibiotic Course
- Prescribe amoxicillin-clavulanate 875 mg/125 mg orally twice daily for a complete 10-day course (or until symptom-free for 7 consecutive days, typically 10–14 days total), starting immediately. 1, 4
- Do not simply "finish" the remaining 4 days; the interruption has allowed bacterial regrowth, and a full 10-day course from restart is essential to achieve adequate eradication. 1, 2
- Emphasize to the patient that the medication must be taken exactly as directed for the full duration, even when symptoms improve after 2–3 days, to prevent acute rheumatic fever and future treatment failures. 4
Why Augmentin Remains Appropriate
- Amoxicillin-clavulanate provides 90–92% predicted clinical efficacy against Group A Streptococcus and covers β-lactamase-producing oral flora that can shield streptococci from penicillin activity, a mechanism implicated in treatment failures. 5, 6, 7, 8
- The clavulanate component inhibits β-lactamases produced by commensal organisms (Staphylococcus aureus, Haemophilus influenzae, anaerobes) that may have contributed to the initial treatment failure. 7, 8, 3
- Bacteriological failure and clinical recurrence are strongly associated with β-lactamase activity in saliva (present in approximately 19% of patients); co-amoxiclav addresses this mechanism. 3
Alternative Regimens (If Augmentin Cannot Be Used)
If Patient Cannot Tolerate Augmentin
- Switch to clindamycin 300 mg orally three times daily for 10 days, which demonstrates substantially higher eradication rates than penicillin or amoxicillin in treatment failures and chronic carriers, with only ~1% resistance among U.S. Group A Streptococcus isolates. 1, 9
- Clindamycin is the optimal choice for documented treatment failures because it achieves superior bacterial eradication even in chronic carriers and persistent infections. 1, 9
If Penicillin Allergy Is Present
- For non-immediate (delayed) penicillin allergy: first-generation cephalosporin (cephalexin 500 mg twice daily for 10 days) with cross-reactivity risk of only ~0.1%. 1, 9
- For immediate/anaphylactic penicillin allergy: clindamycin 300 mg three times daily for 10 days (preferred) or azithromycin 500 mg once daily for 5 days (acceptable but with 5–8% macrolide resistance). 1, 9
Adjunctive Symptomatic Care
- Offer acetaminophen or ibuprofen for moderate-to-severe sore throat, fever, or systemic discomfort. 1, 9
- Avoid aspirin in children due to Reye syndrome risk. 1, 9
- Corticosteroids are not recommended as adjunctive therapy for streptococcal pharyngitis. 1, 9
Monitoring and Follow-Up
- Reassess at 48–72 hours after restarting antibiotics; lack of improvement may indicate non-compliance, an alternative diagnosis, or a suppurative complication requiring urgent evaluation. 9
- Do not order routine post-treatment throat cultures for asymptomatic patients who have completed the full 10-day course; reserve testing for special circumstances such as prior rheumatic fever. 1, 9
Critical Pitfalls to Avoid
- Never prescribe a duration shorter than 10 days (except azithromycin's 5-day regimen) for strep throat, as this dramatically increases treatment failure and rheumatic fever risk. 1, 9, 2
- Do not assume the patient is a chronic carrier without confirming compliance with the initial regimen; premature discontinuation is the most common cause of recurrent symptoms. 1
- Ensure the patient understands that symptom improvement does not mean the infection is eradicated; the full 10-day course is mandatory to prevent acute rheumatic fever. 1, 2, 4
Patient Counseling Points
- Explain that stopping antibiotics early allowed the bacteria to regrow, and a full 10-day course from restart is now required to completely eliminate the infection. 1, 2, 4
- Emphasize that skipping doses or not completing the full course (1) decreases the effectiveness of treatment and (2) increases the likelihood that bacteria will develop resistance and become untreatable. 4
- Counsel that diarrhea is a common side effect (occurring in 40–43% of patients taking amoxicillin-clavulanate); if severe or lasting >2–3 days, the patient should contact their physician. 5, 4
- Advise taking each dose with a meal or snack to reduce gastrointestinal upset. 4