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A 14 yr old girl with sore throat cough with expectorant with fever and dysphagia for 3 days On examination hyperemia of tinsils uvula and post pharynx seen Dd Mx

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pharyngitis AND children

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CDC clinical guidance group A streptococcal pharyngitis children testing treatment

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https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/stre…

Likely diagnosis: acute pharyngotonsillitis, probably viral because cough with expectoration is present. Fever, dysphagia, and tonsillopharyngeal erythema can also occur with group A streptococcal (GAS) pharyngitis, but cough makes GAS less likely.

Differential diagnosis

  1. Acute viral pharyngitis / viral URTI - most likely
    • Rhinovirus, influenza, adenovirus, parainfluenza, COVID-19
    • Cough, coryza, hoarseness, conjunctivitis, oral ulcers, or diarrhoea support viral cause.
  2. GAS acute tonsillopharyngitis
    • More likely with abrupt severe sore throat, high fever, tender anterior cervical nodes, tonsillar exudate or palatal petechiae, scarlatiniform rash, and absence of cough.
    • In children/adolescents, clinical criteria alone cannot reliably confirm it. Textbook of Family Medicine, p. 268.
  3. Infectious mononucleosis (EBV)
    • Marked fatigue, generalized or posterior cervical lymphadenopathy, hepatosplenomegaly, prominent exudative tonsillitis.
  4. Influenza / COVID-19
    • Fever and cough with myalgia, headache, or household/community exposure.
  5. Peritonsillar cellulitis or abscess
    • Usually unilateral severe pain, muffled "hot-potato" voice, trismus, uvular deviation, drooling.
  6. Retropharyngeal/parapharyngeal infection or epiglottitis - urgent exclusions
    • Toxic appearance, neck swelling/stiffness, drooling, stridor, respiratory distress, inability to swallow secretions.
  7. Less likely depending on context: diphtheria (adherent grey pseudomembrane, incomplete immunization), herpangina, oral candidiasis, gonococcal pharyngitis, or Mycoplasma pneumoniae infection with lower-respiratory features. K J Lee’s Essential Otolaryngology, p. 685.

Management

1. Assess severity and airway first

Check:
  • Temperature, pulse, respiratory rate, SpO₂, hydration and urine output
  • Ability to drink and swallow saliva
  • Cervical lymph nodes, tonsillar exudate, palatal petechiae, rash
  • Chest examination because productive cough may indicate bronchitis or pneumonia
  • Look specifically for trismus, uvular displacement, neck swelling, drooling, stridor, muffled voice.
Urgent ENT/emergency referral if airway symptoms, drooling, stridor, respiratory distress, toxic appearance, dehydration, inability to take oral fluids, trismus/uvular deviation, neck swelling, or worsening after 3 to 5 days.

2. Investigations

  • If clear viral features are present, such as cough/coryza/conjunctivitis, manage clinically as viral pharyngitis. GAS testing is usually unnecessary.
  • If GAS remains clinically suspected: perform rapid antigen detection test (RADT) or throat culture.
  • In children and adolescents, a negative RADT should be backed up by throat culture. CDC strep guidance
  • Consider CBC and EBV testing if prolonged illness, generalized/posterior lymphadenopathy, hepatosplenomegaly, or marked fatigue.
  • Consider influenza/COVID testing if it changes isolation or antiviral decisions.

3. Supportive treatment

  • Oral fluids, soft diet, rest.
  • Paracetamol/acetaminophen: 10-15 mg/kg/dose every 4-6 hours as needed, maximum 75 mg/kg/day, not exceeding 4 g/day.
  • Ibuprofen: 5-10 mg/kg/dose every 6-8 hours with food if well hydrated and no renal disease, gastritis, bleeding risk, or NSAID-sensitive asthma. Maximum 40 mg/kg/day.
  • Warm salt-water gargles if able, and throat lozenges for an older child.
  • Avoid aspirin in children/adolescents.
  • Cough syrups with multiple ingredients are usually not helpful; assess the cough and chest clinically instead.

4. Antibiotics

Do not prescribe antibiotics for presumed viral pharyngitis. Most pharyngitis is viral, and antibiotics should not be given without positive GAS testing unless there is another clear bacterial diagnosis. Red Book 2021, p. 1335.
If RADT/culture confirms GAS:
  • Amoxicillin 50 mg/kg orally once daily, maximum 1 g/day, for 10 days, or
  • Penicillin V 250 mg 2-3 times daily for 10 days in children/adolescents, depending on local protocol/weight.
  • Use an appropriate alternative only if genuine penicillin allergy, guided by allergy type and local resistance patterns.
Penicillin or amoxicillin are first-line therapies for confirmed GAS. Delaying treatment briefly for culture results does not compromise prevention of rheumatic fever, provided treatment is begun within 9 days of symptom onset. Textbook of Family Medicine, p. 268.

Working impression for this case

At present: acute viral pharyngotonsillitis with associated URTI/acute bronchitis is more likely than GAS, due to the cough with expectoration. Examine the chest, treat symptomatically, ensure hydration, and test for GAS only if the overall findings create sufficient suspicion or if viral features are absent/unclear.

I prescribe her amoxyclav half adult dose of 635 mg TDS

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acute pharyngitis children antibiotics

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CDC group A strep pharyngitis recommended amoxicillin dosage children 50 mg kg 10 days

Do you mean amoxicillin-clavulanate 625 mg three times daily (usually 500 mg amoxicillin + 125 mg clavulanate per tablet)? There is no usual “635 mg” adult formulation, so verify the exact pack strength.
For uncomplicated acute pharyngitis/tonsillitis, I would not routinely use co-amoxiclav, particularly with cough suggesting a viral URTI. If GAS is confirmed or strongly suspected, plain amoxicillin or penicillin V for 10 days is preferred. Clavulanate adds broader spectrum and more diarrhoea risk without routine benefit for simple strep throat. Red Book 2021, p. 1335. The CDC guidance likewise recommends penicillin or amoxicillin for confirmed GAS.
If you have already prescribed it:
  • A 14-year-old may receive an adult formulation only if she weighs at least 40 kg and has normal renal function.
  • 625 mg TDS gives amoxicillin 1.5 g/day plus clavulanate 375 mg/day. That is generally more clavulanate than needed for pharyngitis, and TDS use raises GI adverse-effect risk.
  • Do not use it simply for pharyngeal erythema and fever without bacterial evidence. A rapid strep test, with culture confirmation after a negative test in children/adolescents if suspicion persists, is preferable.
  • Product strengths vary, so dosing must be based on the amoxicillin component, body weight, renal function, allergy history, and suspected site of infection.
If there are chest signs of bacterial lower respiratory infection, sinusitis, otitis media, dental infection, or a deep neck infection, the indication and regimen may differ. Reassess urgently if she has dyspnoea, low SpO₂, persistent high fever, dehydration, drooling, trismus, muffled voice, unilateral swelling, or uvular deviation.

How should I dose antibiotics based on her weight?

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streptococcal pharyngitis children treatment

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site:cdc.gov group A streptococcal pharyngitis amoxicillin 50 mg/kg once daily 10 days

For this presentation, first decide whether an antibiotic is indicated. Cough suggests viral pharyngitis, so do not dose an antibiotic unless GAS is confirmed by RADT/throat culture or another bacterial infection is identified.

If GAS pharyngitis is confirmed

Use plain amoxicillin, dosed by the amoxicillin component:
  • 50 mg/kg/day orally once daily for 10 days, maximum 1,000 mg/day,
    or
  • 25 mg/kg/dose orally twice daily for 10 days, maximum 500 mg per dose.
Example: if she weighs 40 kg:
  • 50 × 40 = 2,000 mg/day by calculation, but the maximum applies.
  • Prescribe amoxicillin 1 g once daily for 10 days, or 500 mg twice daily for 10 days.
Alternative, if penicillin V is used:
  • Weight <27 kg: 250 mg orally twice or three times daily for 10 days
  • Weight ≥27 kg: 500 mg orally twice daily for 10 days.
CDC GAS pharyngitis guidance recommends penicillin or amoxicillin as first line. Red Book 2021, p. 1335.

About amoxicillin-clavulanate (co-amoxiclav / Augmentin)

It is not first-line for uncomplicated GAS pharyngitis. Do not use “half an adult dose” as a dosing method. If it is needed for a different confirmed indication, calculate the dose from the amoxicillin amount only, not the total combination tablet weight.
For example, a 625 mg tablet usually contains:
  • Amoxicillin 500 mg
  • Clavulanate 125 mg
So 625 mg TDS means amoxicillin 500 mg TDS = 1,500 mg/day and clavulanate 375 mg/day. That is unnecessary clavulanate exposure for simple sore throat and commonly causes diarrhoea.
If a clinician has a separate indication for co-amoxiclav, common pediatric dosing is expressed as 25-45 mg/kg/day of amoxicillin, divided every 12 hours, using a formulation with the lowest suitable clavulanate ratio. The exact regimen depends on the diagnosis, product strength, renal function, and local guideline.
Please provide her exact weight in kg, the formulation available (for example, 400/57 mg per 5 mL, 228.5/32.5 mg per 5 mL, or 625 mg tablet), and whether GAS testing was positive. Then the exact calculated dose in mL/tablets can be worked out safely.

Formula of dose calculation on weight

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CDC strep throat amoxicillin pediatric dosage formula mg kg day 10 days

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streptococcal pharyngitis children treatment

General formula for pediatric weight-based dosing

[ \boxed{\text{Dose per administration (mg)} = \frac{\text{prescribed dose (mg/kg/day)} \times \text{weight (kg)}}{\text{number of doses/day}}} ]
Then apply the drug-specific maximum daily dose and maximum single dose.
For liquid medicines:
[ \boxed{\text{Volume (mL per dose)} = \frac{\text{required dose per administration (mg)}}{\text{concentration (mg/mL)}}} ]
If labeled as “X mg per 5 mL”:
[ \boxed{\text{mL per dose} = \frac{\text{required dose (mg)} \times 5}{\text{strength (mg per 5 mL)}}} ]

Worked example: amoxicillin for confirmed GAS pharyngitis

Usual regimen: 50 mg/kg/day once daily, maximum 1,000 mg/day, for 10 days.
For a 30 kg child:
[ 50 \text{ mg/kg/day} \times 30 \text{ kg} = 1500 \text{ mg/day} ]
But the maximum is 1,000 mg/day, so prescribe:
[ \boxed{1000 \text{ mg once daily for 10 days}} ]
If using twice-daily dosing:
[ \text{Dose per dose} = \frac{25 \text{ mg/kg/dose} \times \text{weight (kg)}}{1} ]
For 20 kg:
[ 25 \times 20 = 500 \text{ mg per dose, twice daily} ]
Maximum is 500 mg per dose.

Example conversion to suspension

If the required dose is 500 mg and the suspension is 250 mg/5 mL:
[ \frac{500 \times 5}{250} = 10 \text{ mL} ]
So give 10 mL per dose.

Safety check sequence

  1. Confirm indication and antibiotic.
  2. Look up the regimen in mg/kg/day or mg/kg/dose.
  3. Use the child’s current weight in kg.
  4. Divide by doses/day only if the regimen is written per day.
  5. Apply maximum dose limits.
  6. Convert mg to mL using the exact bottle concentration.
  7. For combination drugs such as co-amoxiclav, calculate using the amoxicillin component, not total tablet/suspension strength.
For simple suspected strep throat, amoxicillin or penicillin is preferred over co-amoxiclav. Red Book 2021, p. 1335.
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