A summary of empiric antimicrobial therapy for common conditions encountered in otolaryngology can be found in Table 2–1. In general, when culture and susceptibility data are finalized, it is important to use the narrowest agent possible. This may not only be cost effective in many cases but will also decrease selection pressure for the development of antimicrobial resistance. Note that a history of an allergy to penicillin in the past is not reliable. Only a small proportion of patients (< 5%) with a stated history of penicillin allergy actually experience an adverse reaction when challenged with the drug. If there are concerns, penicillin skin testing may be a helpful procedure to truly identify patients at risk of a true IgE-mediated reaction. All others can be safely prescribed β-lactams leading to a wider choice of agents and enhance our ability to use targeted therapy when possible.
Table 2–1Examples of initial antimicrobial therapy for selected conditions in head and neck infection. |Favorite Table|Download (.pdf) Table 2–1Examples of initial antimicrobial therapy for selected conditions in head and neck infection.
|Suspected Clinical Diagnosis ||Involved Organisms ||Empiric Treatment ||Comments |
|Infections of the Ear |
|External otitis || |
Gram-negative rods (Pseudomonas, Enterobacteriaceae), S aureus, S epidermidis, and anaerobic bacteria
Fungi (Candida and Aspergillus)
For mild disease, otic drops with acetic acid and hydrocortisone
For moderate to severe disease, otic drops containing a mixture of a fluoroquinolone or aminoglycoside with corticosteroids, such as ciprofloxacin or neomycin with hydrocortisone.
Duration: 7–10 days or less with symptom resolution
|In severe or recurrent cases, particularly if there is cellulitis of the adjacent periauricular tissue, oral fluoroquinolones such as ciprofloxacin 500 mg twice daily can be added for their antipseudomonal activity. However, increasing resistance is being reported. |
|Malignant external otitis ||Pseudomonas aeruginosa || |
Systemic antibiotics with antipseudomonal activity (such as ciprofloxacin or antipseudomonal β-lactam, tailored to susceptibilities)
Duration: prolonged period until there is radiographic evidence of improvement (see Comments)
|Surgical debridement often necessary, particularly if medical therapy is unsuccessful. It may also be necessary to rule out osteomyelitis by CT scan or MRI, as osteomyelitis requires prolonged therapy for 6–8 weeks. |
|Acute otitis media || |
Viruses (RSV, rhinoviruses)
S pneumoniae, H influenzae, and M catarrhalis
Amoxicillin is first-line (45 mg/kg/day PO in 2–3 divided doses for children; 500 mg PO 3 times daily for adults).
If drug resistance is suspected, a higher dose of amoxicillin or amoxicillin–clavulanate (90 mg/kg/day in 2–3 divided doses for children or 875/125 mg PO twice daily for adults) may be used.
If β-lactam allergy, alternative agents include cefdinir or levofloxacin/moxifloxacin depending on allergy severity.
Duration: 7–10 days
Treatment is a combination of antibiotics and nasal decongestants. Without treatment, there may be a spontaneous resolution of illness (less likely with S pneumoniae).
For recurrent otitis, the insertion of ventilating tubes may be necessary.
While generally not recommended, antibiotic prophylaxis to prevent recurrent acute otitis media in children may be considered.
|Mastoiditis ||S pneumoniae, group A streptococcus, H influenzae, S aureus, and P aeruginosa || |
For first acute episode, ceftriaxone (2 g IV daily)
If chronic, cover for S aureus and Pseudomonas with vancomycin and antipseudomonal β-lactam.
Duration: 14 days if acute, 3–4 weeks if chronic or complicated
|Myringotomy for culture and drainage. Antibiotics may be modified based ...|