Infections of the Ear |
External otitis | Gram-negative rods (Pseudomonas, Enterobacteriaceae, Proteus) or fungi (Aspergillus) | Otic drops containing a mixture of an aminoglycoside and corticosteroids, such as neomycin sulfate and hydrocortisone | In refractory cases, particularly if there is cellulitis of the adjacent periauricular tissue, oral fluoroquinolones such as ciprofloxacin 500 mg twice a day can be used for their antipseudomonal activity. However, there is increasing resistance being reported. Acute infection may be due to Staphylococcus aureus; dicloxacillin 500 mg 4 times a day may be used. |
Malignant external otitis | Pseudomonas aeruginosa | Antibiotics with antipseudomonal activity (such as ciprofloxacin) for a prolonged period until there is radiographic evidence of improvement. | Surgical debridement may be necessary 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 4–6 weeks. |
Acute otitis media | Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses (RSV, rhinoviruses) | Amoxicillin is the first drug of choice at 45 mg/kg/d in two or three divided doses. If drug resistance is suspected, a higher dose of amoxicillin or amoxicillin–clavulanate (90 mg/kg/d) may be used. Prevention of recurrent acute otitis media may be treated with oral doses of sulfisoxazole 50 mg/kg or amoxicillin 20 mg/kg at bedtime. If this strategy fails, the insertion of ventilating tubes may be necessary. | Treatment is a combination of antibiotics and nasal decongestants. Without treatment, there may be a spontaneous resolution of illness (less likely with S pneumoniae). |
Mastoiditis | S pneumoniae, Streptococcus pyogenes, H influenzae, and P aeruginosa | Myringotomy for culture and drainage and ceftriaxone, 1 g IV every 24 hours. | Antibiotics may be modified based on culture results. |
Infections of the Nose & Paranasal Sinuses |
Rhinitis (common cold) | Can be caused by a variety of viruses, including several serologic types of rhinoviruses and adenoviruses | Mainly reassurance of the patient and supportive therapy, such as decongestants (pseudoephedrine 30–60 mg every 4–6 hours). Nasal sprays such as oxymetazoline or phenylephrine can be immediately effective but must not be used for more than a few days at a time since rebound congestion may occur. | Secondary (bacterial) infection may occur and present as acute sinusitis. |
Acute sinusitis | S pneumoniae, H influenzae, M catarrhalis, Group A streptococcus, anaerobes, viruses, and S aureus | Amoxicillin or amoxicillin–clavulanate 500 mg by mouth 3 times a day is a reasonable first choice. If drug-resistant S pneumoniae is suspected, an oral fluoroquinolone such as levofloxacin may be used. | Because two-thirds of untreated patients will improve symptomatically within 2 weeks, antibiotic treatment is usually reserved for those who have maxillary or facial pain (or both), and purulent nasal discharge after 7 days of decongestants and analgesics. In cases of clinical failure, endoscopic sampling or maxillary sinus puncture can yield a specimen for microbiologic evaluation and the targeted selection of antibiotics. |
Sinusitis in an immunocompromised host | Various molds, including Aspergillus and Mucormycosis | Wide surgical debridement and amphotericin B. Liposomal amphotericin, the echinocandins, and the new broad-spectrum azoles may be alternatives in appropriate patients. | These molds are highly angioinvasive and rapid dissemination and death can occur if they are not recognized in a timely fashion. |
Infections of the Oral Cavity & Pharynx |
Candidiasis (thrush) | Candida albicans (usually) | Fluconazole (100 mg by mouth daily for 7–14 days) or an oral solution of itraconazole (200 mg by mouth once daily) | AIDS patients may have fluconazole-resistant disease and may be treated with higher doses of fluconazole or itraconazole solution, or with amphotericin B administered intravenously. |
Necrotizing ulcerative gingivitis (trench mouth, Vincent infection) | Usually coinfection with spirochetes and fusiform bacilli | Penicillin, 250 mg 3 times a day orally, with peroxide rinses | Clindamycin for patients with penicillin allergies. |
Aphthous stomatitis (canker sore, aphthous ulcers) | Unknown, although human herpesvirus 6 is suspected | Mainly untreated. Options include topical steroids (eg, Kenalog in Orabase), other compounds such as mouthwashes containing amyloglucosidase and glucose oxidase, or a short course of systemic steroids. | Immunocompromised hosts, such as HIV-positive patients, may have more severe disease. |
Herpetic stomatitis | Reactivation of herpes simplex virus 1 or 2 | Oral acyclovir 400 mg 3 times daily, famciclovir 125 mg 3 times daily for 5 days, or valacyclovir 500 mg twice a day for 5 days may decrease healing time if initiated within 48 hours from the onset of symptoms. For recurrent disease, suppression with acyclovir 400 mg twice a day, famciclovir 250 mg twice daily, or valacyclovir 1 g daily is effective. | Most adults require no intervention. Immunocompromised hosts, such as HIV-positive patients, may have more severe and acyclovir-resistant disease and should be treated. |
Pharyngitis | Group A, C, and G (β-hemolytic) streptococci, viruses (EBV-related infectious mononucleosis), Neisseria gonorrhoeae, Mycoplasma pneumoniae, human herpesvirus 6, Corynebacterium diphtheriae, Arcanobacterium haemolyticum, and Chlamydia trachomatis | Penicillin V (500 mg orally twice a day for 10 days), a single dose of benzathine penicillin intramuscularly (1–2 million units), or clarithromycin 500 mg by mouth twice a day for 10 days. If gonococcus is diagnosed, this may be treated with ceftriaxone 125 mg intramuscularly once, cefixime 400 mg orally in one dose, or cefpodoxime 400 mg orally in one dose. All patients with gonorrhea must also be treated for the possibility of concomitant genital Chlamydia trachomatis with azithromycin 1 g orally once, or doxycycline 100 mg orally twice daily for 7 days. | One of the main goals in management is to diagnose and treat Group A streptococcal infection and decrease the risk of rheumatic fever. |
Epiglottitis | H influenzae, Group A streptococcus, S pneumoniae, and S aureus | Ceftriaxone (50 mg/kg daily for children) or cefuroxime. Adjunctive steroids are sometimes given but are not of proven benefit. Urgent tracheostomy in children or intubation in adults may be necessary. | |
Parapharyngeal space infection (including Ludwig angina) | Often polymicrobial and include streptococcal species, anaerobes, and Eikenella corrodens | Clindamycin 600–900 mg intravenously every 8 hours, or a combination of penicillin and metronidazole | External drainage is sometimes necessary. |
Jugular vein septic phlebitis (Lemierre disease) | F necrophorum | Clindamycin, or a combination of penicillin and metronidazole | Surgical drainage of the lateral pharyngeal space and ligation of the internal jugular vein may be performed as well. |
Laryngitis | Viral (>90% of cases) | Antibiotics are not usually indicated | |
Sialadenitis | S aureus | Antistaphylococcal intravenous antibiotics such as nafcillin 2 g every 4 hours | |
Acute cervical lymphadenitis | Bartonella henselae (catscratch disease), Group A streptococcus, S aureus, anaerobes, M tuberculosis (scrofula), Mycobacterium avium, toxoplasmosis, and tularemia | Depends on the specific diagnosis after fine-needle aspiration is performed | |