4.05 - Ear, Nose and Throat Infection

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Otitis Externa

 
Acute localized
Staphylococcus aureus
Streptococcus pyogenes

 
Cloxacillin 500 mg PO q6H for 5 days
   
Duration: 5 days.

Antibiotics are only indicated in acute localized otitis externa and malignant / necrotising otitis externa (elderly, immunocompromised, diabetics).

In diffuse otitis externa, antibiotic is not indicated in the absence of fever, spread of infection to pinna or folliculitis.
Debridement required. Rule out OM with CT / MRI. 4 - 6 weeks of treatment if OM.

 
Malignant
Pseudomonas aeruginosa

 
Gentamicin 3 - 5 mg/kg IV q24H
+ Ceftazidime 2 gm IV q8H
(stop Gentamycin if susceptible to Ceftazidime)

 
Piperacillin / Tazobactam  4.5 gm IV q8H

Otitis Media


Viral
H influenza
Moraxella catarrhalis


Amoxicillin 500 mg PO q8H
OR Co-amoxiclav 625 mg PO q8H
 
Cefuroxime 750 mg PO q12H
 
Duration:   5 - 7 days (> 2 years)
               10 days (< 2 years)
 
After > 48 h of nasotracheal intubation. Pseudomonas sp
Klebsiella
Enterobacter

 
Ceftazidime 2 gm IV q8H
 
Piperacillin / Tazobactam  4.5 gm IV q8H
 
Duration: 14 days.

Treatment is only needed for:
  • High risk of suppurative complication (mastoiditis)
  • Children > 2 years: consider if symptoms persist for 2 days
  • Children 6 months - 2 years: as above, reassess after 24 hours
  • Children < 6 months: more likely to respond to antibiotics. Early review and treatment is needed for children with systemic features (vomiting, fever).

Mastoiditis


Acute outpatient:
Strep pneumoniae
S pyogenes
Staph aureus
H influenza
P aeruginosa


As per otitis media
 
 Duration: As per otitis media.
 
Acute inpatient:
Strep pneumoniae
S pyogenes
Staph aureus
H influenza
P aeruginosa


 Ceftriaxone 1 gm IV q24H
 

Chronic:
Often polymicrobial:
Anaerobes
S aureus
Enterobacteriaceae
P aeruginosa

After surgical debridement, start empirical antibiotics with Piperacillin / Tazobactam 4.5 gm IV q8H
 
Adjust antibiotics according to susceptibility.

Consider Vancomycin if patient colonised with MRSA, failure after 3 days of antibiotics.

Antibiotics indicated for patients given decongestants / analgesia for 10 days who have:
  • Maxillary facial pain
  • Purulent nasal discharge. Severe illness - fevers, pain - treat sooner, hospitalize 

Pharynx Tonsilitis Exudative or Diffuse Erythema

 
Streptococcus pyogenes
EBV

 
Penicillin V 500 mg PO q12H for 10 days
 

Penicillin allergy: Clindamycin 300 - 450 mg PO q6 - 8H for 5 days

Quinsy: Requires drainage, give IV Penicillin or Clindamycin + Metronidazole.

Diphtheria: Diphtheria anti-toxin + IV Penicillin or Erythromycin.

Antibiotics is only required if Streptococcus pyogenes is suspected: most likely in: fever > 38, tender cervical LN, tonsillar exudates, no cough, children 3 - 14 years or those at risk of non-suppurative complications (acute rheumatic fever and acute GN).

Epiglottitis (Supraglotitis)

 
Streptococcus pneumonia and viruses (adults)

Ceftriaxone 1 gm IV q24H
   

Parapharyngeal Space Infection; Peritonsillar Abscess

 
Empirical
Polymicrobial: Mostly Anaerobes. Strep sp, Eikenella corrodens

Lemierre's syndrome
Fusobacterium necrophonum

 
Piperacillin / Tazobactam  4.5 gm IV q8H
 
Clindamycin 600 - 900 mg IV q8H
 
Surgical drainage is mandatory for abscess.

Laryngitis

 
90% Viral
 
Not indicated

   

Sinuses and Paranasal Sinuses

 
Indication as above
 
Amoxycillin 500 mg PO q8H (No recent antibiotic use)
 
Co-amoxiclav 625 mg PO q8H
(Recent antibiotic use)

Consider diagnostic tap / aspiration if treatment.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Tonsillo - Pharyngitis

 
Bacteria:
S pyogenes (GABHS)
Other Streptococci (Groups C, G)
Mycoplasma pneumoniae
Chlamydia pneumoniae


Viruses:
Epstein-Barr virus
Coxsackie viruses

 

Penicillin V 10 - 15 mg/kg PO q6H for 10 days
OR
Amoxycillin 15 mg/kg (max 500 mg) PO q8H for 5 - 7 days
OR
Cefuroxime 10 - 15 mg/kg (max 500 mg) PO q12H for 5 - 7 days

 

Erythromycin Ethylsuccinate (EES) 15 - 25 mg/kg PO q12H
OR
Azithromycin 10 mg/kg (max 500 mg) PO q24H for 3 days




Follow-up for complications like acute rheumatic fever, carditis and acute post-streptococcal glomerulonephritis.

Acute Rhinosinusitis


Viruses:
Rhinoviruses (Common cold)

Bacteria:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
S pyogenes
S aureus

Anaerobes

 




Co-amoxiclav 15 mg/kg (Amoxicillin component) PO q12H
OR
Cefuroxime 10 - 15 mg/kg (max 500 mg) PO q12H
 




Clindamycin 6 mg/kg (max 300 mg) PO q6H
 
Vast majority caused by rhinoviruses and settle by 2-3 weeks. The top 3 bacteria account for > 90% of cases of secondary bacterial infection.

Prolonged therapy up to 10 - 14 days may be required.

Acute Otitis Media


Bacteria:
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
S pyogenes
(GABHS)
Staph aureus
Pseudomonas aeruginosa

 

Co-amoxiclav 15 mg/kg (Amoxicillin component) PO q12H
OR
Cefuroxime 10 - 15 mg/kg (max 500 mg) PO q12H
 

Ceftriaxone 50 mg/kg IM q24H for 3 - 5 days

Azithromycin 10 mg/kg PO q24H for 1 day; then 5 mg/kg q24H for 4 days
 
Consider treatment failure if symptoms not resolved by 48 hour.

Duration of oral therapy ranges from 5 days (> 2 years old) to 10 days (< 2 years old). Shorter duration for Azithromycin and Ceftriaxone.

Mastoditis

 
Bacteria:
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis

S pyogenes (GABHS)
Staph aureus (MSSA)
Anaerobes


 

Co-amoxiclav 25 mg/kg (Amoxicillin component) IV q8H
 

Ceftriaxone 50 mg/kg IM q24H