4.05 - Ear, Nose and Throat Infection

A) Adults

European Position Paper on Rhinosinusitis and Nasal Polyps 2012

European Position Paper on Rhinosinusitis and Nasal Polyps 2012

Disease / Etiology

Preferred

Alternative

Comments

Otitis Externa

 
Acute diffuse (swimmer's ear)
Staphylococcus aureus
Pseudomonas aeruginosa
Rarely:
Aspergillus / Candida (due to prolonged antibiotic use)

 
Local ear drops (steroids + antibiotic) for 7 days
   
In diffuse otitis externa, systemic antibiotic is not indicated in the absence of fever, spread of infection to pinna or folliculitis.
Aural toilet and keep external ear canal dry.
Systemic antibiotics may be needed in severely immunocompromised patients.

 
Acute localized
Staphylococcus aureus
Streptococcus pyogenes

 
Cloxacillin 500 mg PO q6H
 
OR

Cefalexin 500 mg q6H

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

Antibiotics are only indicated in acute localized otitis externa and malignant / necrotising otitis externa.

Culture from the ear drainage should be performed ideally before antimicrobial therapy is initiated.  

Debridement required.

 
Malignant
Pseudomonas aeruginosa

 
Ceftazidime 2 gm IV q8H


 
Piperacillin / Tazobactam  4.5 gm IV q6H

OR

Cefepime 2 gm IV q8H

Duration: minimum 4 weeks

Initial IV therapy for minimum 1 week. If initial response is good, switch to Ciprofloxacin PO 750 mg q12H

Otitis Media


H influenza
Moraxella catarrhalis
Streptococcus pneumoniae


Amoxicillin 1 gm PO q8H
OR
Co-amoxiclav 625 mg PO q8H

 
Cefuroxime 500 mg PO q12H
 
Duration: 10 days.
 
After > 48H of nasotracheal intubation 
Pseudomonas sp
Klebsiella
Enterobacter

 
Ceftazidime 2 gm IV q8H
 
Piperacillin / Tazobactam  4.5 gm IV q6H

OR

Cefepime 2 gm IV q8H

 
Duration: 14 days.

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


Cefepime 2 gm IV q8H
 

Chronic:
Often polymicrobial:
Anaerobes
S aureus
Enterobacteriaceae
P aeruginosa

After surgical debridement, start empirical antibiotics with Piperacillin / Tazobactam 4.5 gm IV q6H
 
Cefepime 2 gm IV q8H
+
Metronidazole 500 mg 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 

Acute Pharynx Tonsilitis Exudative or Diffuse Erythema

 
Streptococcus pyogenes
Viral: EBV


Benzathine Benzylpenicillin 1.2 MU IM single dose

OR

Penicillin V 500 mg PO q12H for 10 days

OR

Amoxicillin 500 mg PO q8H for 10 days

OR

Cephalexin 500 mg PO q8H for 10 days


Penicillin allergy:
Azithromycin 500 mg PO on Day 1, followed by 250 mg PO q24H Day 2 - 5

OR

Clindamycin 300 mg PO q6 - 8H for 5 days


Antibiotics is only required if Streptococcus pyogenes is suspected: most likely in: fever > 38, tender cervical LN, tonsillar exudates, no cough, children 2 - 25 years at risk of non-suppurative complications (acute rheumatic fever and acute GN) and existing rheumatic heart disease.

Management of acute rheumatic fever is discussed in the CVS section.

 
Diphtheria


Diphtheria Anti-toxin + Benzylpenicillin 2 - 3 MU IV per day divided 4 - 6 hourly


Diphtheria Anti-toxin + Erythromycin 400 mg PO q6H or 800 mg PO q12H


In children:
Diphtheria Anti-toxin + Benzylpenicillin 50,000 U/kg IV q6H
OR
Oral Erythromycin 20 mg/kg PO q12H (maximum 2 gm daily)

 
Peritonsillar Abscess (Quinsy)
Streptococcus pyogenes
Other gram positive aerobes
Anaerobes


Ampicillin / Sulbactam 3 gm IV q6H


Benzylpenicillin 20 MU IV per day in 4 divided doses
OR
Cefazolin 2 gm IV q8H

+ Metronidazole 500 mg IV q6H

If penicillin allergy: 
Clindamycin 600 mg IV q8H


Surgical drainage is mandatory for abscess.

May convert to oral once afebrile and clinically improved.

Total duration 14 days. Course < 10 days associated with recurrence. 

Acute Epiglottitis (Supraglotitis)

 
Streptococcus pyogenes or pneumonia and viruses (adults)


Ceftriaxone 2 gm IV q24H
   
Duration: 5 days.

Parapharyngeal Space Infection

 
Parapharangeal Abscess
Empirical
Polymicrobial: Mostly Anaerobes. Strep sp, Staph sp, H Eikenella corrodens

Lemierre's syndrome
Fusobacterium necrophonum

 
Benzylpenicillin 24 MU per day divided q4 - 6H
+
Metronidazole IV 500 mg q6H

OR

Ampicillin / Sulbactam 3 gm IV q6H

OR

Cefazolin 2 gm IV q8H
+
Metronidazole 500 mg IV q6H

 
Piperacillin / Tazobactam 4.5 gm IV q6H

OR

If penicillin allergy:
Clindamycin 600 mg - 900 mg IV q8H
 
Surgical drainage is mandatory for abscess.

Duration: Minimum 2 weeks until resolution of abscess. Parenteral antibiotics are preferred throughout the whole course.

Laryngitis

 
90% Viral
 
Not indicated

   

Acute Rhinosinusitis (ARS) - Refer flow chart from European Position Paper on Rhinosinusitis and Nasal Polyps 2012

 
Acute:
Mostly viral
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus
Viral

 
If no recent use of antibiotics,
Amoxycillin 500 mg PO q8H

Recent antibiotic use,
Co-amoxiclav 625 mg PO q8 - 12 H

OR

Cefuroxime 500 mg PO q12H for 5 days

OR

Ampicillin / Sulbactam 1.5 - 3 gm IV q6H

OR

Co-amoxiclav 1.2 gm IV q8H

 
Immediate Beta-lactam allergy:
Doxycycline 100 mg PO q12H

OR

Azithromycin 500 mg PO q24H

Avoid routine use of antibiotics for ARS.

There is high rate of spontaneous resolution of uncomplicated infection within 7 - 10 days without antibiotics:
  1. > 7 days of fever, sinus pain and tenderness, purulent nasal discharge.
  2. Severe symptoms + temperature > 39oC at the onset and lasting for > 3 days.
  3. Worsening of symptoms after initial improvement ("double sickening")
Consider diagnostic tap / aspiration if treating with antibiotics.

Duration of therapy 5 - 7 days depends on clinical response.


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