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Disease / Etiology
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Preferred
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Alternative
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Comments
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Otitis Externa
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Acute diffuse (swimmer's ear)
Staphylococcus aureus
Pseudomonas aeruginosa
Rarely:
Aspergillus / Candida (due to prolonged antibiotic use)
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Local ear drops (steroids + antibiotic) for 7 days |
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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.
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Acute localized
Staphylococcus aureus
Streptococcus pyogenes
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Cloxacillin 500 mg PO q6H
OR
Cefalexin 500 mg q6H
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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.
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Malignant
Pseudomonas aeruginosa
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Ceftazidime 2 gm IV q8H
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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
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Otitis Media
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H influenza
Moraxella catarrhalis
Streptococcus pneumoniae
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Amoxicillin 1 gm PO q8H
OR
Co-amoxiclav 625 mg PO q8H
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Cefuroxime 500 mg PO q12H |
Duration: 10 days. |
After > 48H of nasotracheal intubation
Pseudomonas sp
Klebsiella
Enterobacter
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Ceftazidime 2 gm IV q8H |
Piperacillin / Tazobactam 4.5 gm IV q6H
OR
Cefepime 2 gm IV q8H
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Duration: 14 days.
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Mastoiditis
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Acute outpatient:
Strep pneumoniae
S pyogenes
Staph aureus
H influenza
P aeruginosa
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As per otitis media |
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Duration: As per otitis media. |
Acute inpatient:
Strep pneumoniae
S pyogenes
Staph aureus
H influenza
P aeruginosa
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Cefepime 2 gm IV q8H |
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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
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Acute Pharynx Tonsilitis Exudative or Diffuse Erythema
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Streptococcus pyogenes
Viral: EBV
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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
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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
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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.
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Diphtheria
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Diphtheria Anti-toxin + Benzylpenicillin 2 - 3 MU IV per day divided 4 - 6 hourly
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Diphtheria Anti-toxin + Erythromycin 400 mg PO q6H or 800 mg PO q12H
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In children:
Diphtheria Anti-toxin + Benzylpenicillin 50,000 U/kg IV q6H
OR
Oral Erythromycin 20 mg/kg PO q12H (maximum 2 gm daily)
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Peritonsillar Abscess (Quinsy)
Streptococcus pyogenes
Other gram positive aerobes
Anaerobes
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Ampicillin / Sulbactam 3 gm IV q6H
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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
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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.
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Acute Epiglottitis (Supraglotitis)
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Streptococcus pyogenes or pneumonia and viruses (adults)
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Ceftriaxone 2 gm IV q24H |
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Duration: 5 days. |
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Parapharyngeal Space Infection
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Parapharangeal Abscess
Empirical
Polymicrobial: Mostly Anaerobes. Strep sp, Staph sp, H Eikenella corrodens
Lemierre's syndrome
Fusobacterium necrophonum
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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. |
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Laryngitis
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90% Viral |
Not indicated
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Acute Rhinosinusitis (ARS) - Refer flow chart from European Position Paper on Rhinosinusitis and Nasal Polyps 2012
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Acute:
Mostly viral
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Staphylococcus aureus
Viral
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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
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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:
- > 7 days of fever, sinus pain and tenderness, purulent nasal discharge.
- Severe symptoms + temperature > 39oC at the onset and lasting for > 3 days.
- 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. |
