3.05 - Ear, Nose and Throat Infection [updated]

A) Adults




Fokkens, W. J., et al. "Executive summary of EPOS 2020 including integrated car e pathways." Rhinology (2020).


Disease / Etiology

Preferred

Alternative

Comments

Otitis Externa

 

Acute diffuse (swimmer's ear)
Staphylococcus aureus
Pseudomonas aeruginosa

Other gram negatives

Poly-microbial


Rarely:
Aspergillus spp/ Candida spp (due to prolonged antibiotic use)


 

Ofloxacin 0.3% Ear drop 10 drops q24H for 3-7 days

±

Steroid ear drop*
   
In diffuse otitis externa, systemic antibiotics are 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 (refer to acute localized otitis external)

If fungal infection suspected, use ear drops that contain antifungal.

*not available in UMMC
 
Acute localized
Staphylococcus aureus
Streptococcus pyogenes

 
Cloxacillin 500 mg PO q6H for 5 days
 
OR

Cefalexin 500 mg q6H for 5 days

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

Surgical drainage or debridement usually required.

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

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



Malignant otitis externa:

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

Total duration: minimum 4 weeks. Duration is suggested and can be changed depending on clinical response.

 
Malignant
Pseudomonas aeruginosa

 
Ceftazidime 2 gm IV q8H


 
Piperacillin / Tazobactam  4.5 gm IV q6H

OR

Cefepime 2 gm IV q8H



Otitis Media


Viral


H influenza
Moraxella catarrhalis
Streptococcus pneumoniae

Amoxicillin 1 gm PO q8H 5-7 days
OR 
Co-amoxiclav 625 mg PO q8H 5-7 days

 
Cefuroxime 500 mg PO q12H 5-7 days

 

Total duration: 5-7 days. Duration is suggested and can be changed depending on clinical response.

 

If immediate penicillin allergy:

Co-trimoxazole (480mg) 2-3 tabs PO q12H

 
After > 48H of nasotracheal intubation 
Pseudomonas spp
Klebsiella spp
Enterobacter spp


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

OR

Cefepime 2 gm IV q8H

 

Obtain specimens for C&S


Duration:
10-14 days. Duration is suggested and can be changed depending on clinical response.

 

Mastoiditis


Acute
Streptococcus pneumoniae
Streptococcus pyogenes
Staphylococcus aureus
Haemophilus influenza
Pseudomonas aeruginosa (second episode)

Acute= generally too ill for outpatient therapy



Cefepime 2gm IV q8H


 Piperacillin-Tazobactam 4.5gm IV q6H

Obtain specimen (deep pus in the ear canal) for C&S.

De-escalate/streamline antibiotics once C&S result available

 

Surgical debridement/drainage if mastoid abscess.

Neurosurgical referral if suspicion of intracranial complications.

Total duration: 7-10 days. Duration is suggested and can be changed depending on clinical response.

Acute exacerbation of chronic otitis media

surgical debridement of auditory canal, then,

Vancomycin 15 - 20 mg/kg IV q8 - 12H

+

Piperacillin/ Tazobactam 4.5gm IV q6H



Chronic:
Often polymicrobial: 
Anaerobes
Staphylococcus aureus
Enterobacteriaceae
Pseudomonas aeruginosa

Mycobacterium tuberculosis

Good care of external auditory canal, ear drainage and culture and topical Ofloxacin 10 drops q12H for 2 weeks, is first line.

Surgical evaluation is indicated for cholesteatoma or consideration for  mastoidectomy.

If elective mastoidectomy is indicated, start a brief course of antibiotics based on culture results. If cultures are negative, start empirical antibiotics with


Piperacillin / Tazobactam 4.5 gm IV q6

 


Duration: Change to oral once clinically improved. Total duration is 5-7 days post mastoidectomy.
 



















Cefepime 2 gm IV q8H
+
Metronidazole 500 mg IV q8H

Indications for mastoidectomy:

Chronic drainage and evidence of osteomyelitis by MRI/CT

Evidence of spread to CNS (Epidural abscess, suppurative phlebitis, brain abscess)

Acute Pharyngitis, Tonsilitis 

 

Viral: example Epstein Barr Virus

 

Bacteria- less common: Streptococcus pyogenes


No antibiotic indicated

 

Benzathine Benzylpenicillin 1.2 MU IM single dose

OR

Penicillin V 500 mg PO q8-12H for 5 days

OR

Amoxicillin 500 mg PO q8H for 5days

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





Penicillin allergy:
Azithromycin 500 mg PO q24H for 5 days
OR
Clindamycin 300 mg PO  q8H for 5 days



Antibiotics are only required if *Streptococcus pyogenes is suspected: eg: fever > 38, tender cervical LN, tonsillar exudates

*High risk eg. existing rheumatic heart disease, scarlet fever


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

Total duration: 5 days. Duration is suggested and can be changed depending on clinical response.

 

Diphtheria- refer to guideline on Management of patients with suspected/ confirmed diphteria case in UMMC


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


If patient can take orally:


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

 

OR

Diphtheria Anti-toxin + Penicillin V PO 500mg q6H


Anti-toxin is the primary treatment. Antibiotic are not a substitute for anti-toxin.

IV antibiotics should be de-escalated to oral once clinical improvement occurs

Total duration: 14 days

 

Peritonsillar Abscess (Quinsy)
Streptococcus pyogenes

Streptococcus spp


Other gram positive aerobes
Anaerobes



Co-amoxiclav 1.2g IV q8H

Or

Ampicillin / Sulbactam 3 gm IV q6H

Cefazolin 2 gm IV q8H

+

Metronidazole 500 mg IV q6H

If penicillin allergy: 
Clindamycin 600 mg IV q8H



Surgical drainage is mandatory for abscess.
Obtain specimen for C&S

De-escalate/streamline Antibiotic once C&S result available.
IV antibiotics should be de-escalated to oral once clinical improvement occurs.



Total duration 10-14 days.
Depending on clinical improvement

Acute Epiglottitis (Supraglotitis)

Streptococcus pyogenes

Streptococcus pneumoniae

Staphylococcus aureus

Haemophilus influenza

Moraxella catarrhalis

Viruses eg.Epstein barr, herpes simplex, influenza

Parainfluenza



Ceftriaxone 2 gm IV q24H

 Co-amoxiclav IV 1.2g q8H

 

If immediate penicillin allergy:

Levofloxacin 750mg IV q24H

+

Clindamycin 600mg-900mg IV q6H

±

**Vancomycin 15-20mg/kg q8-12H  

 

IV antibiotics should be de-escalated to oral once clinical improvement occurs and patient able to tolerate orally
Total duration: 5 days.
Duration is suggested and can be changed depending on clinical response.

**If MRSA suspected

Parapharyngeal Space Infection

 
Parapharangeal Abscess
Empirical 
Polymicrobial: Mostly Anaerobes. Streptococcus  spp, Staphylococcus aureus

Lemierre's syndrome 
Fusobacterium necrophonum
 

Co-amoxiclav 1.2g IV q8H

OR

Ampicillin / Sulbactam 3 gm IV q6H

OR

Cefazolin 2 gm IV q8H
+
Metronidazole 500 mg IV q 8H


 
Clindamycin 600 mg - 900 mg IV q8H
 
Surgical drainage is mandatory for abscess. Obtain specimen for C&S

De-escalate/streamline Abx once C&S result available.

IV antibiotics should be de-escalated to oral once clinical improvement occurs


If penicillin allergy:
Clindamycin 600 mg - 900 mg IV q8H


Total duration: Minimum 2 weeks and until resolution of abscess/ clinical improvement.

Laryngitis

 
90% Viral
 
Not indicated

   

Acute Rhinosinusitis (ARS) - Refer flow chart from European Position Paper on Rhinosinusitis and Nasal Polyps 2020

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




Mild















Moderate/Severe
 










Amoxycillin 500 mg PO q8H for 5 days


OR
Co-amoxiclav 625 mg PO q 12 H for 5 days

OR

Cefuroxime 500 mg PO q12H for 5 days






Co-amoxiclav 1.2 gm IV q8H

OR

Cefuroxime 750mg-1500mg IV q8H





 









**

Doxycycline 100 mg PO q12H

OR

Azithromycin 500 mg PO q24H

 

 

 

 

 

Co-amoxiclav 625mg PO q8H

OR

Cefuroxime 500mg PO q12H

Avoid routine use of antibiotics for ARS.

Uncomplicated ARS resolves within 7-10 days without Antibiotic treatment.

 Consider Antibiotics if:

-   symptoms >7 days, purulent nasal discharge, sinus tenderness, maxillary toothache

-    severe symptoms and high fever at onset of illness and lasting > 3 days

-    worsening symptoms after initial improvement

**Immediate penicillin allergy:

Total duration of therapy 5 days.  Duration is suggested and can be changed depending on clinical response

Consider diagnostic tap / aspiration if treating with antibiotics. Send for culture

 




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