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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
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* |
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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.
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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
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Otitis Media
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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
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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
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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.
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Mastoiditis
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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
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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)
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Acute Pharyngitis, Tonsilitis
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Viral: example Epstein
Barr Virus
Bacteria-
less common: Streptococcus
pyogenes
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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
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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
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Diphtheria Anti-toxin + Benzylpenicillin 2 - 3 MU IV per day divided 4 - 6 hourly
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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
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Peritonsillar Abscess (Quinsy)
Streptococcus pyogenes
Streptococcus
spp
Other gram positive aerobes
Anaerobes
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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
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Acute Epiglottitis (Supraglotitis)
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| Streptococcus pyogenes Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenza
Moraxella catarrhalis
Viruses eg.Epstein barr, herpes simplex, influenza
Parainfluenza
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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
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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 |
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Parapharyngeal Space Infection
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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&SDe-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. |
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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 2020
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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
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