Antibiotics - ENT



Acute Pharyngitis Tonsillitis

Infection

Acute pharyngitis tonsillitis

Most likely organisms Viruses, S. pyogenes
Empiric treatment

No antibiotic if viral.

Severe: Benzyl penicillin 1.2-2.4g q6h iv
plus
Metronidazole 500mg q8h IV / 400mg q8h po.

Moderate: Amoxicillin 500mg - 1g q8h po.

In penicillin allergy

Clarithromycin* 500mg q12h po/iv. In severe, hospitalised cases, add Metronidazole 500mg q8h iv / 400mg q8h po.

Duration

10 days.

Comments

Majority viral, most patients do not benefit from antibiotics. Consider infectious mononucleosis.

* Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.


If MUH / SIVUH

No antibiotic if viral.

Severe: Benzyl penicillin 1.2-2.4g q6h iv
plus
Metronidazole 500mg q8h IV / 400mg q8h po.

Moderate: Penicillin V 666mg q6h po.


Vincent's Angina

Acute necrotising ginguvitis

Infection

Vincents Angina (acute necrotising gingivitis)

Most likely organisms Oral anaerobes
Empiric treatment

Benzylpenicillin 1.2-2.4g q4-6h iv
plus
Metronidazole 400mg q8h po.

Oral switch: Amoxicillin 500mg q8h po
plus
Metronidazole 400mg q8h po.

In penicillin allergy

Clindamycin 600mg q4h iv/po.

Oral switch: Clindamycin 450mg q6h po.

Duration 10 days
Comments

If MUH / SIVUH

Benzylpenicillin 1.2-2.4g q4-6h iv
plus
Metronidazole 400mg q8h po.

Oral switch: Penicillin V 666mg q6h po
plus
Metronidazole 400mg q8h po.


Acute Sinusitis

Infection

Acute sinusitis

Most likely organisms Viruses, Streptococci, H. influenzae, Moraxella catarrhalis, S. aureus
Empiric treatment

No antibiotic if considered viral.

Co-amoxiclav 625mg q8h po
Or
Doxycycline 200mg stat then 100-200mg q24h po.

In penicillin allergy

No antibiotic if considered viral.

Clarithromycin* 500mg q12h po
Or
Doxycycline 200mg stat then 100-200mg q24h po.

Duration 7-10 days.
Comments

Many attacks resolve without antibiotics.

Consider allergic conditions or viral infection.

* Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.


Acute Otitis Media

Infection

Acute otitis media

Most likely organisms Viruses, S. pneumoniae, H. influenzae
Empiric treatment

No antibiotic if considered viral.

Co-amoxiclav 625mg q8h po
Or
Doxycycline 200mg stat then 100-200mg q24h po.

In penicillin allergy

No antibiotic if considered viral.

Clarithromycin* 500mg q12h po
or
Doxycycline 200mg stat then 100200mg od po.

Duration

5-7 days.

Comments

Use pain relief for 24 hours before deciding whether antibiotic is required.


Acute Otitis Externa

Infection

Acute otitis externa

Most likely organisms As above
Empiric treatment See comments
In penicillin allergy See comments
Duration
Comments

Antibiotics often not indicated unless cellulitis present. In malignant otitis externa (Pseudomonas), seek advice.


Acute Epiglottitis

Infection

Acute epiglottitis

Most likely organisms H. influenzae
Empiric treatment

Ceftriaxone 2g q12h iv.

In penicillin allergy

Moxifloxacin**400mg q24h po/iv.

Duration

10 days.

Comments

Take blood cultures and contact microbiology

** Moxifloxacin is contraindicated in clinically relevant heart failure with reduced left ventricular ejection fraction, in bradycardia, where there is a history of QT prolongation or history of symptomatic arrythmias. Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval, e.g. amiodarone, sotalol, neuroleptics e.g. haloperidol, chlorpromazine. Seek advice from pharmacy. It is also contraindicated in patients with impaired liver function (Child Pugh C).There are ongoing concerns regarding hepatic and serious skin reactions with moxifloxacin. Only use when there is no other alternative.


Oropharyngeal/Peritonsillar Abscess

Infection

Oro-pharyngeal / peri-tonsillar abscess

Most likely organisms S. pyogenes, anaerobes
Empiric treatment Benzylpenicillin 1.2-2.4g q6h iv
plus
Metronidazole 400mg q8h po
In penicillin allergy Clarithromycin* 500mg q12h po
plus
Metronidazole 400mg q8h po
Duration
Comments

Seek surgical review, as may require drainage.

* Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.


Appendices


Content By Dr. Íomhar O' Sullivan 10/08/2010. Last reviewDr. ÍOS 16/01/14.