Sandbox ID Head and Neck

Anthrax, oropharyngeal

• Oropharyngeal anthrax

• Preferred regimen: (Ciprofloxacin 400 mg IV q8h OR Doxycycline 100 mg IV q12h) AND (Clindamycin 600 mg IV q8h OR Penicillin G 4 MU IV q4-6h OR Meropenem 1 g IV q6-8h OR Rifampin 300 mg IV q12h)

Note: Treatment for 60 days is recommended to avoid relapse or breakthrough of incubating disease. If initial therapy is intravenous, then convert to oral administration (Ciprofloxacin or Doxycycline) when clinically indicated. Steroids may be considered as an adjunct therapy for patients with severe edema and for meningitis. For pregnant women, avoid Doxycycline. Use Ciprofloxacin and switch to oral penicillin once susceptibilities are known.

Buccal cellulitis

• Buccal cellulitis, children < 5 yrs

• Preferred regimen: Cefuroxime50 q8h IV (80 q8h for meningitis) OR PO 10–15mg bid (max 1 gm per day)OR Ceftriaxone 50 q24h (meningitis 100)
• Alternative regimen: Amoxicillin-Clavulanate45 OR 90 (AM/CL-HD) divided 12h ,if over 12weeks OR TMP-SMX8–12 TMP component divided 12h; (Pneumocystis: 20 TMP component divided q6h)

Cervico-facial actinomycosis

• Cervico-facial actinomycosis

• Preferred treatment

• Mild: penicillin V PO 2months OR Doxycycline 100mg PO q12h for 2 months
• Complicated: penicillin G 10-20 MU/d divided q6h for 4-6weeks followed by oral penicillin V 2-4 g/d divided q6h for 6-12 months.

• Allergic to Penicillin : Tetracycline, Clindamycin, and Erythromycin and cephalosporins.

Deep neck infection

• Empiric treatment
• The submandibular space

●The parapharyngeal space

●The retropharyngeal space Immunocompetent host — We suggest one of the following regimens in the immunocompetent host:

●Nafcillin (1.5 g IV every 4 hours) or vancomycin (15 to 20 mg/kg IV every 8 to 12 hours, not to exceed 2 g per dose), plus either:

•Gentamicin or tobramycin (1.7 mg/kg IV every 8 hours or 5 mg/kg IV every 24 hours), or

•Ciprofloxacin (400 mg IV q12h), or

•Ticarcillin-clavulanate (3.1 g IV every 4 hours)

Patients with risk factors for MRSA infection should be treated empirically with vancomycin (15 to 20 mg/kg IV every 12 hours) or linezolid (600 mg orally or IV every 12 hours). Risk factors for MRSA include a history of intravenous drug use, comorbid disease (eg, diabetes mellitus), and residing in a community or hospital where there is a substantial incidence of MRSA.

Immunocompromised host — We suggest one of the following regimens in the immunocompromised host:

●Vancomycin (15 to 20 mg/kg IV every 8 to 12 hours, not to exceed 2 g per dose) or linezolid (600 mg orally or IV every 12 hours) plus either:

•Cefepime (2 g IV every 12 hours) plus metronidazole (500 mg IV every six to eight hours) or

•Imipenem (500 mg IV every six hours) or

•Meropenem (1 g IV every eight hours) or

•Piperacillin-tazobactam (4.5 g IV every six hours)

Duration — For uncomplicated prevertebral space infections without evidence of discitis or osteomyelitis, two to three weeks of therapy is adequate. We favor intravenous antibiotics for the entire duration of treatment. When adjacent osteomyelitis is present, at least six to eight weeks of intravenous antibiotics is necessary.

• Either penicillin in combination with a β-lactamase inhibitor (such as amoxicillin or ticarcillin with clavulanic acid) or a β-lactamase–resistant antibiotic (such as cefoxitin, cefuroxime, imipenem, or meropenem) in combination with a drug that is highly effective against most anaerobes (such as clindamycin or metronidazole)
• Vancomycin should be considered for empiric therapy in intravenous drug

• Ceftriaxone and clindamycin can be used as empiric therapy against community-acquired MRSA

Mastoiditis, Acute

• Mastoiditis

• Preferred Regimen : Ceftriaxone 2 gm IV qd OR Levofloxacin 750 mg IV qd

Mastoiditis, Chronic

• Mastoiditis

• Preferred Regimen : Vancomycin (trough: 15–20 mcg/mL) AND Piperacillin-Tazobactam 3.375 g IV q6h
• Alternative Regimen : Vancomycin (trough: 15–20 mcg/mL) AND Ciprofloxacin 400 mg IV q8h

Odontogenic infection

• Preferred regimen : Clindamycin 300–450 mg po q6h OR 600 mg IV q6–8h
• Alternate regimen : (Amoxicillin-Clavulanic acid 875/125 mg po bid OR 500/125 mg tid or 2000/125 mg bid) or cefotetan 2 gm IV q12h

Orbital cellulitis

• Orbital cellulitis

• Preferred treatment : Nafcillin 2 gm IV q4h (or if MRSA-vancomycin 1 gm IV q12h) AND ceftriaxone 2 gm IV q24h AND metronidazole 1 gm IV q12h
• If penicillin/cephalosporin allergy: Vancomycin AND levofloxacin 750 mg IV once daily AND metronidazole IV. If vancomycin intolerant, another option for s. aureus is daptomycin 6 mg/kg IV q24h.

Oropharyngeal candidiasis

• Oropharyngeal candidiasis

• Preferred treatment : Clotrimazole troches 10 mg 5 times daily OR nystatin suspension or pastilles qid (B-II) OR fluconazole 100–200 mg daily (A-I)
• Alternate treatment : Itraconazole solution 200 mg daily OR posaconazole 400 mg qd (A-II) OR voriconazole 200 mg bid OR AmB oral suspension (B-II) OR IV echinocandin OR AmB-d 0.3 mg/kg daily (B-II) (Fluconazole is recommended for moderate-to-severe disease, and topical therapy with clotrimazole or nystatin is recommended for mild disease. Treat uncomplicated disease for 7–14 days. For refractory disease, itraconazole, voriconazole, posaconazole, or AmB suspension is recommended)

Otitis externa

• Otitis externa

• Preferred regimen (1): Acetic acid 2.0% solution (Acetic acid otic)
• Preferred regimen (2): Acetic acid 2.0%, hydrocortisone 1.0% (Acetasol HC)
• Preferred regimen (3): Ciprofloxacin 0.2%, hydrocortisone 1.0% (Cipro HC)
• Preferred regimen (4): Ciprofloxacin 0.3%, dexamethasone 0.1% (Ciprodex)
• Preferred regimen (5): Neomycin, polymyxin B, hydrocortisone (Cortisporin Otic)
• Preferred regimen (6): Ofloxacin 0.3% (Floxin Otic)

Otitis externa, Chronic

• Otitis externa

• Preferred Regimen : Neomycin, polymyxin B, hydrocortisone 4 drops tid or qid AND Selenium sulfide shampoo

Otitis externa, Fungal

• Otitis externa

• Preferred Regimen : Fluconazole 200 mg po x 1 dose, then 100 mg po x 3–5 days

Otitis externa, Malignant

• Otitis externa

• Preferred Regimen : Ciprofloxacin 400 mg IV q8h
• Alternative Regimen : Piperacillin-Tazobactam 3.375g IV q4h AND Tobramycin 3–5 mg/kg/day IV q8h
• Other Regimens for Susceptible Pseudomonas : Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h OR Cefepime 2 g IV q12h OR Ceftazidime 2 g IV q8h

Otitis externa, Swimmer's ear

• Otitis externa

• Preferred regimen : Ofloxacin 0.3% solution eardrops bid or [(polymyxin B + neomycin + hydrocortisone) qid] or (Ciprofloxacin + hydrocortisone bid) .
• For acute disease : Dicloxacillin 500 mg po 4x/day. If MRSA a concern, use TMP-SMX, doxycycline or clindamycin

Otitis media, Acute

• Otitis media

• Preferred Regimen : Amoxicillin 80–90 mg/kg/d bid OR Amoxicillin 90 mg/kg/d with Clavulanate 6.4 mg/kg/d
• Alternative Regimen (if allergic to penicillin) : Cefdinir 14 mg/kg/d qd or bid OR Cefuroxime 30 mg/kg/d bid OR Cefpodoxime 10 mg/kg/d bid OR Ceftriaxone 50 mg/kg IM/IV qd

Otitis media, Post-intubation

• Otitis media

• Preferred regimen : Ceftazidime 2 gm IV q8h OR Cefepime 2 gm q12h or Imipenem 0.5 gm IV q6h OR Meropenem OR (Piperacillin-Tazobactam)4–6 gm IV q4–6h OR Ticarcillin-Clavulanate 3 gm IV q4h OR Ciprofloxacin 400 mg IV q12h (or 750 mg po q12h).

Otitis media, Prophylaxis

• Preferred regimen : Sulfisoxazole 50 mg/kg PO at bedtime or amoxicillin 20 mg/kg PO q24h

Otitis media, Treatment failure

• Otitis media

• Preferred Regimen : Amoxicillin 90 mg/kg/d with Clavulanate 6.4 mg/kg/d OR Ceftriaxone 50 mg/kg IM/IV qd
• Alternative Regimen : Clindamycin 30–40 mg/kg/d tid OR third generation Cephalosporin

Note: Consider Tympanocentesis if clinically indicated.

Parotitis

• Parotitis

• Preferred regimen

• MSSA : Nafcillin or oxacillin 2 gm IV q4h
• MRSA : vancomycin

• Juvenile recurrent parotitis

• Preferred regimen: B-lactam antibiotics (Penicillin VK or Amoxicillin–clavulanate for staphylococcal coverage)

• Preferred regimen: Short-term, low-dose corticosteroid therapy can reduce inflammation and promote faster restoration of glandular function.

• viral

• Preferred regimen: Currently, the accepted treatment for mumps includes supportive care consisting of hydration, oral hygiene and bed rest