Sandbox ID Upper Respiratory Tract

Epiglottitis

• Epiglottitis

• Pediatrics

• Preferred regimen : Cefotaxime 50 mg/kg IV q8h OR Ceftriaxone 50–75 mg/kg/day IV q12–24h AND Vancomycin 10 mg/kg IV q6h
• Alternate regimen : Levofloxacin 500 mg IV q24h (or 8 mg/kg IV q12h) AND Clindamycin 20–40 mg/kg/day IV q6–8h

• Adults

• Preferred regimen : Cefotaxime 2 g IV q4–8h OR Ceftriaxone 1–2 g/day IV q12–24h AND Vancomycin 2 g/day IV q6–12h
• Alternate regimen : Levofloxacin 750 mg IV q24h AND Clindamycin 600–1200 mg IV q6–12h

Jugular vein phlebitis

• Septic jugular thrombophlebitis (Lemierre's syndrome)

• Causative pathogens

• Fusobacterium
• Viridans and other streptococci
• Staphylococcus
• Peptostreptococcus
• Bacteroides
• Other oral anaerobes

• Preferred regimen (immunocompetent host): (Penicillin G 2–4 MU IV q4–6h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h
• Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h

Laryngitis

• Antibiotic use is not associated with significant improvement of objective symptoms and is not indicated in the treatment of acute laryngitis.

Lemierre's syndrome

• Septic jugular thrombophlebitis (Lemierre's syndrome)

• Causative pathogens

• Fusobacterium
• Viridans and other streptococci
• Staphylococcus
• Peptostreptococcus
• Bacteroides
• Other oral anaerobes

• Preferred regimen (immunocompetent host): (Penicillin G 2–4 MU IV q4–6h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h
• Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h

Ludwig's angina

• Ludwig's angina

• Causative pathogens

• Viridans and other streptococci
• Peptostreptococcus
• Bacteroides
• Other oral anaerobes

• Preferred regimen (immunocompetent host): (Penicillin G 2–4 MU IV q4–6h AND Tobramycin 2 mg/kg IV q8h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h OR Doxycycline 200 mg IV q12h OR Cefoxitin 2 g IV q6h OR Cefotetan 2 g IV q12h
• Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Gatifloxacin 200 mg IV q24h

Parapharyngeal space infection

• Parapharyngeal space infection

• Causative pathogens

• Viridans and other streptococci
• Staphylococcus
• Peptostreptococcus
• Bacteroides
• Other oral anaerobes

• Preferred regimen (immunocompetent host): (Penicillin G 2–4 MU IV q4–6h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h
• Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h

Pharyngitis, diphtheria

• Diphtheria

• The CDC recommends either:

• Preferred regimen: Erythromycin (PO or by IV) for 14 days (40 mg/kg per day with a maximum of 2 g/d), OR Procaine penicillin G given IM for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg).
• Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.

Pharyngitis, streptococcal

• Pharyngitis

• Acute

• Preferred regimen

• Children: Pencillin V PO 250 mg twice daily or 3 times daily
• Adolescents and adults: Pencillin V PO 250 mg 4 times daily or 500 mg twice daily for 10 days OR Amoxicillin 50 mg/kg once daily (max = 1000 mg) alternate:25 mg/kg (max = 500 mg) twice daily for 10 days OR Benzathine Penicillin G I.M 27 kg: 600 000 U; ≥27 kg: 1 200 000 U 1 dose only OR Cephalexin PO 20 mg/kg/dose twice daily (max = 500 mg/dose)for 10 days

• Alternate regimen :

• Cefadroxil PO 30 mg/kg OD (max = 1 g) for 10 days OR Clindamycin PO 7 mg/kg/dose 3 times daily (max = 300 mg/dose) for 10 days OR AzithromycinPO 12 mg/kg once daily (max = 500 mg) for 5 days OR Clarithromycin PO 7.5 mg/kg/dose twice daily (max = 250 mg/dose) for 10 days

• Chronic

• Preferred regimen

• Clindamycin 20–30 mg/kg/d in 3 doses (max = 300 mg/dose) for 10 days OR Penicillin AND Rifampin; Penicillin V: 50 mg/kg/d in 4 doses × 10 d (max = 2000 mg/d) ;rifampin: 20 mg/kg/d in 1 dose × last 4 d of treatment (max = 600 mg/d) for 10 days AND Amoxicillin–clavulanate 40 mg amoxicillin/kg/d in 3 doses (max = 2000 mg amoxicillin/d) for 10 days OR Benzathine penicillin G IM 600 000 U for <27 kg and 1 200 000 U for ≥27 kg single dose AND rifampin PO 20 mg/kg/d in 2 doses (max = 600 mg/d) for 4 days

Sinusitis, Acute

• Sinusitis (Pediatrics)

• Preferred Regimen : Amoxicillin 90 mg / kg / day PO divided q12h OR Amoxicillin-clavulanate (extra strength) suspension, 90 mg / kg / day (based on Amox component), PO divided q12h for 10-14 days
• Alternate Regimen

• If non-type I hypersensitivity to penicillin : Cefuroxime axetil 30 mg / kg / day PO divided q12h for 10-14 days OR Cefdinir 14 mg / kg / day PO divided q12-24h, max of 600 mg / day for 10-14 days OR Cefpodoxime 10 mg / kg / day PO divided q12h for 10-14 days

• Sinusitis (Adults)

• Preferred Regimen : Amoxicillin 250-500 mg q8h or 500-875 mg q12h or extended-release tablet 775 mg once daily OR Amoxicillin-clavulanate (extended release tabs) 1000 / 62.5 mg 2 tabs or 2000/125 mg 1 tab, PO q12h for 5-7 days

• Alternate Regimen

• If type 1 hypersensitivity to penicillin : Levofloxacin 750 mg PO once daily for 5-7 days OR Doxycycline 100 mg PO q12h for 5-7 days

• If type 2 hypersensitivity to penicillin : Cefdinir 600 mg / day divided q12h or q24h for 5-7 days OR Cefpodoxime 200 mg PO q12h for 5-7 days OR Cefuroxime axetil 500 mg PO q12h for 5-7 days

Sinusitis, Chronic

• Sinusitis (Pediatrics)

• Preferred Regimen:Amoxicillin-clavulanate 45 mg/kg per day q12h
• If penicillin allergy and patient is MRSA positive

• Clindamycin 20 to 40 mg/kg per day orally divided every 6 to 8 hours

• If anaerobes are involved

• Metronidazole PLUS one of the following: cefuroxime axetil, cefdinir, cefpodoxime proxetil,azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole (TMP-SMX)

• Sinusitis (Adults)

• Preferred Regimen

• Amoxicillin-clavulanate 500 mg three times daily OR 875 mg twice daily OR two 1000 mg extended-release tablets twice daily)

• If penicillin allergy and patient is MRSA positive

• Clindamycin 300 mg four times daily or 450 mg three times daily)

• If anaerobes are involved

• Metronidazole PLUS one of the following: cefuroxime axetil, cefdinir, cefpodoxime proxetil, levofloxacin , azithromycin, clarithromycin, or trimethoprim-sulfamethoxazole (TMP-SMX)

• Alternate regimen

• Moxifloxacin (400 mg once daily)

Sinusitis, Post-intubation

• Sinusitis

• Preferred regimen : Imipenem 0.5 gm IV q6h OR Meropenem 1 gm IV q8h, MRSA suggestive on Gram - stain then add Vancomycin 1 gm IV q12h
• Alternate Regimen : (Ceftazidime 2 gm IV q8h AND Vancomycin 1 gm IV q12h) OR (Cefepime 2 gm IV q12h AND Vancomycin 1 gm IV q12h)

Sinusitis, Treatment failure

• Sinusitis (Pediatrics)

• If treatment failure then do a culture and treat accordingly or treatment in the absence of cultures and children failing Amoxicillin

• Amoxicillin-clavulanate (extra strength) suspension 90 mg/kg/day (Amoxicllin component) PO divided q12h for 10-14 days.

• Treatment in the absence of cultures and children failing Amoxicillin-clavulanate

• Clindamycin 30-40 mg/kg/day divided q8h AND third generation cephalosporin like Cefuroxime axetil 30 mg/kg/day PO divided q12h OR Cefdinir 14 mg/kg/day PO divided q12h or q24h OR Cefpodoxime 10 mg/kg/day PO divided q12h

• Sinusitis (Adults)

• If failure of treatment even after 7 days of diagnosis : Amoxicillin-clavulanate 4g per day of amoxicillin equivalent OR Levofloxacin 500 mg PO once daily ORMoxifloxacin400 mg PO once daily

Stomatitis, aphthous

• Stomatitis

• Topical steroids may decrease pain and swelling

Stomatitis, herpetic

• Stomatitis

• Acyclovir 15 mg/kg PO q5h For 7 days

Submandibular space infection

• Submandibular space infections including Ludwig angina

• Causative pathogens

• Viridans and other streptococci
• Peptostreptococcus
• Bacteroides
• Other oral anaerobes

• Preferred regimen (immunocompetent host): (Penicillin G 2–4 MU IV q4–6h AND Tobramycin 2 mg/kg IV q8h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h OR Doxycycline 200 mg IV q12h OR Cefoxitin 2 g IV q6h OR Cefotetan 2 g IV q12h
• Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Gatifloxacin 200 mg IV q24h

Tonsillitis

• Tonsillitis

• Preferred regimen:Penicillin V PO 10 days or if compliance unlikely, Benzathine penicillin IM single dose

• Alternate regimen:2nd generation Cephalosporins PO for 4–6 days OR clindamycin or azithromycin for 5 days OR clarithromycin for 10 days OR erythromycin for 10 days. Extended-release amoxicillin is another (expensive) option

Vincent's angina

• Vincent's angina

• Preferred treatment:Penicillin G 4 million units IV q4h
• Alternate treatment: Clindamycin 600 mg IV q8h