Epiglottitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

Overview

Epiglottitis is a medical emergency and warrants immediate establishment of a patent airway. Once the airway has been secured, cultures of blood and epiglottic surface should be obtained before administration of antibiotics. Appropriate antibiotic regimens with coverage of Streptococcus pneumoniae, beta-hemolytic streptococci, and Staphylococcus aureus include parenteral cefotaxime or ceftriaxone in combination with vancomycin (or levofloxacin in combination with clindamycin for penicillin-allergic patients). Racemic epinephrine and systemic corticosteroids are commonly used for the management of stridor associated with acute upper respiratory tract infection. Postexposure prophylaxis with rifampin should be given to selected household contacts when a Haemophilus influenzae epiglottitis is diagnosed. If viral infection is suspected, no treatment other than supportive measures and securing the airway are needed as viral infections are self-limited.

Principles of Therapy for Acute Epiglottitis

Antibiotic Therapy

• In view of the emergence of Streptococcus pneumoniae and beta-hemolytic streptococci as the most common causative bacteria in the post-Hib vaccine era, empiric regimen should consist of a third-generation cephalosporin (such as cefotaxime and ceftriaxone) in combination with an anti-staphylococcal agent (such as vancomycin or clindamycin) in areas with increased prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or penicillin-resistant pneumococci.

• The optimal duration of antimicrobial therapy is unknown. Acute epiglottitis usually responds to a 7 to 10 day course of intravenous antibiotics.

Adjuvant Therapy

• Although adjuvant corticosteroids or racemic epinephrine is commonly used in the management of stridor associated with acute epiglottitis, neither of them appeared effective in reducing the need of airway intervention or shortening the hospitalization.

Empiric Therapy

• The tables below describe the recommended antimicrobial regimens for the treatment of acute epiglottitis in pediatric and adult patients.

Pediatric Patient Preferred Regimen ▸ Cefotaxime 50 mg/kg IV q8h OR ▸ Ceftriaxone 50–75 mg/kg/day IV q12–24h PLUS ▸ Vancomycin 10 mg/kg IV q6h Alternative Regimen (If Allergic to Penicillin) ▸ Levofloxacin 500 mg IV q24h (or 8 mg/kg IV q12h) PLUS ▸ Clindamycin 20–40 mg/kg/day IV q6–8h

Adult Patient Preferred Regimen ▸ Cefotaxime 2 g IV q4–8h OR ▸ Ceftriaxone 1–2 g/day IV q12–24h PLUS ▸ Vancomycin 2 g/day IV q6–12h Alternative Regimen (If Allergic to Penicillin) ▸ Levofloxacin 750 mg IV q24h PLUS ▸ Clindamycin 600–1200 mg IV q6–12h

Pathogen-Based Therapy

▸ Click on the following categories to expand treatment regimens.

Bacteria   ▸  Streptococcus pneumoniae   ▸  Streptococcus pyogenes   ▸  Streptococcus agalactiae   ▸  Streptococcus angiosus   ▸  Staphylococcus aureus   ▸  Haemophilus influenzae   ▸  Klebsiella pneumoniae   ▸  Moraxella catarrhalis   ▸  Neisseria sp   ▸  Pasteurella multocida   ▸  Pseudomonas sp Fungi   ▸  Candida albicans

Streptococcus pneumoniae Preferred Regimen (susceptible to penicillin) ▸ Penicillin G 2 million units IV q4h OR ▸ Ceftriaxone 2 g IV q24h OR ▸ Clindamycin 600 mg IV q6h Alternative Regimen (penicillin resistant strains) ▸ Moxifloxacin 400 mg IV q24h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Vancomycin 1 g IV q12h OR ▸ Linezolid 600 mg IV q12h OR ▸ Ceftaroline 600 mg IV q12h Streptococcus pyogenes Preferred Regimen (susceptible to penicillin) ▸ Penicillin G 1,2 million units IV 1 dose ▸ THEN ▸ Penicillin VK 500 mg PO q12h OR Amoxicillin 500 mg PO q12h Alternative Regimen (penicillin resistant strains) ▸ Clindamycin 300 mg PO q8h OR ▸ Azithromycin 500 mg PO q24h OR ▸ Cephalexin 500 mg PO q12h Streptococcus agalactiae Preferred Regimen (susceptible to penicillin) ▸ Penicillin G 2 million units IV q4h Alternative Regimen (penicillin resistant strains) ▸ Vancomycin 20 mg/kg IV q8h OR ▸ Clindamycin 600 mg IV q6h Streptococcus angiosus Preferred Regimen (susceptible to penicillin) ▸ Penicillin G 4 million units IV q4h OR ▸ Ceftriaxone 2 g IV q24h Alternative Regimen (penicillin resistant strains) ▸ Vancomycin 1 g IV q12h OR ▸ Clindamycin 600 mg IV q6h Meticillin susceptible Staphylococcus aureus Preferred Regimen ▸ Nafcillin 2 g IV q4-6h OR ▸ Oxacillin 2 mg IV q4-6h OR ▸ Cefazolin 2 g IV q8h OR ▸ Vancomycin 15 mg/kg IV q8h Alternative Regimen ▸ Dicloxacillin 500 mg PO q6h OR ▸ Cephalexin 500 mg PO q6h OR ▸ Clindamycin 300 mg PO q6h OR ▸ Clindamycin 300 mg PO q8h OR ▸ TMP/SMZ 160/800 mg PO q12h Meticillin resistant Staphylococcus aureus Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8-12h OR ▸ Daptomycin 4-6 mg/kg IV q24h OR ▸ Linezolid 600 mg IV q12h Alternative Regimen (Vancomycin intermediate susceptibility) ▸ Linezolid 600 mg/kg IV q12h OR ▸ Daptomycin 4-6 mg/kg IV q24h OR ▸ Ceftraoline 600 mg IV q8h Alternative Regimen (Vancomycin resistance) ▸ Teicoplanin 6 mg/kg IV q12h (total of three doses), 6 mg/kg IV q24h OR ▸ Telavancin 10 mg/kg q24h (1 hour infusion) OR ▸ Linezolid 600 mg/kg IV q12h OR ▸ Daptomycin 4-6 mg/kg IV q24h Haemophilus influenzae Preferred Regimen ▸ Ceftriaxone 2 g IV q12h OR ▸ Cefotaxime 2 g IV q8h Alternative Regimen ▸ Levofloxacin 750 mg IV q24h OR ▸ Moxifloxacin 400 mg IV q8h Klebsiella pneumoniae Preferred Regimen ▸ Ceftriaxone 2 g IV q12h OR ▸ Cefotaxime 2 g IV q8h OR ▸ Levofloxacin 750 mg IV q24h Alternative Regimen ▸ Imipenem 500 mg IV q6h OR ▸ Meropenem 1 g IV q8h OR ▸ Ertapenem 1 g IV q24h Moraxella catrrhalis Preferred Regimen ▸ Amoxicillin-clavulanic acid 850/125 mg PO q24h Alternative Regimen ▸ Azithromycin 500 mg PO q24h one day, then 250 mg PO q24h OR ▸ TMP/SMZ 5 mg/kg IV q6—12h (TMP component) Neisseria meningitidis Preferred Regimen ▸ Ceftriaxone 2 g IV q12h OR ▸ Cefotaxime 2 g IV q6h Alternative Regimen ▸ Penicillin G 4 million units IV q4h OR ▸ Chloramphenicol 100 mg/kg/day q6h, not exceed 4 g Neisseria gonorrhoeae Preferred Regimen ▸ Ceftriaxone 250 mg IM single dose Alternative Regimen ▸ Azithromycin 2 g PO single dose Pasteurella maltocida Preferred Regimen ▸ Penicillin VK 500 mg PO q12h OR ▸ Amoxicillin 500 mg PO q8h OR ▸ Amoxicillin-clavulanic acid 850/125 mg PO q12h Alternative Regimen ▸ Cefuroxime 500 mg PO q12h OR ▸ Levofloxacin 750 mg PO q24h OR ▸ Moxifloxacin 400 mg PO q24h OR ▸ Doxycycline 100 mg PO q12h OR ▸ Amoxicillin-clavulanic acid 850/125 mg PO q12h Pseudomonas spp Preferred Regimen ▸ Ceftazidime 2 g IV q8h OR ▸ Cefepime 2 g IV q8h PLUS ▸ Levofloxacin 750 mg IV q24h OR ▸ Moxifloxacin 400 mg PO q24h Alternative Regimen (combination of) Candida albicans Preferred Regimen ▸ Fluconazole 200 mg IV q24h for 14 days OR ▸ Fluconazole 200 mg PO q24h for 14 days PLUS ▸ Nystatin oral suspension PO q6h for 14 days Alternative Regimen (combination of) ▸ Itraconazole solution 200 mg PO q24h for 14 days OR ▸ Amphotericin B 0.3 mg/kg PO q12h 3 days, then q24h for 14 days OR ▸ Caspofungin PO q6h for 14 days