Sandbox ID Head and Neck

Anthrax, oropharyngeal

• Post exposure prophylaxis

• Preferred regimen : ciprofloxacin, 500 mg every 12 h OR doxycycline, 100 mg every 12 h OR levofloxacin, 750 mg every 24 h OR moxifloxacin, 400 mg every 24 h OR clindamycin, 600 mg every 8 h
• Alternatives for penicillin-susceptible strains amoxicillin, 1 g every 8 h OR penicillin VK, 500 mg every 6 h

• Oropharyngeal anthrax

• Preferred regimen: Ciprofloxacin 400 mg intravenously every 8 h OR Doxycycline 100 mg intravenously every 12 h combined with second agent: Clindamycin 600 mg intravenously every 8 h or Penicillin G 4 MU every 4-6 hours OR Meropenem 1 gm intravenously every 6-8 hours or Rifampin 300 mg every 12 h.
• 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

• Preferred regimen (Children <5 yrs) : Cefuroxime or ceftriaxone
• Alternate regimen : Amoxicillin-clavulanate or TMP-SMX With Hib immunization, invasive H. influenzae infections have Ļ by 95%. Now occurring in infants prior to immunization.

Cervico-facial actinomycosis

• Cervico-facial actinomycosis

• Preferred treatment : High doses (18-24 million units a day) of intravenous penicillin G over two to six weeks, followed by oral penicillin V at a dose of 2-4 g/day for six to 12 months.
• Alternate treatment : Doxycycline, minocycline, clindamycin, and erythromycin are suitable for patients who are allergic to penicillin. Erythromycin is a safe option for pregnant patients.

Deep neck infection

• Empiric treatment

• 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

• 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, 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 ± 3° Cephalosporin ± Tympanocentesis

Parotitis

• Preferred treatment

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