ENT antibiotics

Conjunctivitis

Newborn

• Azithromycin 20mg/kg PO once daily for 3 days OR
• Erythromycin 12.5 mg/kg PO q6hrs for 14 days

Chlamydial

• Doxycycline 100mg BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Dual treatment for Chlamydia is recommended with azithromycin
• Ceftriaxone 1g IM one dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg

Bacterial Conjunctivitis

These options do not cover gonococcal or chlamydial infections

• Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
• Erythromycin applied to the conjunctiva q6hrs fir 7 days OR
• Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days

Epiglottitis

Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae

Immunocompetent

• Ceftriaxone 2gm IV once daily (first line) OR
• Cefotaxime 2gm (50mg/kg) IV three times daily OR
• Ampicillin/Sulbactam 3g (50mg/kg) IV q 6 hours OR
• Levofloxacin 750mg IV once daily
• Consider Vancomycin 15-20mg/kg to any of the above if risk of MRSA

Immunocompromised

Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans

• Cefepime 2g (50/kg) IV q8 hours AND Vancomycin 15mg/kg IV q6 hours

Dental Abscess

treatment is broad and focused on polymicrobial infections

• Penicillin VK 500mg PO q6 hours OR
• Clindamycin 300mg PO q8 hours
• Ampicillin/Sulbactam 3g IV q6 hours

Ludwig's Angina

• Must cover typical polymicrobial oral flora and tailored based on patient's immune status
• Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
• If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods

Immunocompetent Host

• Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hrs OR
• Penicillin G 2-4 MU IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
• Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)

Immunocompromised

• Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs OR
• Meropenem 1 g IV q8 hrs OR
• Imipenem/Cilastatin 500mg (20mg/kg) IV q6 hours
• Piperacillin-tazobactam 4.5g (80mg/kg) IV q6 hours
• Add Vancomycin 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors

Mastoiditis

Coverage against S. pneumoniae, S. pyogenes, S. aureus, H. influenzae

• Clindamycin 600mg IV q8 hours OR (if MRSA concern use Vancomycin regimen)
• Vancomycin 15-20mg/kg IV q12 hours PLUS
  • Ceftriaxone 1g (50mg/kg) IV once daily OR
  • Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hours

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis)

• Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella

Options

• Penicillin V 500 mg PO q6 hours AND Metronidazole 500mg PO q8 hours x 10 days OR
• Clindamycin 600 mg PO q8 hours OR
• Ampicillin/Sulbactam 3g IV q 6 hours daily

also nystatin oral rinses of 5ml q6 hrs daily for 14 days will help with concominent fungal infection

HIV positive

in addition to antibiotic regimen consider an oral anti-fungal or nystatin

• Fluconazole 200mg PO daily for 14 days

Otitis Media

Initial Treatment

1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

1. Can use Amoxicillin as same dosing as initial treatment
2. Cefdinir 14mg/kg/day BID x7-10 days
3. Cefpodoxime 10mg/kg PO daily x7-10 days
4. Cefuroxime 15mg/kg PO BID x7-10 days
5. Cefprozil 15mg/kg PO BID x7-10 days

Treatment Failure

defined as treatment during the prior 7-10 days

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day
   • Clavulanate increases vomiting/diarrhea
2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
   • Use if cannot tolerate PO

Penicillin Allergy

1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
2. Clarithromycin 7.5mg/kg PO BID x 10 days
3. Clindamycin 10mg/kg PO three times daily
   • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use

Otitis Externa

1. Floxin Otic: 5 drops in affected ear BID x 7 days
   • Safe with perforations
2. Cipro HC Otic: 3 drops in affected ear BID x 7 days
   • Contains hydrocortisone to promote faster healing
   • Not safe with perforation
3. CiproDex: 3 drops in affected ear BID x 7 days
   • Similar to Cipro HC but contains Dexamethasone
   • Also not recommended with perforations
4. Cortisporin Otic (neomycin/polymixin B/hydrocortisone)
   • 4 gtt in ear TID-QID x 7dy
   • Use suspension (NOT solution) if possiblity of perforation
   • Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking

Streptococcal Pharyngitis

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

• Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent)
• Bicillin L-A 25-50K mg/kg IM x 1 (max dose = 1.2million)

Penicillin allergic (mild):

• Cefuroxime 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d

Penicillin allergic (anaphylaxis):

• Clindamycin 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d OR
• Azithromycin 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5

Periorbital Cellulitis

Antibiotics

Outpatient

• Amoxicillin/Clavulanate 875mg BID x7-10 days OR
• Cefpodoxime 200mg BID x7-10d OR
• Cephalexin 450mg PO three times daily OR
• Cefdinir 600mg PO once daily x7-10 days

Inpatient

Vancomycin 15-20mg/kg IV BID + (one of the following)

• Ampicillin/Sulbactam 3 g IV q6hr OR
• Ticarcillin/Clavulanate 3.1 g IV q4h OR
• Piperacillin-Tazobactam 4.5 g IV q6h OR
• Ceftriaxone 2 g IV q12hr OR
• Cefotaxime 2 g IV q4h

Peritonsillar Abscess

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

• Clindamycin 300mg PO Q6hrs x7-10d
• Amoxicillin/Clavulanate 875 mg PO BID x 7-10d
• Penicillin V 500mg PO + Metronidazole 500mg QID

Inpatient Options

• Ampicillin/Sulbactam 3 gm (75mg/kg) IV four times daily
• Pipericillin/Tazobactam 4.5 gm IV TID
• Ticarcillin/Clavulanate 3.1 g IV QID
• Clindamycin 600-900mg IV TID
• Penicillin G 4 million units (50,000 units/kg) IV four times daily + Metronidazole 500mg IV three times daily

Pertussis

• Antibiotics do not help with severity or duration but may decrease infectivity.
• A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset.
• TMP--SMZ should not be administered to pregnant women, nursing mothers, or infants aged <2 months.
• The following regemins are for active disease or postexposure prophylaxis. If a patient is has confirmed disease and is likely to be in contact with infants or pregnant women then the patient should be treated as up to 6-8 weeks after the onset of their illness.

< 1 month old

Same antibiotics for active disease and postexposure prophylaxis

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days

>1 month old

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days
  • if > 6 months old then day 2-5 of treatment should be reduced to 5mg/kg (250mg/day max)
• TMP/SMX 4mg/kg PO BID daily for 14 days (if > 2 months old)

Adults

andy of the following antibiotics are acceptable although azithromycin is most commonly prescribed

• Azithromycin 500mg PO once daily for day #1 then 250mg PO once daily for days #2-5
• Clarithromycin 500mg BID x7 days
• Erythromycin 500mg QID x7 days

Suppurative Parotitis

Treatment targeted at S. aureus, gram negative bacilli, mumps, enteroviruses, and influenza virus

• Amoxicillin/Clavulanate 875mg (45mg/kg) PO BID OR
• Clindamycin 450mg PO three times daily or 10mg/kg PO four times daily
• Dicloxacillin 500mg (7.5mg/kg) PO four times daily
• Cephalexin 500mg (12.5mg/kg) PO four times daily
• Nafcillin 2g IV six times daily or 50mg/kg IV four times daily
• Vancomycin 15-20mg/kg IV BID daily

Thrush

• Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
• Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
• Fluconazole 200 mg (Peds: 6 mg/kg) PO on day one, followed by 100 mg (Peds: 3 mg/kg_ daily for two weeks.
  • Fluconazole is reserved for moderate to severe disease

Pediatric Dosing

If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding

• Nystatin Oral Suspension
  • 100,000 units/ml for 14 days for all ages
  • Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
• Clotrimazole 10mg PO five times daily for 14 days
  • reserved for patients > 3 years old

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)

References

Authors

Ross Donaldson, Daniel Ostermayer