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Chapter 2. Antimicrobial Therapy for Head & Neck Infection

Peter V. Chin-Hong, MD; Richard A. Jacobs, MD, PhD

A summary of empiric antimicrobial therapy for common conditions encountered in otolaryngology can be found in Table 2–1. In general, when culture and susceptibility data are finalized, it is important to use the narrowest agent possible. This may not only be cost effective in many cases but will also decrease selection pressure for the development of antimicrobial resistance.

Table 2–1. Examples of Initial Antimicrobial Therapy for Selected Conditions in Head and Neck Infection.
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Table 2–1. Examples of Initial Antimicrobial Therapy for Selected Conditions in Head and Neck Infection.
Suspected Clinical DiagnosisLikely Etiologic DiagnosisTreatment of ChoiceComments
Infections of the Ear
External otitisGram-negative rods (Pseudomonas, Enterobacteriaceae, Proteus) or fungi (Aspergillus)Otic drops containing a mixture of an aminoglycoside and corticosteroids, such as neomycin sulfate and hydrocortisoneIn refractory cases, particularly if there is cellulitis of the adjacent periauricular tissue, oral fluoroquinolones such as ciprofloxacin 500 mg twice a day can be used for their antipseudomonal activity. However, there is increasing resistance being reported. Acute infection may be due to Staphylococcus aureus; dicloxacillin 500 mg 4 times a day may be used.
Malignant external otitisPseudomonas aeruginosaAntibiotics with antipseudomonal activity (such as ciprofloxacin) for a prolonged period until there is radiographic evidence of improvement.Surgical debridement may be necessary if medical therapy is unsuccessful. It may also be necessary to rule out osteomyelitis by CT scan or MRI, as osteomyelitis requires prolonged therapy for 4–6 weeks.
Acute otitis mediaStreptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses (RSV, rhinoviruses)Amoxicillin is the first drug of choice at 45 mg/kg/d in two or three divided doses. If drug resistance is suspected, a higher dose of amoxicillin or amoxicillin–clavulanate (90 mg/kg/d) may be used. Prevention of recurrent acute otitis media may be treated with oral doses of sulfisoxazole 50 mg/kg or amoxicillin 20 mg/kg at bedtime. If this strategy fails, the insertion of ventilating tubes may be necessary.Treatment is a combination of antibiotics and nasal decongestants. Without treatment, there may be a spontaneous resolution of illness (less likely with S pneumoniae).
MastoiditisS pneumoniae, Streptococcus pyogenes, H influenzae, and P aeruginosaMyringotomy for culture and drainage and ceftriaxone, 1 g IV every 24 hours.Antibiotics may be modified based on culture results.
Infections of the Nose & Paranasal Sinuses
Rhinitis (common cold)Can be caused by a variety of viruses, including several serologic types of rhinoviruses and adenovirusesMainly reassurance of the patient and supportive therapy, such as decongestants (pseudoephedrine 30–60 mg every 4–6 hours). Nasal sprays such as oxymetazoline or phenylephrine can be immediately effective but must not be used for more than a few days at a time since rebound congestion may occur.Secondary (bacterial) infection may occur and present as acute sinusitis.
Acute sinusitisS pneumoniae, H influenzae, M catarrhalis, Group A streptococcus, anaerobes, viruses, and S aureusAmoxicillin or amoxicillin–clavulanate 500 ...

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