Deep Neck Space Infections Organism-Specific Therapy 

Updated: Nov 04, 2015
  • Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Thomas E Herchline, MD  more...
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Specific Organisms and Therapeutic Regimens

Deep neck space infections, including parapharyngeal abscess, peritonsillar abscess, and retropharyngeal abscess, commonly arise from an odontogenic or upper aerodigestive tract origin. The bacteriology tends to be polymicrobial, involving both aerobic and anaerobic bacteria from the primary source. These infections may be life threatening if not diagnosed and treated promptly, by leading to airway compromise and spread of infection to neighboring compartments. Initial empiric antimicrobial therapy should include broad coverage for beta-lactamase–producing bacteria, including Staphylococcus aureusStreptococcus pyogenes, Streptococcus viridans, anaerobic gram-negative bacilli, and Peptostreptococcus species, until culture results are obtained to help direct treatment. [1, 2, 3, 4, 5, 6, 7] Specific therapy upon obtaining organism and susceptibility information is detailed below.

Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus

See the list below:

Oral anaerobes (eg, Prevotella, Porphyromonas, Fusobacterium, Bacteroides, and Peptostreptococcus species)

See the list below:

  • Clindamycin 600 mg IV q8h  or
  • Penicillin G 2-4 million U IV q4-6h  plus   metronidazole 500 mg IV q8h

Methicillin-susceptible Staphylococcus aureus (MSSA)

See the list below:

  • Clindamycin 600 mg IV q8h  or
  • Nafcillin 1.5 g IV q4h  or
  • Ceftriaxone 1 g IV q12h  or
  • Ampicillin-sulbactam 3 g IV q6h

Methicillin-resistant Staphylococcus aureus (MRSA)

See the list below:

Haemophilus influenzae

See the list below:

  • Ceftriaxone 1 g IV q12h  or
  • Ampicillin-sulbactam 3 g IV q6h

Pseudomonas aeruginosa

See the list below:

  • Piperacillin-tazobactam 4.5 g IV q6h or 3.375 g IV q4h, usually over 30 min or
  • Cefepime 2 g q8h or
  • Ciprofloxacin 400 mg IV q 12h or
  • Aztreonam 2 g q8h or
  • Meropenem 1 g q8h

Duration of therapy

Parenteral therapy is indicated until the patient is afebrile, with a clear clinical improvement in symptoms for 48h. Afterwards, the patient may transition to oral antibiotics and complete a 2- to 3-wk course of treatment. Longer courses may be required when complications are present.

Special considerations

See the list below:

  • Airway protection is the first priority with deep neck space infections; this may involve oxygenation with pressure support, IV steroids, intubation (nasal or oral), tracheostomy, or cricothyroidotomy (for emergent situations) [4]
  • If no clinical improvement is observed after conservative treatment with IV hydration and antibiotics, aspiration or surgical incision and drainage should be considered
  • Anteroposterior and lateral neck radiographs may be useful for evaluating airway patency and as a screening tool for children who are suspected of having a deep neck or retropharyngeal infection
  • Computed tomography (CT) scanning is the imaging modality of choice for deep neck space infections and is useful for evaluating whether a mass has organized into a drainable collection
  • Spread of infection into the mediastinum may result in fever, tachycardia, and chest pain. The clinician should have a low threshold for obtaining surgical consultation when these ominous signs are present
  • Urgent surgical consultation should be obtained for rapidly progressive cutaneous erythema, underlying crepitus, and findings of gas bubbles on CT imaging, as these findings are concerning for necrotizing fasciitis
  • Broad-spectrum empiric antimicrobial therapy should be narrowed once results from culture and susceptibility data are obtained