Retropharyngeal Abscess in Emergency Medicine Medication

  • Author: Joseph H Kahn, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jun 17, 2010
 

Medication Summary

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications. Intravenous broad-spectrum antibiotic coverage is indicated in the treatment of retropharyngeal abscess.

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Antibiotics

Class Summary

Gram-positive organisms (including beta-lactamase producing), gram-negative organisms, and anaerobes must be covered. The list of antibiotic regimens in the table below is from The Sanford Guide to Antimicrobial Therapy 2010.[24]

Some recommend the following regimens, which were not mentioned in The Sanford Guide to Antimicrobial Therapy: penicillin and oxacillin, second- or third-generation cephalosporin and clindamycin, penicillinase-resistant penicillin combined with either clindamycin or metronidazole, or third-generation cephalosporin in combination with clindamycin, nafcillin, or both (triple therapy).

In a review of retropharyngeal infections in children by Wald, the recommendation was to add vancomycin or linezolid to the regimen in patients not responding to clindamycin, and in patients who present with severe disease, in order to cover MRSA.[25]

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Clindamycin (Cleocin) and metronidazole (Flagyl)

 

Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.

Metronidazole is active against various anaerobic bacteria and protozoa. Cells of microorganisms that contain nitroreductase absorb metronidazole. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis, causing cell death.

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Penicillin G (Pfizerpen) and metronidazole (Flagyl)

 

Second DOC, penicillin G interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Metronidazole is active against various anaerobic bacteria and protozoa. Cells of microorganisms that contain nitroreductase absorb metronidazole. Unstable intermediate compounds are then formed that bind DNA and inhibit synthesis, causing cell death.

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Cefoxitin (Mefoxin)

 

Considered an alternative therapy. A second-generation cephalosporin indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria resistant to some cephalosporins and penicillins respond to cefoxitin.

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Clindamycin (Cleocin)

 

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.

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Ticarcillin and clavulanate (Timentin)

 

Alternative treatment that inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth.

Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobes.

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Piperacillin and tazobactam (Zosyn)

 

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits the biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.

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Ampicillin and sulbactam (Unasyn)

 

Drug combination that utilizes a beta-lactamase inhibitor with ampicillin, which covers skin, enteric flora, and anaerobes but is not ideal for nosocomial pathogens.

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Contributor Information and Disclosures
Author

Joseph H Kahn, MD  Director of Medical Student Education, Associate Professor, Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine

Joseph H Kahn, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Physicians for Social Responsibility, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Glick, DMD  Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey

Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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A 5-year-old boy presented to the ED with 2 days of neck pain and fever but with no sore throat. The child had vomited once, and the mother reported that he was irritable. The child's temperature was 101.7° F, pulse was 118 beats per minute, respirations were 24 per minute, and blood pressure was 122/65 mm Hg. A decreased range of motion of the neck and a right anterior cervical node were observed; the child refused to swallow. Lateral neck radiographic findings show increased retropharyngeal space (white arrow). The CT scan did not demonstrate an abscess. The child was seen by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved for 2-3 days and then worsened. Repeat neck CT scan findings demonstrated a retropharyngeal abscess. Incision and drainage was performed in the operating room. Cultures of the pus grew group A beta-hemolytic streptococci and alpha-streptococci, both sensitive to clindamycin. He improved and was discharged on the tenth hospital day on oral clindamycin.
An 8-month-old infant boy presented with fever and a stiff neck. According to the mother, the baby was not moving his neck as much as usual. The mother also reported decreased oral intake. His temperature was 100° F, pulse was 104 beats per minute, respirations were 48 per minute, oxygen saturation was 98% (room air [RA]). The left tympanic membrane (TM) was inflamed and nonmobile. Left submandibular and left postauricular nodes were noted. The lateral neck radiograph shows increased retropharyngeal space. The CT scan demonstrated a small retropharyngeal abscess. The WBC count was 26,000 (24 polymorphonuclear leukocytes [P], 5 bands [B], 63 lymphocytes [L], 8 monocytes [M]). The baby was examined by an ear, nose, and throat specialist; he was admitted and started on intravenous clindamycin. He improved over the next few days and was discharged on the fifth hospital day on oral clindamycin with a plan for repeat CT scans of the neck on an outpatient basis.
 
 
 
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