Deep Neck Space Infections Empiric Therapy 

Updated: Nov 04, 2015
  • Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Thomas E Herchline, MD  more...
  • Print

Empiric Therapy 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]

For cases with an oral or odontogenic source of infection:

For cases with a rhinogenic or otogenic source of infection:

  • Ampicillin-sulbactam 3 g IV q6h or
  • Ceftriaxone 1 g IV q24h plus  metronidazole 500 mg IV q6-8h or
  • Ciprofloxacin 400 mg IV q12 h plus clindamycin 600 mg IV q6-8h

If methicillin-resistant S aureus (MRSA) is suspected, add vancomycin 1000 mg (15 mg/kg) IV q12h or linezolid 600 mg IV q12h.

Immunocompromised patients present an additional challenge to providers, as they are more likely to harbor uncommon organisms as a source of infection.

Treatment regimens for parapharyngeal or retropharyngeal space infections in immunocompromised patients

See the list below:

  • Cefepime 2 g IV q12h  plus   metronidazole 500 mg IV q6-8h  or
  • Imipenem 500 mg IV q6h  or
  • Meropenem 1 g IV q8h  or
  • Piperacillin-tazobactam 4.5 g IV q6h

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.