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 aureus, Streptococcus 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]}

For cases with an oral or odontogenic source of infection:

Clindamycin 600 mg IV q6-8h plus levofloxacin (750mg IV q24h) or
Ampicillin-sulbactam 3 g IV q6h or
Ceftriaxone ( 2g IV q24h) plus metronidazole (500 mg IV q8h)

For cases with an otogenic source of infection:

Cefepime (2 g IV q8h) plus metronidazole (500 mg IV q8h) or
Piperacillin-tazobactam (4.5g IV q6h) or
Meropenem (2g IV q8hr)

For cases with a rhinogenic source of infection:

Vancomycin (15-20 mg/kg q8-12hr) plus ampicillin-sulbactam (3 g IV q6hr) or
Vancomycin (15-20 mg/kg q8-12hr) plus ceftriaxone (2 g IV q24h) plus metronidazole (500 mg IV q8h)
Clindamycin 600 mg IV q6-8h plus levofloxacin (750 mg IV q24h)

If methicillin-resistant S aureus (MRSA) is suspected, add vancomycin (15-20 mg/kg q8-12hr) 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

These include the following:

Cefepime (2 g IV q8h) plus metronidazole (500 mg IV q8h) or
Imipenem Ig IV q6h or
Meropenem 2 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.

Media Gallery

of 0

Author

Udayan K Shah, MD, FACS, FAAP Professor of Otolaryngology-Head and Neck Surgery and Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University; Chief of Credentialing, Nemours Children's Health System; Chief of Otolaryngology, Nemours Delaware Valley

Udayan K Shah, MD, FACS, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, American Society of Pediatric Otolaryngology, Phi Beta Kappa, Society for Ear, Nose and Throat Advances in Children

Disclosure: Nothing to disclose.

Coauthor(s)

Vanessa Christopher, MD Resident Physician, Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College of Thomas Jefferson University

Disclosure: Nothing to disclose.

Specialty Editor Board

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Received research grant from: Regeneron.

Additional Contributors

Christopher R Grindle, MD Assistant Professor of Clinical Otolaryngology, University of Connecticut School of Medicine

Disclosure: Nothing to disclose.

David E Conrad, MD Fellow in Pediatric Otolaryngology, AI DuPont Hospital for Children

David E Conrad, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Michael B Hall, MD Resident Physician, Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital

Michael B Hall, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.