Deep Neck Space Infections Empiric Therapy

Updated: Nov 03, 2020
  • Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Thomas E Herchline, MD  more...
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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, 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.