Deep Neck Space Infections Organism-Specific Therapy

Updated: Nov 03, 2020

Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Thomas E Herchline, MD

Specific Organisms and Therapeutic Regimens

Deep neck space infections, including parapharyngeal abscess, peritonsillar abscess, and retropharyngeal abscess, are often of ontogenic, sinus, or upper aerodigestive tract origin. The bacteriology tends to be polymicrobial, involving both aerobic and anaerobic bacteria from the primary source. If not diagnosed and treated promptly, these infections may be life-threatening, as a result of airway compromise and the spread of infection to neighboring neck spaces. Initial empiric antimicrobial therapy should include broad coverage for aerobic bacteria, including gram-positive organisms such as Staphylococcus aureus and Streptococcus pyogenes, and gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Anaerobic bacteria, including gram-positive organisms such as Peptostreptococcus species, and gram-negative bacteria such as Prevotela species, should be broadly covered as well. Broad coverage should continue until culture results are obtained to help direct treatment.[1, 2, 3, 4, 5, 6, 7, 8] Specific therapy upon obtaining organism and susceptibility information is detailed below.

Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus

See the list below:

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

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:

Vancomycin 1000 mg (15 mg/kg) IV q12h or
Linezolid 600 mg IV q12h or
Daptomycin 4-6 mg/kg IV q24h or
Clindamycin 600 mg IV q8hr

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 q12h 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-week course of treatment. Longer courses may be required when complications are present.

Special considerations

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, after 48-72 hours, no clinical improvement is observed in association with 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 with contrast 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.

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.

Deep Neck Space Infections Organism-Specific Therapy

Specific Organisms and Therapeutic Regimens

Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus

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

Methicillin-susceptible Staphylococcus aureus (MSSA)

Methicillin-resistant Staphylococcus aureus (MRSA)

Haemophilus influenzae

Pseudomonas aeruginosa

Duration of therapy

Special considerations

Contributor Information and Disclosures

References