Medication Summary
Initiate empiric parenteral antibiotic therapy early in patients with concern for RPA. Provide broad-spectrum coverage for gram-positive, gram-negative aerobes, and anaerobes.
Although penicillin G and metronidazole were once considered the mainstays of therapy, the increasing presence of beta-lactamase–producing bacteria forced practice away from this combination. Treatment may be initiated with a beta-lactamase–resistant combination penicillin (eg, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin-sulbactam). In some cases, when concern for MRSA is present, treatment would likely be managed with clindamycin or vancomycin.
Penicillins, Amino
Ampicillin and sulbactam (Unasyn)
Ampicillin is a semisynthetic penicillin and is bactericidal, inhibiting cell wall synthesis. Sulbactam is a beta-lactamase inhibitor. 3 g Unasyn contains 2 g ampicillin and 1 g sulbactam.
Amoxicillin/clavulanate (Augmentin, Augmentin ES-600, Augmentin XR)
Amoxicillin binds to penicillin-binding proteins, thus inhibiting final transpeptidation step of peptidoglycan synthesis in bacterial cell walls; addition of clavulanate inhibits beta-lactamase-producing bacteria, allowing amoxicillin extended spectrum of action.
Glycopeptides
Vancomycin (Vancocin, Firvanq)
Vancomycin inhibits cell-wall biosynthesis; blocks glycopeptide polymerization by binding tightly to D-alanyl-D-alanine portion of cell wall precursor.
Lincosamides
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)
Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Cephalosporins, 2nd Generation
Cefuroxime (Ceftin, Zinacef)
Second generation cephalosporin which binds to penicillin-binding proteins and inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell-wall death; resists degradation by beta-lactamase.
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Bactericidal and inhibits cell wall synthesis.
Penicillins, Extended-Spectrum
Piperacillin/tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor which prevents biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication. Zosyn 3.375 contains 3 g of piperacillin and 0.375 g of tazobactam.
Ticarcillin and clavulanate potassium (Timentin)
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 and gram-negative organisms and most anaerobes. Timentin 3.1 g contains 3 g of ticarcillin and 0.1 g of clavulanate.
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Schematic of neck deep space anatomy, as illustrated in lateral and cross-sectional views. Fascial planes (see color key) surround potential spaces. Anteriorly, retropharyngeal space is bounded by buccopharyngeal fascia, which invests pharynx, trachea, esophagus, and thyroid; posteriorly by alar fascia; and laterally by carotid sheaths and parapharyngeal spaces. Retropharyngeal space extends from skull base to mediastinum at level of tracheal bifurcation. Note danger space located between alar fascia and prevertebral fascia.
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Plain lateral neck x-ray. Top radiograph reveals widening of soft tissues, with anterior airway displacement. Careful examination of this film also reveals gas in soft tissues. Bottom radiograph reveals soft tissue widening at C2.
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Contrast axial CT scan demonstrates left-side retropharyngeal abscess with central hypoattenuation.
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Contrast sagittal CT scan demonstrates central hypodensity with prevertebral soft-tissue stripe widening and oropharyngeal air column narrowing consistent with retropharyngeal abscess formation.
