ENT antibiotics

Acute necrotizing ulcerative gingivitis

Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella

Uncomplicated Disease

• Amoxicillin/Clavulanate 875 mg PO two times daily AND
  • Metronidazole 500mg PO three times daily x 7 days

OR

• Clindamycin 300mg PO three times daily OR
• Doxycycline 100 mg PO BID x 10 days
• If allergic to penicillin, the use Ciprofloxacin 500mg twice daily AND metronidazole 500mg PO three times daily

Additional Therapies for the immunocompromised

For patient with AIDS or immunocompromised with risk of oral candidal infection then add:

• Nystatin oral rinse four times daily x 14 days OR
• Fluconazole 200mg PO daily x 14 days

Additional Therapies for all patients

• Chlorhexidine 0.01% oral rinse BID
• Hydrogen peroxide swishing (innexpensive home remedy)
• Ibuprofen 400-600mg 3 times daily for pain
  • Magic Mouthwash (multiple variations) - 300cc of 1:1:1 viscous lidocaine 2%, Maalox, diphenhydramine 12.5mg/5ml elixir

Conjunctivitis

Newborn

• Azithromycin 20mg/kg PO once daily for 3 days OR
• Erythromycin 12.5 mg/kg PO q6hrs for 14 days

Chlamydial

• Doxycycline 100mg PO BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
• Ceftriaxone 1g IM single dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
  • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

Bacterial Conjunctivitis

• Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
• Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

• Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
• Erythromycin applied to the conjunctiva q6hrs for 7 days OR
• Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
• Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Pediatric

Same topical regimens as adults; erythromycin ointment preferred in neonates and young infants

• Erythromycin 0.5% ophthalmic ointment applied q6hrs x 7 days (preferred in neonates/infants) OR
• Moxifloxacin 0.5% ophthalmic 1 drop TID x 7 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID x 2 days then daily x 5 days

Epiglottitis

Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae

Immunocompetent

• Ceftriaxone 2gm IV once daily (first line) OR
• Cefotaxime 2gm (50mg/kg) IV three times daily OR
• Ampicillin/Sulbactam 3g (50mg/kg) IV q 6 hours OR
• Levofloxacin 750mg IV once daily
• Consider Vancomycin 15-20mg/kg IV to any of the above if risk of MRSA

Immunocompromised

Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans

• Cefepime 2g (50/kg) IV q8 hours AND Vancomycin 15mg/kg IV q6 hours

Pediatric Immunocompetent

• Ceftriaxone 50-100mg/kg IV daily (max 2g) (first line) OR
• Cefotaxime 50mg/kg IV q8hrs (max 2g/dose) OR
• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose)
• Consider Vancomycin 15mg/kg IV q6hrs if risk of MRSA

Pediatric Immunocompromised

• Cefepime 50mg/kg IV q8hrs (max 2g) AND Vancomycin 15mg/kg IV q6hrs

Dental Abscess

Treatment is broad and focused on polymicrobial infection

• Amoxicillin/Clavulanate 875 mg PO q12 hours x 7-14 days
• Clindamycin 450 mg PO q8 hours x 7-14 days
• Penicillin VK 500 mg PO q6 hours x 7-14 days (frequently prescribed but no longer recommended as monotherapy)
• Ampicillin/Sulbactam 3g IV q6 hours x 7 days
• Amoxicillin 1000mg PO x 1, then 500mg PO q8h x 3 days; If I&D

Pediatric

• Amoxicillin/Clavulanate 25-45mg/kg/day PO divided BID x 7-10 days (max 875mg/dose)
• Clindamycin 30mg/kg/day PO divided TID x 7-10 days (max 1.8g/day) (if PCN allergic)
• Amoxicillin 50mg/kg/day PO divided TID x 7-10 days (max 1.5g/day)
• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose)

Ludwig's Angina

• Must cover typical polymicrobial oral flora and tailored based on patient's immune status
• Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
• If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods

Immunocompetent Host

• Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hrs OR
• Penicillin G 2-4 million units IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
• Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)

Pediatric Immunocompetent

• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
• Penicillin G 50,000 units/kg IV q6hrs (max 4 million units) + Metronidazole 7.5mg/kg IV q6hrs (max 500mg) OR
• Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose)

Immunocompromised

• Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs OR
• Meropenem 1 g IV q8 hrs OR
• Imipenem/Cilastatin 500mg (20mg/kg) IV q6 hours
• Piperacillin/Tazobactam 4.5g (80mg/kg) IV q6 hours
• Add Vancomycin 15-20 mg/kg IV q8 hrs (max 2 g per dose) if concern for MRSA risk factors

Pediatric Immunocompromised

• Cefepime 50mg/kg IV q8hrs (max 2g) + Metronidazole 7.5mg/kg IV q6hrs (max 500mg) OR
• Meropenem 20mg/kg IV q8hrs (max 1g) OR
• Piperacillin/Tazobactam 80-100mg/kg IV q6-8hrs (max 4.5g)
• Add Vancomycin 15mg/kg IV q6hrs if concern for MRSA

Mastoiditis

Coverage against S. pneumoniae, S. pyogenes, S. aureus, H. influenzae

• Clindamycin 600mg IV q8 hours OR (if MRSA concern use Vancomycin regimen)
• Vancomycin 15-20mg/kg IV q12 hours PLUS
  • Ceftriaxone 1g (50mg/kg) IV once daily OR
  • Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hours
• If chronic or severe, need pseudomonas coverage
  • Vancomycin + Piperacillin/Tazobactam 100mg/kg/dose piperacillin IV q6h (max 4g piperacillin/dose)

Pediatric

• Ceftriaxone 50mg/kg IV daily (max 2g) OR
• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose)
• If MRSA concern: add Vancomycin 15mg/kg IV q6hrs
• If chronic/severe: Piperacillin/Tazobactam 100mg/kg IV q6hrs (max 4.5g/dose) + Vancomycin
• Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose) as alternative

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis)

• Organisms involved are polymycrobial but often include Fusobacterium necrophorum, Treponema spp, Selenomonas, and Prevotella

Options

• Penicillin V 500 mg PO q6 hours AND Metronidazole 500mg PO q8 hours x 10 days OR
• Clindamycin 600 mg PO q8 hours OR
• Ampicillin/Sulbactam 3g IV q 6 hours daily

also nystatin oral rinses of 5ml q6 hrs daily for 14 days will help with concominent fungal infection

HIV positive

in addition to antibiotic regimen consider an oral anti-fungal or nystatin

• Fluconazole 200mg PO daily for 14 days

Otitis Media

Initial Treatment

High Dose Amoxicillin

• <2 months
  • Amoxicillin 30mg/kg/day PO divided q12h x 10 days
  • First Dose: 15mg/kg PO x 1
• 2 months - 5 years
  • Amoxicillin 80-90mg/kg/day PO divided q12h x 10 days
  • First Dose: 40-45mg/kg PO x 1
  • Max: 1000mg/dose
• 6-12 years
  • Amoxicillin 80-90mg/kg/day PO divided q12h x 5-10 days
  • First Dose: 40-45mg/kg/day PO x 1
  • Max: 1000mg/dose

Treatment during prior Month

1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea
2. Cefdinir 14mg/kg/day BID x7-10 days
3. Cefpodoxime 10mg/kg PO daily x7-10 days
4. Cefuroxime 15mg/kg PO BID x7-10 days
5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

• Suggestive of non-typeable H.flu

1. Amoxicillin/Clavulanate
   • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
   • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

1. Amoxicillin/Clavulanate 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
   • Use if cannot tolerate PO

Penicillin Allergy

1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
2. Clarithromycin 7.5mg/kg PO BID x 10 days
3. Clindamycin 10mg/kg PO three times daily
   • Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use

• Cephalexin 75-100mg/kg/day PO divided q12h x 10 days; Max: 4,000mg/24h

Otitis Externa

1. Ofloxacin 5 drops in affected ear BID x 7 days (Floxin otic)
   • Safe with perforations
2. Ciprofloxacin-hydrocortisone 3 drops in affected ear BID x 7 days
   • Contains hydrocortisone to promote faster healing
   • Not recommended for perforation since non-sterile preparation
3. Ciprofloxacin-dexamethasone 4 drops in affected ear BID x 7 days
   • Similar to Cipro HC but safe for perforations
   • Often more expensive
4. Cortisporin otic 4 drops in ear TID-QID x 7days (neomycin/polymixin B/hydrocortisone)
   • Use suspension (NOT solution) if possibility of perforation
   • Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking

Pediatric: Same topical regimens apply to children

1. Ofloxacin 5 drops (>12yr) or 3 drops (<12yr) in affected ear BID x 7 days
2. Ciprofloxacin 3-4 drops in affected ear BID x 7 days (with dexamethasone or hydrocortisone)

Streptococcal Pharyngitis

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

• Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
• Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
• Amoxicillin 50 mg/kg once daily (maximum = 1000 mg) for 10 days

Penicillin allergic (mild):

• Cephalexin 20 mg per kg PO BID (maximum 500 mg per dose) x 10 days
• Cefadroxil 30 mg per kg PO QD (maximum 1 g daily) x 10 days

Penicillin allergic (anaphylaxis):

• Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days
• Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days
• Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days

Pediatric Dosing:

• Amoxicillin 50mg/kg PO once daily x 10 days (max 1000mg)
• Penicillin V <27kg: 250mg PO BID-TID x 10 days; >27kg: 500mg PO BID-TID x 10 days
• Penicillin G Benzathine <27kg: 600,000 units IM x 1; >27kg: 1.2 million units IM x 1
• PCN allergy (mild): Cephalexin 20mg/kg PO BID x 10 days (max 500mg/dose)
• PCN allergy (mild): Cefadroxil 30mg/kg PO daily x 10 days (max 1g)
• PCN allergy (severe): Azithromycin 12mg/kg PO day 1 (max 500mg), then 6mg/kg daily x 4 days (max 250mg)
• PCN allergy (severe): Clindamycin 7mg/kg/dose PO TID x 10 days (max 300mg/dose)
• PCN allergy (severe): Clarithromycin 7.5mg/kg PO BID x 10 days (max 250mg/dose)

• Clindamycin 7mg/kg/dose PO q8h x 10 days; Max: 300mg/dose
• Azithromycin Children ≥2 years and Adolescents: Oral: 12mg/kg/dose once daily for 5 days (maximum: 500mg daily)
• Amoxicillin 50mg/kg PO q24h x 10 days; Max: 1000mg/day
• Clarithromycin >6mo: 15mg/kg/day PO divided q12h x 7-10d
• Cephalexin 40mg/kg/day PO divided q12h x 10 days; Max: 500mg/dose
• Cefpodoxime 100mg q 12 h for 5-10 days
• Cefuroxime 250mg PO bid x10 days
• Cefuroxime 250mg PO bid x10 days

Periorbital Cellulitis

Antibiotics

Outpatient

Treatment recommended for 5-7 days. If signs of cellulitis persist at the end of this period, treatment should be continued until the eyelid erythema and swelling have resolved or nearly resolved.

• TMP/SMX 1-2 double-strength tablets BID OR

- In children: TMP/SMX 8 to 12 mg/kg QD of the TMP component divided every 12 hours

• Clindamycin 300mg Q8H - In children: Clindamycin 30 to 40 mg/kg per day in three to four equally divided doses, maximum 1.8 grams per day

PLUS one of the following agents:

• Amoxicillin 875 mg BID OR

- In children: Amoxicillin 45-90 mg/kg per day divided every 12 hours

• Cefpodoxime 400mg BID OR

- In children: Cefpodoxime 10 mg/kg per day divided every 12 hours, max 200 mg

• Cefdinir 300 mg BID - In children: Cefdinir 14 mg/kg per day, divided every 12 hours, max daily 600 mg

Inpatient

• Vancomycin 15-20mg/kg IV BID + (one of the following)
  • Ampicillin/Sulbactam 3 g IV q6hr OR
  • Ticarcillin/Clavulanate 3.1 g IV q4h OR
  • Piperacillin/Tazobactam 4.5 g IV q6h OR
  • Ceftriaxone 2 g IV q12hr OR
  • Cefotaxime 2 g IV q4h

Pediatric:

• Vancomycin 15mg/kg IV q6hrs + (one of the following)
  • Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
  • Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g) OR
  • Ceftriaxone 50mg/kg IV q12hrs (max 2g/dose) OR
  • Cefotaxime 50mg/kg IV q6hrs (max 2g/dose)

Peritonsillar Abscess

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

• Clindamycin 300mg PO Q6hrs x7-10d
• Amoxicillin/Clavulanate 875 mg PO BID x 7-10d
• Penicillin V 500mg PO + Metronidazole 500mg QID

Inpatient Options

• Ampicillin/Sulbactam 3 gm (75mg/kg) IV four times daily
• Piperacillin/Tazobactam 4.5 gm IV TID
• Ticarcillin/Clavulanate 3.1 g IV QID
• Clindamycin 600-900mg IV TID
• Penicillin G 4 million units (50,000 units/kg) IV four times daily + Metronidazole 500mg IV three times daily

Pediatric Outpatient

• Clindamycin 30-40mg/kg/day PO divided TID (max 1.8g/day)
• Amoxicillin/Clavulanate 45mg/kg/day PO divided BID (max 875mg/dose)

Pediatric Inpatient

• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose)
• Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose)
• Penicillin G 50,000 units/kg IV q6hrs (max 4 million units/dose) + Metronidazole 7.5mg/kg IV q8hrs (max 500mg/dose)

Pertussis

• Antibiotics do not help with severity or duration but may decrease infectivity.
• A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset.
• TMP--SMZ should not be administered to pregnant women, nursing mothers, or infants aged <2 months.
• The following regemins are for active disease or postexposure prophylaxis. If a patient is has confirmed disease and is likely to be in contact with infants or pregnant women then the patient should be treated as up to 6-8 weeks after the onset of their illness.

< 1 month old

Same antibiotics for active disease and postexposure prophylaxis

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days

>1 month old

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days
  • if > 6 months old then day 2-5 of treatment should be reduced to 5mg/kg (250mg/day max)
• TMP/SMX 4mg/kg PO BID daily for 14 days (if > 2 months old)

• Clarithromycin >6 months: 7.5mg/kg PO BID x 7 days (max 500mg/dose)
• Erythromycin 10mg/kg PO QID x 14 days (max 2g/day)

Adults

any of the following antibiotics are acceptable although azithromycin is most commonly prescribed

• Azithromycin 500mg PO once daily for day #1 then 250mg PO once daily for days #2-5
• Clarithromycin 500mg BID x7 days
• Erythromycin 500mg QID x7 days

Suppurative Parotitis

Treatment targeted at S. aureus, gram negative bacilli, mumps, enteroviruses, and influenza virus

• Amoxicillin/Clavulanate 875mg (45mg/kg) PO BID OR
• Clindamycin 450mg PO three times daily or Clindamycin 10mg/kg PO four times daily
• Dicloxacillin 500mg (7.5mg/kg) PO four times daily
• Cephalexin 500mg (12.5mg/kg) PO four times daily
• Nafcillin 2g IV six times daily or Nafcillin 50mg/kg IV four times daily
• Vancomycin 15-20mg/kg IV BID daily

Pediatric

• Amoxicillin/Clavulanate 45mg/kg/day PO divided BID (max 875mg/dose)
• Cephalexin 50mg/kg/day PO divided QID (max 500mg/dose)
• Dicloxacillin 25-50mg/kg/day PO divided QID
• Vancomycin 15mg/kg IV q6hrs

Thrush

• Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
• Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
• Fluconazole 200 mg PO on day one, followed by 100 mg daily for two weeks
  • Fluconazole is reserved for moderate to severe disease

Pediatric Dosing

If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding

• Nystatin Oral Suspension 100,000 units/ml for 14 days for all ages
  • Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
• Clotrimazole 10mg PO five times daily for 14 days
  • reserved for patients > 3 years old
• Fluconazole 6 mg/kg PO on day one, followed by 3 mg/kg daily for two weeks

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)