Page 950 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 73: Life-Threatening Infections of the Head, Neck, and Upper Respiratory Tract 681

TABLE 73-2 Usual Causative Organisms and Initial Empirical Antimicrobial Regimens for Life-Threatening Infections of the Head, Neck, and Upper Respiratory Tract
Antimicrobial Regimens
Infection Usual Causative Organisms Normal Host Compromised Host
Deep cervical fascial space infections
Submandibular space infections (including Viridans and other streptococci, Penicillin G 2–4 MU IV q4-6h, plus Cefotaxime 2 g IV q6h plus metronidazole 0.5 g IV
Ludwig angina) Peptostreptococcus spp, Bacteroides metronidazole 0.5 g IV q6h; or q6h; or
• Predominantly odontogenic spp, Porphoromonas spp, Prevotella Ampicillin-sulbactam 2g IV q4h; or Ceftriaxone 1 g IV q12h plus metronidazole 0.5 g IV q6h; or
spp, and other oral anaerobes
Clindamycin 600 mg IV q6h; or Cefepime 2 g IV q12h plus metronidazole 0.5 g IV q6h
Doxycycline 200 mg IV q12h; or Piperacillin-tazobactam 4.5 g IV q6h; or
Moxifloxacin 400 mg IV q24h Imipenem 500 mg IV q6 h or meropenem 1 g IV q8h
Lateral pharyngeal or retropharyngeal space Viridans and other streptococci, Same as above for submandibular space Same as above for submandibular space infections
infections Staphylococcus spp, Peptostreptococcus infections
• Odontogenic spp, Bacteroides spp, Porphoromonas spp,
Prevotella spp, and other oral anaerobes
• Rhinogenic or otogenic Streptococcus pneumoniae, Ampicillin-sulbactam 3 g IV q6h; or Same as for odontogenic space infections
Haemophilus influenzae, viridans and Ciprofloxacin 0.2 g IV q12h, plus metroni-
other streptococci, Bacteroides spp, dazole 0.5 g IV q6h; or
Peptostreptococcus spp, and other oral
anaerobes Ciprofloxacin 400 mg IV q12h plus
clindamycin 600 mg IV q6h
Suppurative parotitis Staphylococcus aureus, viridans and Nafcillin 1.5 g IV q4-6h plus metronidazole Vancomycin 1 g IV q12h or linezolid 600 mg IV q12h;
other streptococci, Bacteroides spp, 0.5 g IV q6h; or clindamycin 600 mg IV q6h each plus
Peptostreptococcus spp, and other oral Cefotaxime 2 g IV q6h; or
anaerobes
Piperacillin-tazobactam 4.5 g IV q6h; or
Imipenem 500 mg IVq6h
Peritonsillar abscess (Quinsy) Group A Streptococcus (S pyogenes), Penicillin g 2–4 MU IV q4-6h, plus metroni- Cefotaxime 2 g IV q6h or ceftriaxone 1 g IV q12h;
Fusobacterium spp, Porphoromonas dazole 0.5 g IV q6h; or each plus metronidazole 0.5 g IV q6h and vancomycin
spp, Prevotella spp, Peptostreptococcus Ampicillin-sulbactam 3 g IV q6h; or 1 g IV q12h
spp, and other oral anaerobes
Clindamycin 600 mg IVq6h; or
Suppurative jugular thrombophlebitis Viridans and other streptococci, Same as for odontogenic space infections Same as for odontogenic space infections
(Lemierre syndrome) Staphylococcus spp, Peptostreptococcus
spp, Bacteroides spp, Porphoromonas spp,
Prevotella spp, and other oral anaerobes
Suppurative cavernous sinus thrombosis Depending on source, same as odonto- Same as for odontogenic or rhinogenic Same as for odontogenic or rhinogenic space infections
genic or rhinogenic space infections space infections
Extension of osteomyelitis from prevertebral Staphylococcus aureus, facultative Nafcillin 1.5 g IV q4-6 h, plus tobramycin Vancomycin 0.5 g IV q6h linezolid 600 mg IV q12h,
space infection gram-negative bacilli 2 mg/kgq8h; or each plus
Nafcillin 1.5 g IV q4-6 h plus ciprofloxacin Cefotaxime 2gIVq6h; or
0.2 g q12h Piperacillin-tazobactam 4.5 g IV q6h; or
Imipenem 500 mg IVq6h
Pott puffy tumor (frontal osteitis) Same as for rhinogenic space infections Same as for rhinogenic space infections Same as for rhinogenic space infections
Acute epiglottitis Streptococcus pneumoniae, Ampicillin-sulbactam 3 g IV q6h; or Cefotaxime 2 g IV q6h or ceftriaxone 1 g IV q12h, each
Haemophilus influenza, Staphylococcus Cefepime 2 g IV q12h plus vancomycin 1 g IV q12h
aureus
Malignant otitis media and petrous osteitis Pseudomonas aeruginosa Ciprofloxacin 200 mg IV q12h; or Ciprofloxacin 200 mg IV q12h; or
Tobramycin 2 mg/kg q8h plus ceftazidime Tobramycin 2 mg/kg q8h plus ceftazidime 2 g IV
2 g IV q6h; or q6h; or
Piperacillin-tazobactam 4.5 g IV q6h; or Piperacillin-tazobactam 4.5 g IV q6h; or
Imipenem 1 g IV q6h Imipenem 1 g IV q6h
IV, intravenous; MU, million units; q, every.
procedure under general anesthesia should be performed. In addition, ■ LATERAL PHARYNGEAL SPACE INFECTIONS

the infected teeth implicated in the sepsis should be extracted. Lateral pharyngeal space infections are potentially life threatening
With the combined use of systemic antibiotics and aggressive surgical because of involvement of vital structures within the carotid sheath and
intervention, the mortality rate for Ludwig angina has declined dramati- a tendency to bacteremic dissemination. Anatomically, the lateral pha-
cally from over 50% in the pre-antibiotic era to 0% to 4% currently. 8 ryngeal space (also known as the pharyngomaxillary space) is shaped

section05_c61-73.indd 681 1/23/2015 12:49:07 PM