Antibiotics - ENT

Acute Pharyngitis Tonsillitis

Infection	Acute pharyngitis tonsillitis
Most likely organisms	Viruses, S. pyogenes
Empiric treatment	No antibiotic if viral. Severe: Benzyl penicillin 1.2-2.4g q6h iv plus Metronidazole 500mg q8h IV / 400mg q8h po. Moderate: Amoxicillin 500mg - 1g q8h po.
In penicillin allergy	Clarithromycin 500mg q12h po/iv. In severe, hospitalised cases, add Metronidazole 500mg q8h iv / 400mg q8h po.
Duration	10 days.
Comments	Majority viral, most patients do not benefit from antibiotics. Consider infectious mononucleosis. * Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary. If MUH / SIVUH No antibiotic if viral. Severe: Benzyl penicillin 1.2-2.4g q6h iv plus Metronidazole 500mg q8h IV / 400mg q8h po. Moderate: Penicillin V 666mg q6h po.

Vincent's Angina

Acute necrotising ginguvitis

Infection	Acute necrotising gingivitis(Vincent's angina)
Most likely organisms	Oral anaerobes
Empiric treatment	Benzylpenicillin 1.2-2.4g q4-6h iv plus Metronidazole 500mg q8h iv OR 400mg q8h po. Oral switch: Amoxicillin 500mg q8h po plus Metronidazole 400mg q8h po.
In penicillin allergy	Clindamycin 600mg q6h iv. Oral switch: Clindamycin 450mg q6h po.
Duration	10 days
Comments	If MUH / SIVUH Benzylpenicillin 1.2-2.4g q4-6h iv plus Metronidazole 400mg q8h po. Oral switch: Penicillin V 666mg q6h po plus Metronidazole 400mg q8h po.

Acute Sinusitis

Infection	Acute sinusitis
Most likely organisms	Viruses, Streptococci, H. influenzae, Moraxella catarrhalis, S. aureus
Empiric treatment	No antibiotic if considered viral. Co-amoxiclav 625mg q8h po Or Doxycycline 200mg stat then 100-200mg q24h po.
In penicillin allergy	No antibiotic if considered viral. Clarithromycin 500mg q12h po or Doxycycline 200mg stat then 100mg q12h po.
Duration	7-10 days.
Comments	Many attacks resolve without antibiotics. Consider allergic conditions or viral infection. * Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.

Acute Otitis Media

Infection	Acute otitis media
Most likely organisms	Viruses, S. pneumoniae, H. influenzae
Empiric treatment	No antibiotic if considered viral. Co-amoxiclav 625mg q8h po or Doxycycline 200mg stat then 100mg q12h po.
In penicillin allergy	No antibiotic if considered viral. Clarithromycin 500mg q12h po or Doxycycline 200mg stat then 100�200mg od po.
Duration	5-7 days.
Comments	Use pain relief for 24 hours before deciding whether antibiotic is required.

Acute Otitis Externa

Infection	Acute otitis externa
Most likely organisms	As above
Empiric treatment	See comments
In penicillin allergy	See comments
Duration
Comments	Antibiotics often not indicated unless cellulitis present. In malignant otitis externa (Pseudomonas), seek advice.

Acute Epiglottitis

Infection	Acute epiglottitis
Most likely organisms	H. influenzae
Empiric treatment	Ceftriaxone 2g q12h iv.
In penicillin allergy	Levofloxacin 500mg q12h po/iv
Duration	10 days.
Comments	Take blood cultures and contact microbiology ** Moxifloxacin is contraindicated in clinically relevant heart failure with reduced left ventricular ejection fraction, in bradycardia, where there is a history of QT prolongation or history of symptomatic arrythmias. Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval, e.g. amiodarone, sotalol, neuroleptics e.g. haloperidol, chlorpromazine. Seek advice from pharmacy. It is also contraindicated in patients with impaired liver function (Child Pugh C).There are ongoing concerns regarding hepatic and serious skin reactions with moxifloxacin. Only use when there is no other alternative.

Oropharyngeal/Peritonsillar Abscess

Infection	Oro-pharyngeal / peri-tonsillar abscess
Most likely organisms	S. pyogenes, anaerobes
Empiric treatment	Benzylpenicillin 1.2-2.4g q6h iv plus Metronidazole 400mg q8h po. For chronic abscesses: Co-amoxiclav 1.2g q8h iv
In penicillin allergy	Clarithromycin 500mg q12h po plus Metronidazole 400mg q8h po
Duration
Comments	Seek surgical review, as may require drainage. * Clarithromycin can cause significant increases in INR. For patients on Warfarin and Clarithromycin, INR must be monitored very closely and appropriate Warfarin dose adjustments made as necessary.

Appendices

Appendix 1 Switching from IV to PO therapy
Appendix 2 Aminoglycoside monitoring
Appendix 3 Vancomycin
Appendix 4 Clostridium difficile diarrhoea
Appendix 5 MRSA
Appendix 6 Renal impairment, antibiotics
Appendix 7 IV preparations
Appendix 8 Prescribing Tips
Prophylaxis - Endocarditis
Prophylaxis - Meningitis
Prophylaxis - Post Splenectomy /Hyposplenic
Penicillin Allergy
SEPSIS.

Links

Content By Dr. Íomhar O' Sullivan 10/08/2010. Last review Dr. ÍOS 10/06/17.