OTORHINOLARYNGOLOGICAL INFECTIONS

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

The modified Centor Criteria (McIsaac criteria) can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy.

The cumulative score determines the likelihood of streptococcal (GAS – Group A Streptococcus) pharyngitis and the need for antibiotics:

CRITERIA                                                                                                       SCORE

Absence of cough, rhinorrhea, hoarseness, and oral ulcer                              1

Swollen and tender anterior cervical lymph nodes                                           1

Temperature > 100.4° F (38° C)                                                                             1

Tonsillar exudates or swelling                                                                               1

Age less than 15 years (1 point is deducted if age >44years)                            1

Cumulative Score:

TOTAL SCORE

0 or 1                                                         No antibiotic or culture needed

2-3                                                             Antibiotics based on culture or Rapid Antigen Detection Test (RADT)

>3                                                              Empirical antibiotics

Treatment – as Throat and Upper Respiratory Tract, Rhinology & Otology

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Tonsillitis/Pharyngitis

Common organism:

Group A Streptococcus

Phenoxymethylpenicillin (Penicillin V) 500mg PO q12h for 5-10 days

OR

Amoxicillin 500mg PO q8h for 5-10 days

Benzathine penicillin G 1.2MU IM, one single dose

Antibiotics should be prescribed in suspected (Modified Centor Score ≥3)/proven bacterial infections, as sore throats are commonly viral in origin.

For Penicillin allergic

Cephalexin 500mg q12h for 10 days

OR

Cefixime 200-400mg q12h for 7 days

For Penicillin allergic

Clindamycin 300mg PO q8h for 10 days

OR

Azithromycin 500mg PO  q24h for 3-5 days

Acute Peritonsillar Abscess

Common organisms:

Group A Streptococcus

Staphylococcus aureus

Haemophilus influenza

Fusobacterium necrophorum

Amoxicillin-clavulanate 625mg PO q8h

OR

Phenoxymethylpenicillin (Penicillin V) 500mg PO q6h

PLUS

Metronidazole 500mg PO q6h

Ceftriaxone 1gm IV q12h for 7 days

PLUS

Metronidazole 500mg IV q8h for 5 days

OR

Clindamycin 300-450 PO q6h

For Penicillin allergic

Clindamycin 600mg IV q8h for 7-10 days

Abscess to be drained.

Diphtheria Corynebacterium diphtheriae

*Antitoxin

PLUS

Benzylpenicillin 50,000 units/kg to a maximum of 1.2 MU IV q12h followed by

Phenoxymethylpenicillin (Penicillin V) 250mg PO q6h for a total of 14 days

Erythromycin 500mg IV q6h followed by Erythromycin 800mg PO q12h for a total of 14 days

*Diphtheria Antitoxin:

Pharyngeal/laryngeal disease of 2 days duration 20,000 – 40,000 units

Nasopharyngeal disease 40,000 – 60,000 units

Systemic disease of ≥3 days or any patient with diffuse neck swelling 80,000 – 120,000 units

Administer over 60 mins to inactivate toxins rapidly

Acute Epiglottitis

Common organisms:

Haemophilus influenza type B

Viruses

Streptococcus pneumoniae

Ampicillin-sulbactam 3gm IV q6h

OR

Ceftriaxone 2gm IV q24h

For Penicillin allergic:

Clindamycin 600-900mg IV q8h

PLUS

Ciprofloxacin 400mg IV q12h

Urgent hospitalization. May present with life threatening upper airway obstruction, especially in paediatric population.

Consider adding Vancomycin for patients with moderate to severe sepsis, meningitis or previously colonized with MRSA.

Oral step-down therapy: Amoxicillin-clavulanate 625mg PO q8h for 7-14 days

Deep Neck Space Abscess

Common organisms:

Streptococcus pyogenes

Staphylococcus aureus

Fusobacterium necrophorum

Ampicillin-sulbactam 3gm IV q6h

OR

Ceftriaxone 2gm IV q24h

PLUS

Metronidazole 500mg IV q6h

Duration 7-14 days

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Acute Bacterial Rhinosinusitis (ABRS)

Common organisms:

Streptococcus pneumoniae

Haemophilus influenza

Moraxella catarrhalis

Mild case

Amoxicillin-clavulanate 1000mg PO q12h for 5-7 days or 625mg q8h 10-14 days

For Penicillin allergic:

Cefuroxime 500mg PO q12h for 10-14 days

OR

Roxithromycin 150mg PO q12h for 10-14 days

Any of the following clinical presentations be used to identify patients with acute bacterial vs. viral rhinosinusitis;

-Symptoms and signs persistent and not improving for more than 10 days

- Severe symptoms or signs for at least 3-4 days

-Worsening symptoms or signs OR becoming worse after initial recovery

Severe infection requiring hospitalization Amoxicillin-clavulanate 1.2mg IV q8h for 10-14days

For Penicillin allergic:

Cefuroxime 500mg PO q12h for 10-14 days

OR

Levofloxacin 500mg PO/ IV q24 h for 10-14 days

Chronic Rhinosinusitis

Doxycycline 100mg PO q12h for 10-14 days

Roxithromycin 150mg q12h for 2-4 weeks

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Acute otitis media (AOM)

Common organisms:

Streptococcus pneumoniae

Haemophilus influenza

Moraxella catarrhalis

*For non-severe AOM: Amoxicillin 500mg PO q8h for 7-10days

If symptoms not improve in 48-72 hours, treat as severe AOM

For Penicillin allergic: Cefixime 200-400mg q12h for 7-10 days

OR

Azithromycin 500mg PO on day 1, Followed by 250mg PO q24h until day5

*Non-severe AOM:

Mild otalgia

Temp < 39°C

May consider 48-72 hours of observation with symptomatic therapy before prescribing antibiotic.

**Severe AOM: Moderate to severe otalgia

Temperature > 39°C

**For severe AOM or perforated tympanic membrane:

Amoxicillin-clavulanate 625mg PO q8h for 7-10 days

Malignant Otitis Externa/ Necrotizing Otitis Externa

Common organism:

Pseudomonas aeruginosa

Ciprofloxacin 200-400mg IV q8h

OR

Ceftazidime 2gm IV q8h

Followed by oral therapy (upon clinical response): Ciprofloxacin 750mg PO q12h to complete 6 weeks

Ciprofloxacin 750mg PO q12h for initial 2 weeks then 500mg PO q12h for 4 weeks.

Acute Localized Otitis Externa

Flucloxacillin/Cloxacillin 500mg PO q6h for 5-7 days

With Neomycin + Steroid ointment pack

Acute Diffuse Otitis Externa

Common organisms:

Pseudomonas aeruginosa

Staphylococcus aureus

Ofloxacin 0.3% otic solution

Instill 3 drops into affected ear(s) q24h for 7 days

OR

(Flu)Cloxacillin 500mg PO q6h for 5-7 days

With Neomycin + Steroid ointment pack

Aural toileting required in discharging ears.

Chronic Suppurative Otitis Media

Pseudomonas aeruginosa

Staphylococcus aureus

Ofloxacin 0.3% otic solution Instill 3 drops into affected ear(s) q12h for 10-14 days

PLUS

Ciprofloxacin 500mg q12h for 5-7 days

Aural toileting required in discharging ears.

Otomycosis

Common organisms:

Aspergillus spp. Candida

Clotrimazole 1% ear solution, applied q12h for 10-14 days

Aural toileting required.

Acute Mastoiditis

Amoxicillin-clavulanate 1.2g IV q12h for 10-14 days

OR

Ceftriaxone 2g IV q12h for 14 days

PLUS

Metronidazole 500mg IV q8h for 5 days