ENT / Respiratory Tract Infections

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Community acquired pneumonia (CAP) in children

Pneumonia is an acute inflammation of the lung parenchyma. Children typically present with cough, difficulty breathing, and fever. Clinical signs include bronchial breath sounds and focal crackles.

In infants <12 months, bronchiolitis is a more common cause of fast breathing and chest indrawing than pneumonia.

Antimicrobial 

Infants under 3 months:

Admit to hospital.

Ampicillin 50mg/kg IV TID

PLUS

Gentamicin 5mg/kg IV OD

Infants and children over 3 months:

Mild:

Amoxicillin 40mg/kg (max 1g) PO BID

Moderate:

Ampicillin 50mg/kg (max 2g) IV TID

If atypical infection (Mycoplasma, Legionella, B. pertussis) is suspected ADD:

Azithromycin 10mg/kg IV/PO

Severe:

Ceftriaxone 50mg/kg (max 2g) IV OD

PLUS

Azithromycin 10mg/kg IV/PO OD

If a parapneumonic effusion is present, or Staphylococcus aureus is considered likely, add:

Cloxacillin 50mg/kg (max 2g) IV QID

(See Appendix H for neonatal dose intervals)

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics if systemically unwell.

If cough has been present for more than 3 weeks, or there is associated weight loss or a known TB contact, consider TB in the differential diagnosis.

Severe pneumonia in children is associated with grunting, chest indrawing, oxygen saturation <90% or danger signs including inability to feed, lethargy or convulsions. See Community acquired pneumonia (CAP) in adults below for when to suspect Staphylococcus aureus infection.

Duration:

Mild-Moderate: Treat for 3-5 days
Severe: Change to oral antibiotics when improving. Treat for a total of 5-7 days.
Azithromycin: Stop after 5 days.

See Community acquired pneumonia (CAP) in adults in Chapter 6: ENT / Respiratory Tract Infections, comments section for further work-up if there is failure to improve despite broad spectrum antibiotics.

Community acquired pneumonia (CAP) in adults

For adults with pneumonia use CORB score to assess severity:

C = acute confusion = 1

O = oxygen saturation ≤90% = 1

R = respiratory rate ≥30 = 1

B = blood pressure <90mmHg systolic, or <60mmHg diastolic = 1

Treat as severe if score is 2 or more.

Community acquired pneumonia is commonly caused by Streptococcus pneumoniae. Atypical bacteria including Mycoplasma pneumonia, Chlamydophila pneumoniae and Legionella spp. are also important causes of CAP. These atypical organisms are not adequately treated with beta-lactam antibiotics; this is the rational for the inclusion of doxycycline or azithromycin in empiric treatment regimes.

If cough persists for longer than 2-3 weeks, investigate for TB.

Antimicrobial 

Mild:

Amoxicillin 1g PO TID

Alternative:

Procaine penicillin 2.5 million IU (1.5g) IM OD

OR

Doxycycline 100mg PO BID

Moderate:

Benzylpenicillin 2 million IU (1.2g) IV QID

PLUS

Doxycycline 100mg PO BID

Alternative:

If benzylpenicillin is unavailable, replace this with:
Ampicillin 1g IV QID

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use empiric treatment for mild pneumonia.

Severe:

Ceftriaxone 2g IV OD

PLUS

Azithromycin 500mg IV/PO OD

If Staphylococcus aureus is considered likely ADD:
Vancomycin IV loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

Alternative:

Cloxacillin 2g Q4H IV

If no improvement after 48 hours or ICU admission with pneumonia change to:

Meropenem 1g IV TID

PLUS

Azithromycin 500mg IV OD

And consider adding MRSA cover.

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin 1g PO TID

Comments and Duration of Therapy 

Send sputum culture in patients admitted with moderate or severe pneumonia, and patients with mild pneumonia who fail to respond to empiric treatment. Take blood cultures prior to antibiotics in patients who are systemically unwell. Consider performing nasopharyngeal swabs for influenza, RSV and COVID.

In patients with severe CAP suspect Staphylococcus aureus if any of the following:

  • Rapid progression to sepsis
  • Cavitary or necrotising pneumonia
  • Multilobar consolidation
  • Multiple lung abscesses or empyema
  • Significant history of Staphylococcus skin and soft tissue infection
  • Gram positive cocci in clusters in sputum gram stain

Duration:

Mild: Treat for 5-7 days
Moderate: Change to oral antibiotic when improving. Treat for a total of 7 days.
Severe: Stop azithromycin after 5 days. Change to oral antibiotics when well and treat for a total of 7-10 days.

If there is failure to improve despite broad spectrum antibiotics consider the following:

  • TB testing
  • CXR and / or CT to look for empyema, abscess, tumour
  • HIV testing
  • Non-infective cause of presentation (e.g. pulmonary oedema, pulmonary thromboembolic disease)

Hospital acquired pneumo- nia (HAP)

Pneumonia that develops more than 48 hours after admission to hospital. This typically presents with fever, purulent sputum, new radiological infiltrate, raised inflammatory markers and deterioration in gas exchange.

Antimicrobial 

Mild:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Moderate to severe:

Ceftriaxone 1g (child: 50mg/kg) IV BID

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

If no improvement after 48 hours and microbiology results are not available to direct treatment, change to:

Meropenem 1g (child 25mg/kg) IV TID

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics in patients who are systemically unwell, and send sputum culture in all patients with HAP.

Most HAP is caused by micro-aspiration of bacteria that colonise the oropharynx. Prolonged hospitalization can result in changes to the oropharyngeal flora, with an increase in gram-negative colonization.

If there is no improvement despite broad-spectrum antibiotics, consider repeat CXR and/or CT to look for complications such as pleural effusion, empyema, or abscess.

Duration:

Mild: Treat for 7 days
Moderate to severe: Change to orals when well. Treat for 7-10 days

Ventilator associated pneumonia

Pneumonia that develops in patient who has been mechanically ventilated for longer than 48 hours. This typically presents as fever, increased or purulent lower respiratory track secretions, new radiological infiltrates,raised inflammatory markers, and deterioration in gas exchange.

Antimicrobial 

Meropenem 1g (child 25mg/kg) IV TID

If Staphylococcus aureus is considered likely ADD:

Vancomycin loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Comments and Duration of Therapy 

In all patients send tracheal aspirate for culture and send blood cultures prior to antibiotics.

Change from meropenem to targeted antibiotic cover as soon as culture and antibiotic sensitivity results available, to minimise development of antibiotic resistance in the ICU.

See Community acquired pneumonia (CAP) in adults in Chapter 6: ENT / Respiratory Tract Infections, for when to suspect Staphylococcus aureus pneumonia.
If there is no improvement despite broad-spectrum antibiotics, consider repeat CXR and/or CT to look for complications such as pleural effusion, empyema, or abscess.

Duration:

Change to orals when well. Treat for 7-10 days

Aspiration pneumonia

This is a bacterial infection caused by aspiration of organisms from the oropharynx. Minor aspirations and aspiration without evidence of infection do not require treatment.

Antimicrobial 

Benzylpenicillin 2 million IU (1.2g) (child 80 000 IU (50mg)/kg) IV QID

Alternative:

Ampicillin 1g (child: 50mg/kg) IV TID

If anaerobic organisms suspected, ADD:

Metronidazole 500mg (child: 12.5mg/kg) IV/ PO BID

If Staphylococcus aureus is considered likely ADD:

Vancomycin loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

OR

Cloxacillin 2g (child 50mg/kg) IV QID

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin 1g PO TID (child: 40mg/kg PO BID)

OR (if Staphylococcus or anaerobes suspected)

Amoxicillin/Clavulanic acid 500/125mg (child 25/5 mg/kg) PO TID

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics in patients who are systemically unwell, and send sputum culture in all patients.

Causative organisms may be oral Streptococci, anaerobes, occasionally Gram-negative bacilli, and Staphylococcus aureus.

Anaerobic cover should only be considered in the setting of severe peri- odontal disease, malodorous sputum, or hazardous alcohol consumption.

See Community acquired pneumonia (CAP) in adults in Chapter 6: ENT / Respiratory Tract Infections, for when to suspect Staphylococcus aureus pneumonia.

Duration:

Change to orals when well. Treat for 7 days.

Lung abscess and empyema in adults

Lung abscess is due to pulmonary tissue necrosis and formation of cavities containing necrotic debris and purulent fluid. Lung abscesses may be caused by aspiration of oral bacteria (polymicrobial including anaerobic organisms), a complication of pneumonia (e.g. Klebsiella pneumoniae, Staphylococcus aureus), or a metastatic complication of bacteraemia (e.g. Staphylococcus aureus).

Empyema is a collection of pus in the pleural space and usually occurs as a complication of pneumonia. Adequate drainage is essential for cure of empyema. Seek Surgical review.

Antimicrobial 

Mild to moderate:

Benzylpenicillin 2 million IU (1.2g) IV QID

PLUS

Metronidazole 500mg IV/PO BID

Alternative:

If benzylpenicillin is unavailable, replace this with:
Ampicillin 1g IV TID

Severe:

Ceftriaxone 2g IV BID

PLUS

Clindamycin 600mg IV/PO TID

Alternative:

If clindamycin is unavailable, replace this with:
Metronidazole 500mg IV BID

If patient is in septic shock treat with:

Meropenem 1g IV TID

AND

Vancomycin loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

Alternative:

Vancomycin loading dose 25-30mg/kg IV, then dose according to Vancomycin dosing section.

PLUS

Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

If amikacin is not available and patient is likely to have normal renal function add Gentamicin 7mg/kg IV for first dose. If renal function is likely to be abnormal give Gentamicin 4-5mg/kg.

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg PO BID

Alternative:

Cefuroxime 500mg PO BID

PLUS

Metronidazole 500mg PO BID

OR

Amoxicillin 1 g PO TID

PLUS

Metronidazole 500 mg PO BID

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics, and send sputum culture in all patients. Send pleural fluid aspirate for culture, TB testing if indicated, and chemistry.

Change antibiotics according to results of cultures and susceptibilities when available.

Duration:

Change to orals when well. Treat for a total of 3-4 weeks.

If there is failure to improve despite antibiotics, adequate drainage, and no microbiology results are available, consider alternative diagnosis:

  • TB
  • Nocardia
  • Cryptococcus
  • Melioidosis
  • Non-infective cause (e.g. tumour, vasculitis).

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Lung abscess and empyema in children

Adequate drainage is essential. Seek Surgical opinion for consideration of intercostal drain insertion.

Antimicrobial

Ceftriaxone 50mg/kg (max 2g) IV BID

PLUS

Clindamycin 15mg/kg (max 600mg) IV/PO TID

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics. Send pleural fluid aspirate for culture, TB testing if indicated, and chemistry.

If no improvement despite adequate drainage, and no microbiology results available, consider alternative diagnoses such as:

  • TB
  • Nocardia infection
  • Melioidosis

Duration:

Step down to oral antibiotics based on susceptibilities when improving. Treat for a total of 3-6 weeks.

Bronchiectasis – acute exacerbation

Bronchiectasis is irreversible abnormal dilatation of one or more bronchi with chronic airway inflammation. Clinical features include chronic sputum production, recurrent chest infections, and airflow obstruction.

An exacerbation of bronchiectasis is an acute deterioration in a patient’s symptoms from their usual baseline as evidenced by increased cough, sputum volume or purulence, dyspnoea, hypoxia or fever. Patients should only be treated with antibiotics during an acute exacerbation.

Antimicrobial 

Mild to moderate:

Amoxicillin 1 g (child: 25mg/kg) PO TID

Alternative:

Doxycycline 100 mg PO BID

OR

Chloramphenicol 500mg (child 10mg/kg) PO QID

Severe:

Benzylpenicillin 2 million IU (1.2g) (child 80 000 IU (50mg)/kg) IV, QID

PLUS

Ciprofloxacin 500mg (child 10mg/kg) PO BID

If no improvement after 48 hours and microbiology results are not available change to:

Meropenem 1g (child 25mg/kg) IV TID

Change to oral antibiotics when well, according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

OR if Pseudomonas suspected

Ciprofloxacin 500mg (child 15mg/kg) PO BID

Comments and Duration of Therapy 

Send sputum culture, and if systemically unwell send blood cultures prior to antibiotics. Consider performing nasopharyngeal swabs for influenza, RSV and COVID.

Patients with bronchiectasis are commonly colonized with pathogens including Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Sputum cultures need to be interpreted in the clinical context, as organisms isolated may be colonizing rather than causing infection. If patient is improving on empiric antibiotics there is no need to change the antibiotics if a resistant organism is grown from sputum cultures.

Duration:

Treat for 10-14 days

Chronic obstructive pulmonary disease (COPD) – acute exacerbation

An exacerbation of COPD is an acute deterioration in a patient’s symptoms from their usual baseline as evidenced by increased cough, sputum volume or purulence, dyspnoea, hypoxia or fever. Acute exacerbations may be triggered by viral or bacterial infection, or non-infective causes. Respiratory viruses are the most common cause.

Antimicrobial 

Only use antibiotics if patient has symptoms suggestive of a bacterial infection.

Amoxicillin 500mg PO TID

Alternative:

Doxycycline 100mg PO BID

Comments and Duration of Therapy

Consider performing nasopharyngeal swabs for influenza, RSV and COVID.

Increased sputum volume, increased sputum purulence or change in colour, and fever can suggest a bacterial cause.

If consolidation on CXR treat as Community-acquired pneumonia.

Duration:

Treat for 5 days

Asthma – acute exacerbation

Most respiratory infections that trigger asthma exacerbations are viruses. Routine antibiotic use is not beneficial.

Antimicrobial 

Avoid routine antibiotic use.

Comments and Duration of Therapy

Consider performing nasopharyngeal swabs for influenza, RSV and COVID. If there is consolidation on CXR treat as Community-acquired pneumonia.

Acute Bronchitis

Characterised by inflammation and bronchospasm of the airways with coughing, wheeze, and shortness of breath.

Antimicrobial 

Avoid routine antibiotic use

Comments and Duration of Therapy

Most patients have a viral infection or history of exposure to cigarette smoke or other toxic inhaled substances.
If consolidation on CXR, purulent sputum and/or increased work of breathing, treat as Community-acquired pneumonia.

Bronchiolitis

Acute bronchiolitis is a lower respiratory viral infection in children <24 months, which typically occurs in annual epidemics and is characterized by airways obstruction and chest wheeze. Respiratory Syncytial Virus (RSV) is the most common cause, and secondary bacterial infection is uncommon (<2%).

Antimicrobial 

If antibiotics are indicated give:

Ampicillin 50mg/kg IM/IV QID

Comments and Duration of Therapy

Consider performing nasopharyngeal swabs for influenza, RSV and COVID.

Antibiotics are not indicated routinely, but should be given for severe disease, infants < 2 months, or when secondary bacterial infection is suspected based on CXR changes.

If evidence of sepsis, aspiration, or acute consolidation on CXR, treat a Community-acquired pneumonia.

Duration:

Treat for 3 days.

Tuberculosis (TB)

TB is an infectious disease that is spread by airborne droplets containing Mycobacterium tuberculosis complex. Symptoms and signs include persistent cough for more than two weeks, haemoptysis, fever, chest pain, night sweats, lethargy, anorexia, and weight loss.

See Timor-Leste Comprehensive TB Guidelines for National Tuberculosis Program.

If drug resistant TB is detected or suspected refer to Pulmonology and Infectious Diseases if available.

Antimicrobial

Adult:

Intensive phase:

Four drug fixed combination (Rifampicin 150mg / Isoniazid 75mg / Pyrazinamide 400mg / Ethambutol 275mg)
Dosed according to body weight.

Continuation phase:

Two drug fixed combination (Rifampicin 150mg / Isoniazid 75mg)
Dosed according to body weight.

Children:

Intensive phase:

Three drug fixed combination (Rifampicin 75mg / Isoniazid 50mg / Pyrazinamide 150mg)
Dosed according to body weight.

Continuation phase:

Two drug fixed combination (Rifampicin 75mg / Isoniazid 50mg)
Dosed according to body weight.

Comments and Duration of Therapy

Send sputum (and other relevant samples) for TB GeneXpert, AFB, and culture. If suspicion of pulmonary TB is high, but sputum is negative, repeat sputum testing twice more.

All patients with TB should be tested for HIV. Monitor chemistry and liver function in all patients on TB treatment.

A bacteriologically confirmed TB case is one from whom a biological specimen is positive by smear microscopy or GeneXpert MTB/RIF, LPA, or culture. A clinically diagnosed TB case is someone who does not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician, or other medical practitioner who has decided to give the patient a full course of TB treatment. This definition includes cases diagnosed on the basis of CXR abnormalities or suggestive histology and extrapulmonary cases without laboratory confirmation.

Duration:

Intensive phase: Treat for 2 months.

Continuation phase: Treat for 4 months.

Adult pulmonary TB patients should be asked if they have close household contacts <5 years of age, who are at high risk of progressing to TB disease following likely exposure. Household contacts should be offered TB preventative therapy once active TB is excluded.

See Neonatal TB Prophylaxis in Chapter 11: Paediatric Infections (Neonates, Infants and Children), and Paediatric TB in Chapter 11: Paediatric Infections (Neonates, Infants and Children)

Acute Bacterial Otitis Media

Viral upper respiratory tract infections are often accompanied by mild inflammation of the middle ear. Acute otitis media is very likely if there is an acute onset of symptoms with an erythematous, bulging, immobile tympanic membrane or pus draining from the ear for <2 weeks. Pain alone is not sufficient for a diagnosis of otitis media. Most do not require antibiotics and recover with supportive therapy alone within 48 hours

Antimicrobial 

Without perforation:

Amoxicillin 500mg PO TID (child 50mg/kg PO BID)

If no improvement after 3 days change to:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/ kg) PO BID

With perforation:

Amoxicillin 500mg PO TID (child 50mg/kg PO BID)

PLUS

Ear toileting

PLUS

Ciprofloxacin 0.3% solution 5 drops BID (child only add if no response after 7 days of amoxicillin, give 2-5 drops QID).

Comments and Duration of Therapy

Consider sending middle ear fluid for culture if poor response to empiric therapy.

Ear toileting involves dry mopping the ear with rolled tissue spears or similar, performed QID until the ear is dry. Perform prior to instilling eardrops.

Gentamicin eardrops are contraindicated in the setting of a perforated tympanic membrane due to risk of ototoxicity.

Duration:

Without perforation: Treat for 5-7 days

With perforation: Treat for 14 days

Acute mastoiditis

Infection of the mastoid air cells of the temporal bone. In children mastoiditis is a rare complication of acute otitis media. In adults mastoiditis can be a complication of chronic suppurative otitis media or cholesteatoma. Symptoms include conductive hearing loss and tenderness, swelling, and pain behind the ear. Complications include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy.

Consider CT and/or MRI to detect bone involvement or intracranial complications.

Refer to ENT.

Antimicrobial 

Adult:

Ceftriaxone 2g IV OD

PLUS

Cloxacillin 2g IV QID

If no improvement and no culture results available, consider changing to:

Meropenem 1g IV TID

Child:

Ceftriaxone 50mg/kg IV OD

Adult and child: Change to oral antibiotics when appropriate (see duration), according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Alternative:

Azithromycin 10mg/kg PO OD

OR

Cefuroxime 15mg/kg PO BID

Comments and Duration of Therapy

Aspiration and drainage of middle ear, or mastoidectomy may be required. Send operative samples for culture.

Duration:

Adult: Treat with IV antibiotics for 4 weeks then change to oral antibiotics to complete 6 weeks total treatment.
Child: Treat with IV antibiotic for at least 5 days then change to oral antibiotics when improving. Treat for a total of 12-15 days. Longer antibiotic treatment is required if there are intracranial complications.

Acute diffuse otitis externa

Often caused by skin breakdown in the external auditory canal following excessive water exposure. Pseudomonas aeruginosa and Staphylococcus aureus are common organisms.

Topical therapy alone is sufficient in most cases of acute diffuse otitis externa.

Antimicrobial 

Betamethasone 0.1%/Polymyxin 5000U/ Bacitracin 400U solution 3 drops to affected ear(s) TID

PLUS

Ear toileting (see comments)

Alternative:

Betamethasone 0.1%/Ciprofloxacin 0.3% solution 3 drops to affected ear(s) TID

PLUS

Ear toileting (see comments)

For otitis externa with systemic symptoms, spread of inflammation to pinna, or folliculitis, to topical treatment ADD:

Cloxacillin 500mg (child 12.5mg/kg) PO QID

PLUS

Ciprofloxacin 750mg (child 15mg/kg) PO BID

Comments and Duration of Therapy

Send swab for culture in patients with severe or recurrent otitis externa, and in patients who are immunocompromised.

The ear canal must be kept as dry as possible during treatment and for 2 weeks afterwards. Ear toileting involves dry mopping the ear with rolled tissue spears or similar, performed QID until the ear is dry. Perform prior to instilling eardrops.

Duration:

Simple otitis externa: Treat for 5-7 days
Otitis externa with systemic symptoms, spread of inflammation to pinna, or folliculitis: Treat for 7-10 days

Consider the possibility of necrotising otitis externa in patients who fail to improve with above treatment.

Necrotising otitis externa

A rare complication of acute diffuse otitis externa, involving spread of infection to cartilage and bone in the external ear canal and base of skull. Mostly occurs in elderly, immunocompromised, or diabetic patients. Infection is most commonly caused by Pseudomonas aeruginosa.

Consider CT and/or MRI to detect bone involvement or intracranial complications.

Antimicrobial 

Meropenem 2g (child 40mg/kg) IV TID

Alternative:

Ciprofloxacin 400mg (child 10mg/kg) IV TID

OR

Ciprofloxacin 750mg (child 15mg/kg) PO BID

Change to oral antibiotics when improving according to susceptibility results. If susceptibility results are not available use:

Ciprofloxacin 750mg (child 20mg/kg) PO BID

Alternative:

Levofloxacin 750mg (child 10mg/kg) PO OD

Comments and Duration of Therapy

Send swabs and tissue samples for culture prior to antibiotics. Send blood cultures if systemically unwell or immunocompromised. Consider biopsy if no pathogen is isolated from other cultures and patient fails to improve with empiric therapy.

Duration:

Change to oral antibiotics when clinically improving. Treat for a total of 6-8 weeks.

Refer to ENT and Infectious Diseases where available.

Acute sinusitis

Often follows viral upper respiratory tract infections. Common causes of bacterial rhinosinusitis are Streptococcus pneumoniae and Haemophilus influenzae. Most do not require antibiotics and recover with supportive care alone within 10 days.

Antimicrobial 

Avoid routine antibiotic use.

If antibiotics are indicated (see comments), use:

Amoxicillin 500mg (child: 15mg/kg) PO TID

Alternative:

Phenoxymethylpenicillin 500mg (child 12.5mg/kg) PO QID

OR

Doxycycline 100mg BID

If worsening symptoms after initial improvement seek ENT review and change to:

Ceftriaxone 2g (child 50mg/kg) IV OD

Comments and Duration of Therapy

Consider antibiotics in patients with high fever for more than 3 days, or severe symptoms for more than 5 days, including purulent nasal discharge, sinus tenderness or maxillary toothache.

Patient with severe features or worsening symptoms after initial improvement may require ENT review and consideration of nasal endoscopy or surgical intervention.

Duration:

Treat for 7 days

Pharyngitis / Tonsilitis

Acute pharyngitis is commonly caused by viruses, but it can also be caused by Streptococcus pyogenes. Distinguishing viral from bacterial pharyngitis on clinical findings alone has not proven to be accurate. In Timor-Leste, due to the high incidence of Rheumatic Heart Disease someone who presents with sore throat with pain or swelling or exudate, with or without associated fever of lymphadenopathy should be treated for presumed Streptococcus pyogenes pharyngitis.

Antimicrobial 

Benzathine Penicillin 1.2 million IU (900mg) (child <20kg 0.6 million IU (450mg)) IM

Alternative:

Phenoxymethylpenicillin 500mg (child 15mg/kg) PO BID

OR

Amoxicillin 500mg (child 25mg/kg) PO BID

OR

Azithromycin 500mg (child 12 mg/kg) PO OD

Comments and Duration of Therapy

It is important to complete the antibiotic course even after recovery to prevent Rheumatic Heart Disease.

Duration:

Benzathine Penicillin: single dose only

Phenoxymethylpenicillin or Amoxicillin: Treat for 10 days

Azithromycin: Treat for 5 days

See Rheumatic Fever secondary prophylaxis in Chapter 1: Antibiotic Prophylaxis.

Peritonsillar abscess (Quinsy)

Presents with trismus, severe unilateral throat pain, high fever, change in voice. Most abscesses are polymicrobial; pathogens include Streptococcus pyogenes, and Fusobacterium spp.

Monitor patients for signs of airway obstruction.

Antimicrobial 

Adequate drainage is essential, usually requiring aspiration in hospital.

Benzylpenicillin 2 million IU (1.2g) (child 80 000 IU (50mg)/kg) IV, QID

Alternative:

Ampicillin 2g (child 50mg/kg) IV QID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

Change to oral antibiotics when improving according to susceptibility results. If susceptibility results are not available use:

Phenoxymethylpenicillin 500mg 12.5mg/kg) PO BID

OR

Amoxicillin 500mg (child 15mg/kg) PO TID

OR

Clindamycin 450mg (child 10mg/kg) PO TID

Comments and Duration of Therapy 

Send aspirated fluid for culture.

Duration:

Change to oral antibiotics 1-2 days after abscess drainage once patient improves. Treat for a total of 10 days.

Acute Epiglottitis / Supraglottitis

This is a life-threatening infection caused by infection of the epiglottis and surrounding structures. Pathogens include Haemophilus influenzae and Streptococcus pyogenes.

All patients require urgent hospitalisation, with intensive monitoring for airway obstruction. Refer all patients to ENT and/or Anaesthetics for airway management.

Antimicrobial 

Ceftriaxone 1g (child 50mg/kg) IV OD (if patient requires ICU use BID dosing)

Alternative:

Levofloxacin 750mg (child 10mg/kg) IV OD

Change to oral antibiotics when improving according to susceptibility results. If susceptibility results are not available use:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Alternative:

Levofloxacin 750mg (child 10mg/kg) PO OD

Comments and Duration of Therapy 

Take blood cultures prior to antibiotics. If patient is septic give antibiotics within 1 hour of presentation.

In children minimize distress, unnecessary examination, and invasive procedures.

Duration:

Change to oral antibiotics when clinically improving. Treat for a total of 7-10 days

Diphtheria

Caused by toxin-producing Corynebacterium diphtheriae. Diphtheria can present as a respiratory or cutaneous disease with possible cardiac, neurological, or renal complications. The respiratory presentation can be rapidly fatal due to the risk of upper airway obstruction by a pseudomembrane.

All patients require urgent hospitalisation, with close monitoring for airway obstruction. Refer all patients to ENT.

Diphtheria antitoxin is the primary treatment however this is not currently available in Timor-Leste.

Antimicrobial

Benzylpenicillin 2 million IU (1.2g) (child 50 000 IU (30mg)/kg) IV, QID

Alternative:

Ampicillin 2g (child 50mg/kg) IV QID

OR

Azithromycin 500mg (child 10mg/kg) IV OD

Change to oral antibiotics when improving according to susceptibility results. If susceptibility results are not available use:

Phenoxymethylpenicillin 500mg (child 12.5mg/kg) PO BID

OR

Amoxicillin 500mg (child 15mg/kg) PO TID

OR

Azithromycin 500mg (child 10mg/kg) PO OD

Comments and Duration of Therapy 

Swab membrane and material beneath membrane for culture. Transport swabs to laboratory as soon as possible and inform laboratory of suspected diagnosis.
In the absence of microbiological evidence, there should be a strong clinical suspicion of Diphtheria when a bluish-white or grey membrane forms in the throat or on the tonsils on the background of sore throat, low-grade fever, and cervical lymphadenopathy. The membrane typically bleeds on scraping.

An ECG can be useful to monitor toxin-induced myocarditis and its complications such as severe arrhythmias.

Duration:

Change to oral antibiotics when clinically improving.

Phenoxymethylpenicillin or Amoxicillin: Treat for total of 14 days.

Azithromycin: Treat for total of 5 days.

 

References

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