10/26/2017 Treatment of deep neck space infections

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Usual causative organisms and initial empiric antimicrobial regimens for

suppurative peripharyngeal infections in adults*

Antimicrobial regimens
Usual causative
Infection Immunocompromised
organisms Normal host
host Δ

NOTE: Coverage for methicillin-resistant Staphylococcus aureus (MRSA) should be included for those with
risk factors ◊

Peritonsillar abscess Group A Streptococcus Ampicillin-sulbactam 3 g Cefepime 2 g IV Q 12 h

(Quinsy) (S. pyogenes), IV Q 6 h PLUS metronidazole
Fusobacterium spp, OR 500 mg IV Q 6-8 h
Peptostreptococcus spp, OR monotherapy
Penicillin G 2-4 MU IV Q
and other oral with:
4-6 h
anaerobes Δ
Imipenem 500 mg IV
plus
Q 6 h or
Metronidazole 500 mg
Meropenem 1 g IV Q
IV Q 6-8 h
8 h or
OR Piperacillin-
Clindamycin 600 mg IV tazobactam 4.5 g IV
Q 6-8 h Q6h

Suppurative parotitis Staphylococcus aureus, Nafcillin 1.5 g IV Q 4 h ◊ Vancomycin 15-20

viridans and other or mg/kg IV Q 8-12 h § or
streptococci, Bacteroides linezolid 600 mg orally
Vancomycin 15-20
spp, Peptostreptococcus or IV Q 12 h PLUS one
mg/kg IV Q 8-12 h §
spp, and other oral of the following
anaerobes Δ or regimens:
Linezolid 600 mg orally Cefepime 2 g IV Q 12
or IV Q 12 h h PLUS
metronidazole 500
mg IV Q 6-8 h or
PLUS
Imipenem 500 mg IV
Either metronidazole Q 6 h or
500 mg IV Q 6-8 h Meropenem 1 g IV Q
or 8 h or

Clindamycin 600 mg IV Piperacillin-

tazobactam 4.5 g IV
Q 6-8 h
Q6h

Submandibular space Viridans and other Ampicillin-sulbactam 3 g Cefepime 2 g IV Q 12 h

infections (Ludwig's streptococci, IV Q 6 h PLUS metronidazole
angina) Staphylococcus spp, OR 500 mg IV Q 6-8 h
Peptostreptococcus spp, OR monotherapy
Bacteroides spp, and Penicillin G 2-4 MU IV Q
with:
4-6 h
other oral anaerobes Δ
Imipenem 500 mg IV
plus
Q 6 h or
Metronidazole 500 mg
Meropenem 1 g IV Q
IV Q 6-8 h 8 h or

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10/26/2017 Treatment of deep neck space infections

OR Piperacillin-
tazobactam 4.5 g IV
Clindamycin 600 mg IV
Q6h
Q 6-8 h

Parapharyngeal or retropharyngeal space infections

Odontogenic Viridans and other Ampicillin-sulbactam 3 g Cefepime 2 g IV Q 12 h

streptococci, IV Q 6 h PLUS metronidazole
Staphylococcus spp, OR 500 mg IV Q 6-8 h
Peptostreptococcus spp, OR monotherapy
Penicillin G 2-4 MU IV Q
Bacteroides spp, and with:
other oral anaerobes Δ 4-6 h
Imipenem 500 mg IV
plus
Q 6 h or
Metronidazole 500 mg Meropenem 1 g IV Q
IV Q 6-8 h
8 h or
OR Piperacillin-
Clindamycin 600 mg IV tazobactam 4.5 g IV
Q 6-8 h Q6h

Rhinogenic Streptococcus Ampicillin-sulbactam 3 g Same as for odontogenic

pneumoniae, IV Q 6 h space infections
Haemophilus influenzae, OR
viridans and other
Ceftriaxone 1 g IV Q 24
streptococci, Bacteroides
h
spp, Peptostreptococcus
spp, and other oral plus
anaerobes Δ Metronidazole 500 mg
IV Q 6-8 h

OR

Doxycycline 200 mg IV
per day in one to two
divided doses

Otogenic Same as for rhinogenic Same as for rhinogenic Same as for odontogenic
space infections space infections space infections

Septic jugular Fusobacterium Ampicillin-sulbactam 3 g Same as for odontogenic

thrombophlebitis necrophorum; same as IV Q 6 h space infections
(Lemierre syndrome) for peritonsillar abscess OR
or odontogenic space
Penicillin G 2-4 MU IV Q
infections Δ
4-6 h
plus
Metronidazole 500 mg
IV Q 6-8 h

OR

Clindamycin 600 mg IV
Q 6-8 h

Prevertebral space Staphylococcus Nafcillin 1.5 g IV Q 4 h ◊ Vancomycin 15-20

infection aureus, ◊ facultative or mg/kg IV Q 8-12 h § or
gram-negative bacilli Δ linezolid 600 mg orally
Vancomycin 15-20
or IV Q 12 h PLUS one
mg/kg IV Q 8-12 h §
of the following
or regimens:
Linezolid 600 mg orally Combination therapy
or IV Q 12 h with:

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10/26/2017 Treatment of deep neck space infections

PLUS Cefepime 2 g IV Q 12
h PLUS
Either gentamicin or
metronidazole 500
tobramycin 1.7 mg/kg
mg IV Q 6-8 h
IV Q 8 h or 5 mg/kg IV
Q 24 h
OR monotherapy
or
with:
Ciprofloxacin 400 mg IV
Imipenem 500 mg IV
Q 12 h Q 6 h or
Meropenem 1 g IV Q
8 h or
Piperacillin-
tazobactam 4.5 g IV
Q6h

* The doses recommended in this table are intended for patients with normal renal and hepatic function.
Δ Immunocompromised hosts are at increased risk for facultative gram-negative bacilli, including extended-
spectrum-β-lactamase (ESBL)-producing Enterobacteriaceae and Pseudomonas aeruginosa.
◊ In patients with risk factors for MRSA infection, vancomycin 15-20 mg/kg IV Q 8-12 h or linezolid 600 mg
orally or IV Q 12 h should be added, or substituted for nafcillin. Risk factors for MRSA infection include a history
of intravenous drug use, comorbid disease (eg, diabetes mellitus), or residing in a community or hospital where
there is a substantial incidence of MRSA.
§ Not to exceed 2 g per dose.

Graphic 77338 Version 14.0

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