Sandbox ID Head and Neck

# Anthrax, oropharyngeal
- Oropharyngeal anthrax
- Preferred regimen: Ciprofloxacin 400 mg IV q8h  AND (Clindamycin 900 mg IV q8h OR Linezolid 600 mg IV q12h)
- Alternative regimen: (Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Meropenem 2 g IV q8h OR Imipenem 1 g IV q6h OR Doripenem 500 mg IV q8h OR Vancomycin 60 mg/kg/24h IV q8h OR Ampicillin 3 g IV q6h OR Penicillin G 4 MU IV q4h) AND (Doxycycline 200 mg IV initially, then 100 mg IV q12h OR Rifampin 600 mg IV q8h)
- Note: Treatment is for 14 days or until patient is clinically stable. Patients with exposure to aerosolized spores require 60 days of therapy (PO after first 2 weeks). Ampicillin and Penicillin G are only recommended for penicillin-susceptible strains. If Vancomycin is used, maintain serum trough concentrations of 15-20 mcg/mL. For pregnant or lactating women and children below the age of 8, avoid Doxycycline.

# Buccal cellulitis
- Buccal cellulitis
- 1. Empiric antimicrobial therapy
- Preferred regimen: Cefuroxime 50 mg/kg IV q8h OR Cefuroxime 1015 mg/kg PO q12h (maximum dose is 1 g/day) OR Ceftriaxone 50 mg/kg IV q24h
- Alternative regimen: Amoxicillin-Clavulanate 90 mg/kg/day PO q12h
- Note: In case of suspected meningitis, increase Cefuroxime dose to 80 mg/kg IV q8h, or Ceftriaxone dose to 50 mg/kg IV q24h.

# Cervico-facial actinomycosis
- Cervico-facial actinomycosis
- Preferred regimen: Ampicillin 50 mg/kg/day IV q8h (4-6 weeks) THEN Penicillin V 2-4 g/day PO q6h (3-6 months)
- Alternative regimen: Penicillin G 10-20 MU/day IV q6h (4-6 weeks) THEN Penicillin V 2-4 g/day PO q6h (3-6 months)
- Note: In patients allergic to Penicillin, consider Doxycycline, Clindamycin, or Erythromycin.

# Deep neck infection
- Deep neck infection
- 1. Empiric antimicrobial therapy
- 1.1 Community-acquired deep neck infection
- Preferred regimen: Ampicillin-Sulbactam 1.53.0 g IV q6h OR Clindamycin 600900 mg IV q8h OR Moxifloxacin 400 mg IV q24h (if Eikenella is suspected)
- 1.2 Nosocomial deep neck infection or immunocompromised host
- Preferred regimen: Ticarcillin-Clavulanate 3 g IV q6h OR Piperacillin-Tazobactam 3 g IV q6h OR Imipenem-Cilastatin 500 mg IV q6h OR Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h
- 1.3 Deep neck infection with high-risk of MRSA
- Preferred regimen: (Clindamycin 600900 mg IV q8h OR Trimethoprim-Sulfamethoxazole 10 mg/kg/day IV q8h AND Vancomycin 1 g IV q12h
- 1.4 Necrotizing fasciitis
- Preferred regimen: Ceftriaxone 2 g IV q8h AND Clindamycin 600900 mg IV q8h AND Metronidazole 500 mg IV q6h
- 2. Specific anatomic considerations
- 2.1 Submandibular space infections including Ludwig angina
- Causative pathogens
- Viridans and other streptococci
- Peptostreptococcus
- Bacteroides
- Other oral anaerobes
- Preferred regimen (immunocompetent host): (Penicillin G 24 MU IV q46h AND Tobramycin 2 mg/kg IV q8h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h OR Doxycycline 200 mg IV q12h OR Cefoxitin 2 g IV q6h OR Cefotetan 2 g IV q12h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Gatifloxacin 200 mg IV q24h
- 2.2 Lateral pharyngeal or retropharyngeal space infections (odontogenic)
- Causative pathogens
- Viridans and other streptococci
- Staphylococcus
- Peptostreptococcus
- Bacteroides
- Other oral anaerobes
- Preferred regimen (immunocompetent host): (Penicillin G 24 MU IV q46h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h
- 2.3 Lateral pharyngeal or retropharyngeal space infections (rhinogenic)
- Causative pathogens
- Streptococcus pyogenes
- Fusobacterium
- Peptostreptococcus
- Other oral anaerobes
- Preferred regimen (immunocompetent host): Penicillin G 24 MU IV q46h OR (Ciprofloxacin 200 mg q12h AND Metronidazole 0.5 g IV q6h) OR Gatifloxacin 400 mg IV q24h OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h
- 2.4 Lateral pharyngeal or retropharyngeal space infections (otogenic)
- Causative pathogens
- Streptococcus pneumoniae
- Haemophilus influenzae
- Viridans and other streptococci
- Peptostreptococcus
- Bacteroides
- Other oral anaerobes
- Preferred regimen (immunocompetent host): Penicillin G 24 MU IV q46h OR (Ciprofloxacin 200 mg q12h AND Metronidazole 0.5 g IV q6h) OR Gatifloxacin 400 mg IV q24h OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h
- 2.5 Peritonsillar abscess (quinsy)
- Causative pathogens
- Viridans and other streptococci
- Peptostreptococcus
- Bacteroides
- Other oral anaerobes
- Preferred regimen (immunocompetent host): (Penicillin G 24 MU IV q46h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h OR Cefoxitin 2 g IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h
- 2.6 Suppurative parotitis
- Causative pathogens
- Staphylococcus
- Viridans and other streptococci
- Bacteroides
- Peptostreptococcus
- Other oral anaerobes
- Preferred regimen (immunocompetent host): (Nafcillin 1.5 g IV q46h AND Metronidazole 0.5 g IV q6h) OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): (Vancomycin 0.5 g IV q6h AND Cefotaxime 2 g IV q6h) OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h
- 2.7 Extension of osteomyelitis from prevertebral space infection
- Causative pathogens
- Staphylococcus
- Facultative gram-negative bacilli
- Preferred regimen (immunocompetent host): (Nafcillin 1.5 g IV q46h AND Metronidazole 0.5 g IV q6h) OR Ciprofloxacin 200 mg q12h
- Preferred regimen (immunocomppromised host): (Vancomycin 0.5 g IV q6h AND Cefotaxime 2 g IV q6h) OR Ceftizoxime 4 g IV q8h OR Imipenem 500 mg IV q6h
- 2.8 Pott's puffy tumor (frontal osteitis)
- Causative pathogens
- Streptococcus pyogenes
- Fusobacterium
- Peptostreptococcus
- Other oral anaerobes
- Preferred regimen (immunocompetent host): Penicillin G 24 MU IV q46h OR (Ciprofloxacin 200 mg q12h AND Metronidazole 0.5 g IV q6h) OR Gatifloxacin 400 mg IV q24h OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h
- 2.9 Malignant otitis media
- Causative pathogens
- Pseudomonas aeruginosa
- Preferred regimen (immunocompetent host): Ciprofloxacin 200 mg q12h OR (Tobramycin 2 mg/kg IV q8h AND Ceftazidime 2 g IV q6h) OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h
- Preferred regimen (immunocomppromised host): (Tobramycin 2 mg/kg IV q8h AND Ceftazidime 2 g IV q6h) OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h
- 2.10 Petrous osteitis
- Causative pathogens
- Pseudomonas aeruginosa
- Preferred regimen (immunocompetent host): Ciprofloxacin 200 mg q12h OR (Tobramycin 2 mg/kg IV q8h AND Ceftazidime 2 g IV q6h) OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h
- Preferred regimen (immunocomppromised host): (Tobramycin 2 mg/kg IV q8h AND Ceftazidime 2 g IV q6h) OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h
- 2.11 Septic jugular thrombophlebitis (Lemierre syndrome)
- Causative pathogens
- Fusobacterium
- Viridans and other streptococci
- Staphylococcus
- Peptostreptococcus
- Bacteroides
- Other oral anaerobes
- Preferred regimen (immunocompetent host): (Penicillin G 24 MU IV q46h AND Metronidazole 0.5 g IV q6h) OR Ampicillin-Sulbactam 2 g IV q4h OR Clindamycin 600 mg IV q6h
- Preferred regimen (immunocomppromised host): Cefotaxime 2 g IV q6h OR Ceftizoxime 4 g IV q8h OR Piperacillin 3 g IV q4h OR Imipenem 500 mg IV q6h OR Imipenem 500 mg IV q6h OR Gatifloxacin 400 mg IV q24h

# Facial erysipelas
- Facial erysipelas
- 1. Causative pathogens
- Staphylococcus aureus
- Streptococcus spp. (Group A, B, C, & G)
- Enterobacteriaceae
- Clostridium spp.
- 2. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 g IV q12h
- Alternative regimen: Daptomycin 4 mg/kg IV q24h OR Linezolid 600 mg IV q12h

# Mastoiditis
- 1. Acute Mastoiditis 
- 1.1 Causative pathogens:
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Staphylococcus aureus
- Hemophilus influenzae
- Pseudomonas aeruginosa
- 1.2 Acute mastoiditis, outpatient
- 1.2.1 Empiric antimicrobial therapy
- Preferred regimen (no abx in past month): Amoxicillin 50 mg/kg/day PO q6h
- Preferred regimen (abx in past month): Amoxicillin-Clavulanate 90 mg/kg/day PO q12h OR Cefdinir 14 mg/kg PO q24h OR Cefpodoxime 10 mg/kg/day PO q12h (maximum dose is 400 mg/day) OR  Cefprozil 30 mg/kg/day PO q12h (maximum dose is 1 g/day) OR Cefuroxime 15 mg/kg/day PO q12h (Maximum dose is 1 g/day)
- Note: Duration of treatment in children <2 years-old is 10 days. In children 2 years, recommended duration is 57 days.
- 1.2.2 Pathogen-directed antimicrobial therapy
- 1.2.2.1 Staphylococcus aureus (MSSA)
- Preferred regimen: Oxacillin 37 mg/kg IV q6h (maximum dose is 8-12 g/day)
- 1.2.2.2 Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 40 mg/kg/day IV q6-8h
- Note: Maintain Vancomycin serum trough concentrations of 15-20 mcg/mL
- 1.3 Acute mastoiditis, inpatient
- 1.3.1 Empiric antimicrobial therapy
- Preferred regimen: Cefotaxime 1-2 g IV q4-8h OR Ceftriaxone 1 g IV q24h
- 1.3.2 Pathogen-directed antimicrobial therapy
- 1.3.2.1 Staphylococcus aureus (MSSA)
- Preferred regimen: Oxacillin 37 mg/kg IV q6h (maximum dose is 8-12 g/day)
- 1.3.2.2 Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 40 mg/kg/day IV q6-8h
- Note: Maintain Vancomycin serum trough concentrations of 15-20 mcg/mL
- 2. Chronic Mastoiditis
- 2.1 Causative pathogens:
- Polymicrobial
- Enterobacteriaceae
- Staphylococcus aureus
- Pseudomonas aeruginosa
- 2.2 Empiric antimicrobial therapy
- Preferred regimen: Imipenem 0.5 g IV q6h OR Piperacillin-Tazobactam 3.375 g IV q4-6h OR Meropenem 1 g IV q8h OR Ticarcillin-Clavulanate 3.1 g IV q6h
- Note: Treatment is reserved for acute exacerbations or perioperatively. It is recommended not to treat without surgical cultures.

# Odontogenic infections
- Odontogenic infections
- 1. Empiric antimicrobial therapy
- Preferred regimen: Clindamycin 300450 mg PO q6h OR Clindamycin 600 mg IV q68h
- Alternative regimen: Amoxicillin-Clavulanic acid 875/125 mg PO q12h OR Amoxicillin-Clavulanic acid 500/125 mg PO q8h OR Amoxicillin-Clavulanic acid 2000/125 mg PO q12h OR Cefotetan 2 g IV q12h

# Orbital cellulitis
- Orbital cellulitis 
- 1. Causative pathogens
- Streptococcus pneumoniae
- Hemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
- 2. Empiric antimicrobial therapy
- Preferred regimen: Vancomycin 1 g IV q12h AND Ceftriaxone 2 g IV q24h AND Metronidazole 1 g IV q12h
- Alternative regimen (1): Vancomycin 1 g IV q12h AND Levofloxacin 750 mg IV q24h AND Metronidazole 1 g IV q12h
- Alternative regimen (2): Daptomycin 6 mg/kg IV q24h AND Ceftriaxone 2 g IV q24h AND Metronidazole 1 g IV q12h
- Alternative regimen (3): Daptomycin 6 mg/kg IV q24h AND Levofloxacin 750 mg IV q24h AND Metronidazole 1 g IV q12h

# Oropharyngeal candidiasis
- Oropharyngeal candidiasis
- Preferred regimen: Clotrimazole troches 10 mg TOP q4-5h OR Nystatin suspension or pastilles TOP q6h OR Fluconazole 100200 mg PO q24h
- Alternative regimen: Itraconazole solution 200 mg PO q24h OR Posaconazole 400 mg PO q24h OR Voriconazole 200 mg PO q24h OR Amphotericin B oral suspension PO q24h OR (Anidulafungin 200 mg IV once THEN Anidulafungin 100 mg IV q24h) OR (Caspofungin 70 mg IV once THEN Caspofungin 50 mg IV q24h) OR Micafungin 100 mg IV q24h OR Amphotericin B 0.3 mg/kg IV q24h
- Note: Treat uncomplicated disease for 714 days. Fluconazole is recommended in moderate-to-severe disease, and topical therapy with Clotrimazole or Nystatin is recommended for mild disease.  For refractory disease, consider the alternative regimen.

# Otitis externa
- 1. Otitis externa, acute 
- 1.1 Causative pathogens
- Pseudomonas aeruginosa
- Candida spp.
- Enterobacteriaceae
- Proteus spp.
- Staphylococcus aureus
- 1.2 Empiric antimicrobial therapy
- Preferred regimen (1): Acetic acid 2.0% TOP tid for 7-10 days
- Preferred regimen (2): Acetic acid 2.0%, Hydrocortisone 1.0% TOP tid for 7-10 days
- Preferred regimen (3): Ciprofloxacin 0.2%, Hydrocortisone 1.0% TOP tid for 7-10 days
- Preferred regimen (4): Ciprofloxacin 0.3%, Dexamethasone 0.1% TOP tid for 7-10 days
- Preferred regimen (5): Neomycin, Polymyxin B, Hydrocortisone TOP tid for 7-10 days
- Preferred regimen (6): Ofloxacin 0.3% TOP tid for 7-10 days
- 1.3 Pathogen-directed therapy
- 1.3.1 Fungal otitis externa
- Preferred regimen: Fluconazole 200 mg PO once THEN Fluconazole 100 mg PO q24h for 35 days
- 1.3.2 Malignant otitis media, Pseudomonas aeruginosa
- Preferred regimen: Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h OR Ciprofloxacin 400 mg IV q8h OR Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q12h OR (Piperacillin-Tazobactam 4-6g IV q4h AND Tobramycin 35 mg/kg/day IV q8h)
- Note: Oral Ciprofloxacin may be used by only in patients with very early disease
- 2. Otitis externa, chronic
- 2.1 Empiric antimicrobial therapy
- Preferred regimen: Neomycin, Polymyxin B, Hydrocortisone TOP q6-8h AND Selenium Sulfide Shampoo
- Note: Selenium sulfide shampoo is recommended as the disease is usually secondary to seborrhea.

# Acute Otitis media
- Acute otitis media 
- 1. Causative pathogens
- Streptococcus pneumoniae
- Hemophilus influenzae
- Moraxella catarrhalis
- Polymicrobial
- Viral
- 2. Empiric antimicrobial therapy
- Preferred regimen: Amoxicillin 4090 mg/kg/day PO q12h OR Amoxicillin-Clavulanate 90/6.4 mg/kg/day PO q12h
- Alternative regimen: Cefdinir 14 mg/kg/day PO q12 or q24h OR Cefuroxime 30 mg/kg/day PO q12h OR Cefpodoxime 10 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h
- Note: Amoxicillin-Clavulanate may be considered in patients with recent Amoxicillin intake or concomitant conjunctivitis. Alternative regimens should be considered in patients with Penicillin allergies. Re-evaluate after 2-3 days for treatment response.
- 3. Special considerations
- 3.1 Acute otitis media post-treatment failure (48-72 hours)
- Preferred regimen: Amoxicillin-Clavulanate 90/6.4 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h
- Alternative regimen: Clindamycin 3040 mg/kg/day PO q8h  (Cefdinir 14 mg/kg/day PO q12 or q24h OR Cefuroxime 30 mg/kg/day PO q12h OR Cefpodoxime 10 mg/kg/day PO q12h OR Ceftriaxone 50 mg/kg/day IM or IV q24h)
- 3.2 Acute otitis media post-intubation
- Preferred regimen: Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q12h OR Imipenem 0.5 g IV q6h OR Meropenem 500 mg IV q8h OR Piperacillin-Tazobactam 46 g IV q46h OR Ticarcillin-Clavulanate 3 g IV q4h OR Ciprofloxacin 400 mg IV q12h OR Ciprofloxacin 750 mg PO q12h

# Parotitis
- Parotitis
- 1. Causative pathogens
- Staphylococcus aureus
- Streptococcus pyogenes
- Mumps
- Aerobic gram-negative bacilli
- Enterovirus
- Influenza virus
- 2. Empiric antimicrobial therapy
- Preferred regimen (MSSA suspected): Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- Preferred regimen (MRSA suspected): Vancomycin 1 g IV q12h