Epiglottitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2] Prince Tano Djan, BSc, MBChB [3]

Epiglottitis is a medical emergency and warrants immediate establishment of a patent airway. Once the airway has been secured, cultures of blood and epiglottic surface should be obtained before administration of antimicrobial therapy. Administering high-flow oxygen, establishing intravenous access, and calling the ENT specialist are standard first-line interventions for epiglottitis.^[1] An appropriate antibiotic regimen that covers Streptococcus pneumoniae, beta-hemolytic streptococci, and Staphylococcus aureus includes parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin (or Levofloxacin in combination with Clindamycin for Penicillin-allergic patients). Adjuvant therapy is commonly used in the management of stridor associated with acute epiglottitis. Adjuvant therapy includes corticosteroids and racemic Epinephrine.^[2][3]

• In view of the emergence of Streptococcus pneumoniae, beta-hemolytic streptococci, and ampicillin-resistant Haemophilus influenzae as the most common causative bacteria of acute epiglottitis, empiric therapy with a third-generation cephalosporin (such as cefotaxime and ceftriaxone) or ampicillin-sulbactam is recommended.^[4]

• An anti-staphylococcal agent (such as vancomycin or clindamycin) should be added to the initial treatment in areas with increased prevalence of methicillin-resistant Staphylococcus aureus (MRSA) or penicillin-resistant pneumococci.^[5][6]

• The optimal duration of antimicrobial therapy is yet to be determined. Acute epiglottitis usually responds to a 7– to 10–day course of intravenous antibiotics.

• Although adjuvant corticosteroids and racemic epinephrine are commonly used in the management of stridor associated with acute epiglottitis, neither of them were proved effective in reducing the need of airway intervention or shortening the hospitalization.^[7][2][3]

• Epiglottitis^[8]

• 1. Empiric antimicrobial therapy

• 1.1 Pediatrics

• Preferred regimen (1): Cefotaxime 50 mg/kg IV q8h
• Preferred regimen (2): Ceftriaxone 50–75 mg/kg/day IV q12–24h AND Vancomycin 10 mg/kg IV q6h
• Alternate regimen (1): Levofloxacin 500 mg IV q24h (or 8 mg/kg IV q12h) AND Clindamycin 20–40 mg/kg/day IV q6–8h

• 1.2 Adults

• Preferred regimen (1): Cefotaxime 2 g IV q4–8h
• Preferred regimen (2): Ceftriaxone 1–2 g/day IV q12–24h AND Vancomycin 2 g/day IV q6–12h
• Alternate regimen (1): Levofloxacin 750 mg IV q24h AND Clindamycin 600–1200 mg IV q6–12h

• 2. Pathogen-directed antimicrobial therapy

• 2.1 Streptococcus pneumoniae

• Preferred regimen: Penicillin G 2 MU IV q4h OR Ceftriaxone 2 g IV q24h OR Clindamycin 600 mg IV q6h
• Alternative regimen: Moxifloxacin 400 mg IV q24h OR Levofloxacin 750 mg IV q24h OR Vancomycin 1 g IV q12h OR Linezolid 600 mg IV q12h OR Ceftaroline 600 mg IV q12h

• 2.2 Streptococcus pyogenes

• Preferred regimen: (Penicillin G 1.2 MU IV single dose THEN Penicillin VK 500 mg PO q12h) OR Amoxicillin 500 mg PO q12h
• Alternative regimen: Clindamycin 300 mg PO q8h OR Azithromycin 500 mg PO q24h OR Cephalexin 500 mg PO q12h

• 2.3 Streptococcus agalactiae

• Preferred regimen: Penicillin G 2 MU IV q4h
• Alternative regimen: Vancomycin 20 mg/kg IV q8h OR Clindamycin 600 mg IV q6h

• 2.4 Streptococcus anginosus

• Preferred regimen: Penicillin G 4 MU IV q4h OR Ceftriaxone 2 g IV q24h
• Alternative regimen: Vancomycin 1 g IV q12h OR Clindamycin 600 mg IV q6h

• 2.5 Methicillin-sensitive Staphylococcus aureus

• Preferred regimen: Nafcillin 2 g IV q4-6h OR Oxacillin 2 mg IV q4-6h OR Cefazolin 2 g IV q8h
• Alternative regimen: Dicloxacillin 500 mg PO q6h OR Cephalexin 500 mg PO q6h OR Clindamycin 300 mg PO q6h OR Clindamycin 300 mg PO q8h OR Trimethoprim-Sulfamethoxazole 160/800 mg PO q12h

• 2.6 Methicillin-resistant Staphylococcus aureus

• Preferred regimen: Vancomycin 15-20 mg/kg IV q8-12h OR Daptomycin 4-6 mg/kg IV q24h OR Linezolid 600 mg IV q12h
• Alternative regimen: Linezolid 600 mg/kg IV q12h OR Daptomycin 4-6 mg/kg IV q24h OR Ceftaroline 600 mg IV q8h

• 2.7 Haemophilus influenzae

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q8h
• Alternative regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q8h

• 2.8 Klebsiella pneumoniae

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q8h OR Levofloxacin 750 mg IV q24h
• Alternative regimen: Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Ertapenem 1 g IV q24h

• 2.9 Moraxella catarrhalis

• Preferred regimen: Amoxicillin-clavulanate 850/125 mg PO q24h
• Alternative regimen: (Azithromycin 500 mg PO q24h first day THEN 250 mg PO q24h) OR Trimethoprim-Sulfamethoxazole 5 mg/kg IV q6—12h

• 2.10 Neisseria meningitidis

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q6h
• Alternative regimen: Penicillin G 4 MU IV q4h OR Chloramphenicol 100 mg/kg/day q6h (maximum dose 4 g/day)

• 2.11 Neisseria gonorrhoeae

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q6h
• Alternative regimen: Penicillin G 4 MU IV q4h OR Chloramphenicol 100 mg/kg/day q6h (maximum dose 4 g/day)

• 2.12 Pasteurella multocida

• Preferred regimen: Penicillin VK 500 mg PO q12h OR Amoxicillin 500 mg PO q8h OR Amoxicillin-clavulanate 850/125 mg PO q12h
• Alternative regimen: Cefuroxime 500 mg PO q12h OR Levofloxacin 750 mg PO q24h OR Moxifloxacin 400 mg PO q24h OR Doxycycline 100 mg PO q12h

• 2.13 Pseudomonas aeruginosa

• Preferred regimen: (Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h) AND (Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg PO q24h)

• 2.14 Candida albicans

• Preferred regimen: (Fluconazole 200 mg IV q24h for 14 days OR Fluconazole 200 mg PO q24h for 14 days) AND Nystatin oral suspension PO q6h for 14 days
• Alternative regimen: Itraconazole solution 200 mg PO q24h for 14 days OR (Amphotericin B 0.3 mg/kg PO q12h 3 days THEN q24h for 14 days) OR Caspofungin PO q6h for 14 days