Epiglottitis medical therapy: Difference between revisions

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__NOTOC__
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{{Epiglottitis}}
{{Epiglottitis}}
{{CMG}}; {{AE}} {{Alonso}}
{{CMG}}; {{AE}} {{Alonso}} {{PTD}}


==Overview==
==Overview==


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. An appropriate antibiotic regimen that covers ''[[Streptococcus pneumoniae]]'', [[hemolysis|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.
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.<ref name="pmid159835742">{{cite journal| author=Nickas BJ| title=A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy. | journal=J Emerg Nurs | year= 2005 | volume= 31 | issue= 3 | pages= 234-5; quiz 321 | pmid=15983574 | doi=10.1016/j.jen.2004.10.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15983574  }}</ref>  An appropriate antibiotic regimen that covers ''[[Streptococcus pneumoniae]]'', [[hemolysis|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]].
Adjuvant therapy includes [[corticosteroids]] and racemic [[Epinephrine]].<ref name="pmid15983574">{{cite journal| author=Nickas BJ| title=A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy. | journal=J Emerg Nurs | year= 2005 | volume= 31 | issue= 3 | pages= 234-5; quiz 321 | pmid=15983574 | doi=10.1016/j.jen.2004.10.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15983574  }} </ref><ref name="pmid12557859">{{cite journal| author=Wick F, Ballmer PE, Haller A| title=Acute epiglottis in adults. | journal=Swiss Med Wkly | year= 2002 | volume= 132 | issue= 37-38 | pages= 541-7 | pmid=12557859 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12557859  }} </ref>


==Principles of Therapy for Acute Epiglottitis==
==Principles of Therapy for Acute Epiglottitis==
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===Adjuvant Therapy===
===Adjuvant Therapy===


* 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.<ref name="pmid7933397">{{cite journal| author=Frantz TD, Rasgon BM, Quesenberry CP| title=Acute epiglottitis in adults. Analysis of 129 cases. | journal=JAMA | year= 1994 | volume= 272 | issue= 17 | pages= 1358-60 | pmid=7933397 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7933397  }} </ref>
* 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.<ref name="pmid7933397">{{cite journal| author=Frantz TD, Rasgon BM, Quesenberry CP| title=Acute epiglottitis in adults. Analysis of 129 cases. | journal=JAMA | year= 1994 | volume= 272 | issue= 17 | pages= 1358-60 | pmid=7933397 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7933397 }} </ref><ref name="pmid15983574">{{cite journal| author=Nickas BJ| title=A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy. | journal=J Emerg Nurs | year= 2005 | volume= 31 | issue= 3 | pages= 234-5; quiz 321 | pmid=15983574 | doi=10.1016/j.jen.2004.10.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15983574  }} </ref><ref name="pmid12557859">{{cite journal| author=Wick F, Ballmer PE, Haller A| title=Acute epiglottis in adults. | journal=Swiss Med Wkly | year= 2002 | volume= 132 | issue= 37-38 | pages= 541-7 | pmid=12557859 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12557859 }} </ref>


===Antimicrobial Regimens===
===Antimicrobial Regimens===
*'''Epiglottitis'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:*'''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


==Pathogen-Based Therapy==
<SMALL><font color="#FF4C4C"> ▸ '''Click on the following categories to expand treatment regimens.'''</font></SMALL>
{|
|valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Bacteria'''
</font>
</div>
<div class="mw-customtoggle-table1" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Streptococcus pneumoniae'''''
</font>
</div>
<div class="mw-customtoggle-table2" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Streptococcus pyogenes'''''
</font>
</div>
<div class="mw-customtoggle-table10" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Streptococcus agalactiae'''''
</font>
</div>
<div class="mw-customtoggle-table11" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Streptococcus anginosus'''''
</font>
</div>
<div class="mw-customtoggle-table3" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Staphylococcus aureus'''''
</font>
</div>
<div class="mw-customtoggle-table4" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Haemophilus influenzae'''''
</font>
</div>
<div class="mw-customtoggle-table5" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Klebsiella pneumoniae'''''
</font>
</div>
<div class="mw-customtoggle-table6" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Moraxella catarrhalis'''''
</font>
</div>
<div class="mw-customtoggle-table7" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Neisseria spp.'''''
</font>
</div>
<div class="mw-customtoggle-table8" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Pasteurella multocida'''''
</font>
</div>
<div class="mw-customtoggle-table9" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Pseudomonas aeruginosa'''''
</font>
</div>
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Fungi'''
</font>
</div>
<div class="mw-customtoggle-table12" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Candida albicans'''''
</font>
</div>
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table1" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Streptococcus pneumoniae''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen (susceptible to penicillin)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2 million units IV q4h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 600 mg IV q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (penicillin resistant strains)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Moxifloxacin]] 400 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]] 1 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV q12h'''''<BR> OR <BR> ▸ '''''[[Ceftaroline]] 600 mg IV q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table2" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Streptococcus pyogenes''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen (susceptible to penicillin)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 1,2 million units IV 1 dose'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''THEN'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin VK]] 500 mg PO q12h'''''<BR> OR <BR> '''''[[Amoxicillin]] 500 mg PO q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (penicillin resistant strains)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 300 mg PO q8h'''''<BR> OR <BR> ▸ '''''[[Azithromycin]] 500 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Streptococcus agalactiae''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen (susceptible to penicillin)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 2 million units IV q4h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (penicillin resistant strains)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 20 mg/kg IV q8h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 600 mg IV q6h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Streptococcus anginosus''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen (susceptible to penicillin)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 million units IV q4h'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 2 g IV q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (penicillin resistant strains)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 1 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 600 mg IV q6h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table3" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Meticillin susceptible Staphylococcus aureus''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nafcillin]] 2 g IV q4-6h'''''<BR> OR <BR> ▸ '''''[[Oxacillin]] 2 mg IV q4-6h'''''<BR> OR <BR> ▸ '''''[[Cefazolin]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]] 15 mg/kg IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Dicloxacillin]] 500 mg PO q6h'''''<BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO q6h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 300 mg PO q6h'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 300 mg PO q8h'''''<BR> OR <BR> ▸ '''''[[TMP/SMZ]] 160/800 mg PO q12h'''''
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Meticillin resistant Staphylococcus aureus''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15-20 mg/kg IV q8-12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4-6 mg/kg IV q24h'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (Vancomycin intermediate susceptibility)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg/kg IV q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4-6 mg/kg IV q24h'''''<BR> OR <BR>▸ '''''[[Ceftaroline]] 600 mg IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (Vancomycin resistance)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Teicoplanin]] 6 mg/kg IV q12h (total of three doses), 6 mg/kg IV q24h'''''<BR> OR <BR> ▸ '''''[[Telavancin]] 10 mg/kg q24h (1 hour infusion)'''''<BR> OR <BR>▸ '''''[[Linezolid]] 600 mg/kg IV q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4-6 mg/kg IV q24h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table4" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Haemophilus influenzae''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Cefotaxime]] 2 g IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV q8h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table5" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Klebsiella pneumoniae''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Cefotaxime]] 2 g IV q8h'''''<BR> OR <BR>▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Imipenem]] 500 mg IV q6h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 1 g IV q8h'''''<BR> OR <BR>▸ '''''[[Ertapenem]] 1 g IV q24h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table6" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Moraxella catrrhalis''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amoxicillin-clavulanic acid]] 850/125 mg PO q24h'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 500 mg PO q24h one day, then 250 mg PO q24h'''''<BR> OR <BR>▸ '''''[[TMP/SMZ]] 5 mg/kg IV q6—12h''''' <SMALL>(TMP component)</SMALL>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table7" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Neisseria meningitidis''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 2 g IV q12h'''''<BR> OR <BR> ▸ '''''[[Cefotaxime]] 2 g IV q6h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin G]] 4 million units IV q4h'''''<BR> OR <BR> ▸ '''''[[Chloramphenicol]] 100 mg/kg/day q6h, not exceed 4 g'''''
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Neisseria gonorrhoeae''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 250 mg IM single dose'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 2 g PO single dose'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table8" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Pasteurella maltocida''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin VK]] 500 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Amoxicillin]] 500 mg PO q8h'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-clavulanic acid]] 850/125 mg PO q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefuroxime]] 500 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg PO q24h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]] 100 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-clavulanic acid]] 850/125 mg PO q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table9" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Pseudomonas spp''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV q24h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg PO q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (combination of)'''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table12" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|''Candida albicans''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Preferred Regimen'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluconazole]] 200 mg IV q24h for 14 days'''''<BR> OR <BR> ▸ '''''[[Fluconazole]] 200 mg PO q24h for 14 days'''''<BR> PLUS <BR> ▸ '''''[[Nystatin|Nystatin oral suspension]] PO q6h for 14 days'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | '''Alternative Regimen (combination of)'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Itraconazole]] solution 200 mg PO q24h for 14 days'''''<BR> OR <BR> ▸ '''''[[Amphotericin B]] 0.3 mg/kg PO q12h 3 days, then q24h for 14 days'''''<BR> OR <BR> ▸ '''''[[Caspofungin]] PO q6h for 14 days'''''
|}
|}
|}
<br>
==Antimicrobial regimen==
*Epiglottitis <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:*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
:*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
==References==
==References==


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Latest revision as of 21:36, 29 July 2020

Epiglottitis Microchapters

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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]

Overview

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]

Principles of Therapy for Acute Epiglottitis

Antibiotic Therapy

  • 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.

Adjuvant Therapy

Antimicrobial Regimens

  • Epiglottitis[8]
  • 1. Empiric antimicrobial therapy
  • 1.1 Pediatrics
  • 1.2 Adults
  • 2. Pathogen-directed antimicrobial therapy
  • 2.1 Streptococcus pneumoniae
  • 2.2 Streptococcus pyogenes
  • 2.3 Streptococcus agalactiae
  • 2.4 Streptococcus anginosus
  • 2.5 Methicillin-sensitive Staphylococcus aureus
  • 2.6 Methicillin-resistant Staphylococcus aureus
  • 2.7 Haemophilus influenzae
  • 2.8 Klebsiella pneumoniae
  • 2.9 Moraxella catarrhalis
  • 2.10 Neisseria meningitidis
  • 2.11 Neisseria gonorrhoeae
  • 2.12 Pasteurella multocida
  • 2.13 Pseudomonas aeruginosa
  • 2.14 Candida albicans

References

  1. Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
  2. 2.0 2.1 Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
  3. 3.0 3.1 Wick F, Ballmer PE, Haller A (2002). "Acute epiglottis in adults". Swiss Med Wkly. 132 (37–38): 541–7. PMID 12557859.
  4. Kessler A, Wetmore RF, Marsh RR (1993). "Childhood epiglottitis in recent years". Int J Pediatr Otorhinolaryngol. 25 (1–3): 155–62. PMID 8436460.
  5. Alcaide ML, Bisno AL (2007). "Pharyngitis and epiglottitis". Infect Dis Clin North Am. 21 (2): 449–69, vii. doi:10.1016/j.idc.2007.03.001. PMID 17561078.
  6. Loftis L (2006). "Acute infectious upper airway obstructions in children". Semin Pediatr Infect Dis. 17 (1): 5–10. doi:10.1053/j.spid.2005.11.003. PMID 16522499.
  7. Frantz TD, Rasgon BM, Quesenberry CP (1994). "Acute epiglottitis in adults. Analysis of 129 cases". JAMA. 272 (17): 1358–60. PMID 7933397.
  8. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.