Epiglottitis medical therapy

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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]

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 antibiotics. Appropriate antibiotic regimens with coverage of Streptococcus pneumoniae, beta-hemolytic streptococci, and Staphylococcus aureus include parenteral cefotaxime or ceftriaxone in combination with vancomycin (or levofloxacin in combination with clindamycin for penicillin-allergic patients). Racemic epinephrine and systemic corticosteroids are commonly used for the management of stridor associated with acute upper respiratory tract infection. Postexposure prophylaxis with rifampin should be given to selected household contacts when a Haemophilus influenzae epiglottitis is diagnosed. If viral infection is suspected, no treatment other than supportive measures and securing the airway are needed as viral infections are self-limited.[1]

Principles of Therapy for Acute Epiglottitis

Antibiotic Therapy

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

Adjuvant Therapy

  • Although adjuvant corticosteroids or racemic epinephrine is commonly used in the management of stridor associated with acute epiglottitis, neither of them appeared effective in reducing the need of airway intervention or shortening the hospitalization.[4]

Empiric Therapy

  • The tables below describe the recommended antimicrobial regimens for the treatment of acute epiglottitis in pediatric and adult patients.
Pediatric Patient
Preferred Regimen
Cefotaxime 50 mg/kg IV q8h
OR
Ceftriaxone 50–75 mg/kg/day IV q12–24h
PLUS
Vancomycin 10 mg/kg IV q6h
Alternative Regimen (If Allergic to Penicillin)
Levofloxacin 500 mg IV q24h (or 8 mg/kg IV q12h)
PLUS
Clindamycin 20–40 mg/kg/day IV q6–8h
Adult Patient
Preferred Regimen
Cefotaxime 2 g IV q4–8h
OR
Ceftriaxone 1–2 g/day IV q12–24h
PLUS
Vancomycin 2 g/day IV q6–12h
Alternative Regimen (If Allergic to Penicillin)
Levofloxacin 750 mg IV q24h
PLUS
Clindamycin 600–1200 mg IV q6–12h

Pathogen-Based Therapy

▸ Click on the following categories to expand treatment regimens.

Bacteria

  ▸  Streptococcus pneumoniae

  ▸  Streptococcus sp

  ▸  Staphylococcus aureus

  ▸  Haemophilus influenzae

  ▸  Klebsiella pneumoniae

  ▸  Moraxella catarrhalis

  ▸  Neisseria sp

  ▸  Pasteurella multocida

  ▸  Pseudomonas sp

Fungi

  ▸  Candida albicans

Streptococcus pneumoniae
Preferred Regimen (sussceptible to penicillin)
Penicillin G 2 million units IV q4h
OR
Ceftriaxone 2 g IV q24h
OR
Clindamycin 600 mg IV q6h
Alternative Regimen (penicillin resistant strains)
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
Streptococcus pyogenes
Preferred Regimen (sussceptible to penicillin)
Penicillin G 1,2 million units IV 1 dose
THEN
Penicillin VK 500 mg PO q12h
OR
Amoxicillin 500 mg PO q12h
Alternative Regimen (penicillin resistant strains)
Clindamycin 300 mg PO q8h
OR
Azithromycin 500 mg PO q24h
OR
Cephalexin 500 mg PO q12h
Streptococcus agalactiae
Preferred Regimen (sussceptible to penicillin)
Penicillin G 2 million units IV q4h
Alternative Regimen (penicillin resistant strains)
Vancomycin 20 mg/kg IV q8h
OR
Clindamycin 600 mg IV q6h
Streptococcus angiosus
Preferred Regimen (sussceptible to penicillin)
Penicillin G 4 million units IV q4h
OR
Ceftriaxone 2 g IV q24h
Alternative Regimen (penicillin resistant strains)
Vancomycin 1 g IV q12h
OR
Clindamycin 600 mg IV q6h
Meticillin susceptible Staphylococcus aureus
Preferred Regimen
Nafcillin 2 g IV q4-6h
OR
Oxacillin 2 mg IV q4-6h
OR
Cefazolin 2 g IV q8h
OR
Vancomycin 15 mg/kg 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
TMP/SMZ 160/800 mg PO q12h
Meticilling 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 (Vancomycin intermmediate sussceptibility)
Linezolid 600 mg/kg IV q12h
OR
Daptomycin 4-6 mg/kg IV q24h
OR
Ceftraoline 600 mg IV q8h
Alternative Regimen (Vancomycin resistance)
Teicoplanin 6 mg/kg IV q12h (total of three doses), 6 mg/kg IV q24h
OR
Telavancin 10 mg/kg q24h (1 hour infusion)
OR
Linezolid 600 mg/kg IV q12h
OR
Daptomycin 4-6 mg/kg IV q24h
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
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
Moraxella catrrhalis
Preferred Regimen
Amoxicillin-clavulanic acid 850/125 mg PO q24h
Alternative Regimen
Azithromycin 500 mg PO q24h one day, then 250 mg PO q24h
OR
TMP/SMZ 5 mg/kg IV q6—12h (TMP component)
Neisseria meningitidis
Preferred Regimen
Ceftriaxone 2 g IV q12h
OR
Cefotaxime 2 g IV q6h
Alternative Regimen
Penicillin G 4 million units IV q4h
OR
Chloramphenicol 100 mg/kg/day q6h, not exceed 4 g
Neisseria gonorrhoeae
Preferred Regimen
Ceftriaxone 250 mg IM single dose
Alternative Regimen
Azithromycin 2 g PO single dose
Pasteurella maltocida
Preferred Regimen
Penicillin VK 500 mg PO q12h
OR
Amoxicillin 500 mg PO q8h
OR
Amoxicillin-clavulanic acid 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
OR
Amoxicillin-clavulanic acid 850/125 mg PO q12h
Pseudomona sp
Preferred Regimen
Ceftazidime 2 g IV q8h
OR
Cefepime 2 g IV q8h
PLUS
Levofloxacin 750 mg IV q24h
OR
Moxifloxacin 400 mg PO q24h
Alternative Regimen (combination of)
Candida albicans
Preferred Regimen
Fluconazole 200 mg IV q24h for 14 days
OR
Fluconazole 200 mg PO q24h for 14 days
PLUS
Nystatin oral suspension PO q6h for 14 days
Alternative Regimen (combination of)
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


References

  1. Bisno AL (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144.
  2. 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.
  3. 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.
  4. Frantz TD, Rasgon BM, Quesenberry CP (1994). "Acute epiglottitis in adults. Analysis of 129 cases". JAMA. 272 (17): 1358–60. PMID 7933397.