ADULT
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OTORHINOLARYNGOLOGY INFECTIONS
In this topic:
1. THROAT AND UPPER RESPIRATORY TRACT
1. THROAT AND UPPER RESPIRATORY TRACT
1.1 Tonsilitis/Pharyngitis (Sore throat)
Common organism:
Respiratory virus (>80% of cases)
Group A Streptococcus
Use Modified Centor Score to determine infection origin (bacterial or viral) and whether antibiotics are necessary.
Treatment for Modified Centor Score <3:
Modified Centor Score < 3 does not require antibiotic treatment, as sore throats are commonly viral in origin. Give symptomatic treatment only (E.g.: analgesics, antipyretics).
Treatment for Modified Centor Score 3-5:
Modified Centor Score ≥ 3 requires antibiotic therapy due to a higher risk of Group A Streptococcus (GAS) infection.
Preferred
Phenoxymethylpenicillin (Pen V) 500mg PO q6h or 1g PO q12h
OR
Benzathine Penicillin 1.2MU IM, one single dose
Alternative
Amoxicillin 500mg PO q8h
Antibiotic allergy:
Erythromycin ethylsuccinate 800mg q12h
Comments
Duration: 5-10 days
Consider 10 days in settings with a high prevalence of rheumatic fever or in patients with a history of rheumatic fever or rheumatic heart disease and who are aged between 3 and 21 years.
Refer to Appendix 3 for antibiotic allergy.
1.2 Acute Peritonsillar Abscess (Quinsy)
Common organisms:
Group A Streptococcus
Fusobacterium necrophorum
Streptococcus anginosus group
Drainage or aspiration of the abscess is the mainstay of treatment for peritonsillar abscess.
Preferred
Benzylpenicillin 2MU IV q6h
PLUS
Metronidazole 500mg IV q6-8h
OR
Ampicillin/sulbactam 3g IV q6h
OR
Amoxicillin/clavulanate 1.2g IV q8h
Alternative
Antibiotic allergy:
Clindamycin 600 - 900mg IV q8h
Comments
Duration: 10-14 days of therapy (Intravenous + Oral)
Refer to Appendix 6 for IV to PO switch.
Refer to Appendix 3 for antibiotic allergy.
1.3 Diphteria
Corynebacterium diphtheriae
Preferred
*Erythromycin lactobionate 500mg IV q6h,
followed by **Erythromycin ethylsuccinate 800 mg PO q6h
OR
*Benzylpenicillin 25,000 units/kg q6h to a maximum of 1 MU IV/IM q6h, followed by Phenoxymethylpenicillin (Pen V) 500mg PO q6h
PLUS
Diphtheria Antitoxin
Alternative
***Azithromycin 500mg OD IV/PO
***(There is no CLSI / EUCAST breakpoint for azithromycin. Thus, azithromycin is adviced to be given only for patients who cannot tolerate penicillin or erythromycin)
PLUS
Diphtheria Antitoxin
Comments
Duration: 14 days (intravenous + oral therapy)
Antibiotics are not a substitute for treatment with diphtheria antitoxin. The role of adjunctive antibiotic treatment is to eradicate C.diphtheriae, which prevents further toxin production.
*IV to PO switch:
Parenteral treatment is preferred for patients who are unable to swallow. Once the patient improves and can swallow comfortably, switch to oral therapy. Refer to Appendix 6 for IV to PO switch.
Close contact management:
IM Benzathine Penicillin 1.2 MU single dose
OR
Erythromycin ethylsuccinate 800mg q6h for 7-10 days
OR
***Azithromycin 500mg OD for 7-10 days
**Erythromycin base 250mg = Erythromycin Ethylsuccinate 400mg
Diphtheria Antitoxin (dose depends on severity):
Pharyngeal/ laryngeal disease of 2 days duration : 20,000 - 40,000 units
Nasopharyngeal disease : 40,000 – 60,000 units
Systemic disease of ≥3 days or any patient with diffuse neck swelling : 80,000 – 120,000 units
Administer over 60 mins to inactivate toxins rapidly
1.4 Acute Epiglottitis (Supraglottitis)
Common organisms:
Streptococcus pneumoniae
Group A Streptococcus
Haemophilus influenzae Type B Virus
Preferred
Ceftriaxone 2g IV q24h
OR
Ampicillin/sulbactam 3g IV q6h
OR
Amoxycillin/clavulanate 1.2g IV q8h
Alternative
Antibiotic allergy:
Clindamycin 600-900mg IV q8h
PLUS
Ciprofloxacin 400mg IV q12h
Comments
Duration: 7 to 10 days (intravenous + oral). Longer in cases of bacteremia, concomitant meningitis or immunocompromised.
Requires urgent hospitalisation. May present with life-threatening upper airway obstruction, especially in paediatrics.
Consider adding vancomycin for patients with moderate to severe sepsis, concomitant meningitis or previously colonized with MRSA.
Refer to Appendix 3 for antibiotic allergy.
Refer to Appendix 6 for IV to PO switch.
1.5 Deep Neck Space Abscess / Parapharyngeal Abscess / Retropharyngeal Abscess / Ludwig Angina
Common organisms (usually polymicrobial):
Anaerobes (eg Fusobacteria sp, Prevotella sp)
Streptococcus spp.
Staphylococcus aureus
Preferred
Ampicillin/sulbactam 3g IV q6h
OR
Amoxycillin/clavulanate 1.2g IV q8h
OR
Cefuroxime 1.5g IV q8h
PLUS
Metronidazole 500mg IV q6h
Alternative
Penicillin Allergy:
Immediate / Delayed Non-Severe:
Cefazolin 2g IV q8h
OR
Ceftriaxone 2g IV q24h
PLUS
Metronidazole 500mg IV q6h
Immediate / Delayed Severe Penicillin Allergy:
Clindamycin 600-900mg IV q8h
Comments
Duration: 10-14 days (intravenous + oral)
For significant abscess, surgical drainage and debridement are required.
If there is evidence of necrotising fasciitis (clinical / radiological evidence), may add IV clindamycin.
Once the patient improves, switch to oral therapy after a minimum of 3 to 5 days of intravenous therapy. Refer to Appendix 6 for IV to PO switch.
2. NOSE
2. NOSE
2.1 Acute Rhinosinusitis (ARS)
Common organisms:
Virus (most common)
Bacterial (0.5 - 2%)
Antibiotics are not needed in the great majority of cases. Most cases of sinusitis occur as a complication of a viral upper respiratory tract infection and are self-limited.
Use the algorithm below to determine the infection origin (bacterial or viral) and whether antibiotics are necessary.
2.2 Acute Bacterial Rhinosinusitis (ABRS)
Common organisms:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Preferred
Amoxicillin 500-1000mg PO q8h
OR
Amoxicillin/clavulanate 625mg PO q8h
*If no improvement after 3 days of oral antibiotic, refer to Otorhinolaryngology department.
Alternative
Penicillin allergy:
Doxycycline 100mg q12h
Pregnant patients with antibiotic allergy would need to be treated with:
Azithromycin 500mg PO q24hr for 3 days
Comments
*Refer to the algorithm for Acute Rhinosinusitis in Adults.
Duration: 5 days
Refer to Appendix 3 for antibiotic allergy.
3. EAR
3. EAR
3.1 Acute otitis media (AOM)
Refer to section Clinical Pathway in Primary Care – Acute Otitis Media.
3.2 Malignant Otitis Externa/ Necrotizing Otitis Externa
Common organism:
Pseudomonas aeruginosa (95%)
Staphylococcus aureus
Preferred
Ceftazidime 2g IV q8h
OR
*Piperacillin/tazobactam 4.5g IV q6–8h
Alternative
Ciprofloxacin 400mg IV q8h (option for beta-lactam allergic patients)
Comments
Duration: 6 weeks (intravenous + oral)
Once showing a clinical response, consider switching to oral therapy:
Ciprofloxacin 750mg PO q12h to complete 6 weeks.
*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).
3.3 Acute Localised Otitis Externa
Common organisms:
Staphylococcus aureus
Streptococcus pyogenes
Preferred
Cloxacillin 500mg PO q6h
OR
Cephalexin 500mg PO q6h
Alternative
Penicillin allergy:
Clindamycin 600mg PO q8h
Comments
Duration: 5 days
3.4 Acute Diffuse Otitis Externa (Swimmer’s ear)
Common organisms:
Pseudomonas aeruginosa
Staphylococcus aureus
Preferred
Ofloxacin 0.3% otic solution. Instill 10 drops into affected ear(s) q24h
MAY ADD
Steroid ear drops (when fungal infection is NOT suspected
Alternative
--
Comments
Aural toileting is required in discharging ears.
Duration: 7 days
3.5 Chronic Suppurative Otitis Media
Common organism (often polymicrobial):
Anaerobes
Staphylococcus aureus
Enterobacterales
Pseudomonas aeruginosa
Mycobacterium tuberculosis
Preferred
Ofloxacin 0.3% otic solution. Instill 10 drops into affected ear(s) q12h
Referral to ENT is recommended for further examination to exclude cholesteatoma or chronic osteitis.
Alternative
--
Comments
Aural toileting required in discharging ears.
Duration:10-14 days
3.6 Otomycosis
Common organism:
Candida sp.
Aspergillus sp.
Preferred
Clotrimazole 1% ear solution, apply q6-8h
Alternative
--
Comments
Aural toileting required.
Duration:10-14 days
References:
Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults, Warren J. McIsaac, JAMA, April 7, 2004—Vol 291, No. 13, 2004
WHO AWaRe (Access, Watch, Reserve) Antibiotics Group 2022
Altamimi, Saleh et al., Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children, The Cochrane database of systematic reviews ,8 CD004872. 15 Aug. 2012
Sore Throat (Acute): Antimicrobial Prescribing. NICE Guideline January 2018
ESCMID Guideline for the Management of Acute Sore Throat 2012
Skoog Ståhlgren, G., et al (2019). Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ (Clinical research ed.), 367, l5337. https://doi.org/10.1136/bmj.l5337
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WHO. Field Guide for Preparedness and Response to Diphtheria Outbreaks in the Western Pacific Region.
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