Antibiotic Guidelines: Ear Nose and Throat

(ENT) Infections.
Classification: Clinical Guideline
Lead Author: Antibiotic Steering Committee
Additional author(s):
Authors Division: DCSS & Tertiary Medicine

Unique ID: 144TD(C)25(E3)

Issue number: 3
Expiry Date: January 2018

Contents

Section Page

Intro Who should read this document 2

Key practice points 2
Background/ Scope/ Definitions 2
What is new in this version 3
Guideline
Guidelines for Ear Infections 3
Guidelines for Nasal and Para-nasal Infections 5
Guidelines for Throat & Neck Infections 6
Roles and Responsibilities 8

Appendix 8

Document control information (Published as separate document) 9

Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis

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Who should read this document?

This policy applies to all clinical staff involved the prescribing of antimicrobials.

Key Practice Points

This policy recommends empiric antimicrobial treatment options for adult patients
with specified ear, nose and throat infections.

Background

Antimicrobial agents are among the most commonly prescribed drugs and account
for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to
individual patients are compromised by the development of bacterial drug resistance.
Resistance is a natural and inevitable result of exposing bacteria to antimicrobials.

Good antimicrobial prescribing will help to reduce the rate at which antibiotic
resistance emerges and spreads. It will also minimise the many side effects
associated with antibiotic prescribing, such as Clostridium difficile infection. It should
be borne in mind that antibiotics are not needed for simple coughs and colds. In
some clinical situations, where infection is one of several possibilities and the patient
is not showing signs of systemic sepsis, a wait and see approach to antibiotic
prescribing is often justified while relevant cultures are performed.

This document provides treatment guidelines for the most common situations in
which antibiotic treatment is required. The products and regimens listed here have
been selected by the Trust's Medicines Management Group on the basis of
published evidence. Doses assume a weight of 60-80kg with normal renal and
hepatic function. Adjustments may be needed for the treatment of some patients.

This document provides treatment guidelines for the appropriate use of antibiotics.
The recommendations that follow are for empirical therapy and do not cover all
clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20%
of cases. Alternative recommendations will be made by the microbiologist in
consultation with the clinical team.

This document refers to the treatment of adult patients (unless otherwise stated).

Please refer to up to date BNF/SPC for a full list of cautions, contra-indications,

interactions and adverse effects of individual drugs.

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What is new in this version?

Oral stepdown for mod/severe pharyngitis, and quinsy, changed to penicillin V

500mg qds plus metronidazole 400mg tds (not amoxicillin or co-amoxiclav)
after d/w ENT team
Option to use co-amoxiclav in quinsy added
Statement to stop antibiotics if infectious mononucleosis confirmed and no
positive culture
Warning re: risk of aminopenicillin use in undifferentiated sore throat

Guideline

Ear Infections

Clinical Antibiotic Duration Penicillin allergy Comments

diagnosis
Flucloxacillin 5 days Clarithromycin oral Prescribe IV initially
Acute oral 1g 6 500mg 12 hourly in severe cases.
Localised Otitis hourly
Externa
Plus
(furuncle)
Topical
steroids
Mild
moderate:
7 days
Acute Diffuse Topical
Otitis Externa Antimicrobial
Severe (e.g 7 days Topical drops to be
(swimmers ear) cellulitis or prescribed at the
blocked ear discretion of the
canal): ENT consultant.

Ciprofloxacin
oral 500mg 12
hourly
1st line -
Perichondritis Ciprofloxacin 7 days
oral 500mg
750mg 12
hourly

2nd line
Add

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 clindamycin
oral 450mg 6
hourly
Malignant Otitis Piperacillin / 46 Clindamycin IV -Ensure swabs are
Externa tazobactam IV weeks 900mg taken prior to
4.5g 8 hourly 8 hourly AND starting topical
Ciprofloxacin oral therapy
Plus 500mg 750mg - Switch to orals
12 hourly based on clinical
Topical assessment and
treatment microbiological
results
Oral Step - Assess for any
down: bone and
intracranial
Ciprofloxacin extension
oral 500mg - All cases to be
750mg 12 discussed with
hourly microbiology

Acute Otitis Antibiotics 5 days Antibiotics should - Most cases are

Media should not be not be routinely viral and self
routinely prescribed for limiting.
prescribed for uncomplicated - Antibiotics should
uncomplicated AOM. be delayed for 2-3
AOM. days and patient
For severe re-assessed.
For severe disease or when
disease or risk of
when risk of complications:
complications: 1st line
1st line clarithromycin oral
Amoxicillin 500mg 12 hourly
oral 500mg 8
hourly 2nd line
doxycycline oral
2nd line Co- 100mg 12 hourly
Amoxiclav AND
oral 625mg 8 metronidazole oral
hourly 400mg 8 hourly

Chronic Otitis Topical - - Discuss with duty

Media treatment microbiologist if
considering systemic
antibiotics

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 Acute Co-Amoxiclav 10 14 Clindamycin IV IV to oral switch
Mastoiditis IV 1.2g days 900mg when clinically
8 hourly 8 hourly AND suitable (24 48hrs)
Ciprofloxacin oral Review culture and
Oral Step 500mg 12 hourly sensitivity results
down: Assess for any bone
Co-amoxiclav Oral Step down: and intracranial
625mg 8 Clindamycin oral extension
hourly 450mg QDS AND
Ciprofloxacin oral
500mg 12 hourly

Nasal and Para-nasal Sinus Infection

Clinical Antibiotic Duration Penicillin allergy Comments

diagnosis

Acute Antibiotics should ONLY be prescribed in SEVERE infection as this

Rhinosinusitis condition can have a viral cause.

Acute Bacterial 1st line 5 days 1st line -

Rhinosinusitis Co- Clarithromycin oral
Amoxiclav 500mg 12 hourly
(severe or oral 625mg 8
persistent hourly 2nd line
symptoms) Doxycycline oral
2nd line 100mg 12 hourly
Doxycyline
oral
100mg 12
hourly

Peri-orbital Clindamycin 2 weeks Clindamycin IV - IV to oral switch

Cellulitis IV 900mg 900mg when clinically
8 hourly AND 8-hourly AND suitable (24 48hrs)
Ciprofloxacin Ciprofloxacin oral
oral 500mg 500mg 12 hourly
12 hourly
Oral Step down:
Oral Step Clindamycin oral
down: 450mg QDS AND
Clindamycin Ciprofloxacin oral
oral 450mg 500mg 12 hourly
QDS AND
Ciprofloxacin
oral 500mg
12 hourly

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 Throat and Neck Infection

Clinical diagnosis Antibiotic Duration Penicillin allergy Comments

Please note that sore throats can be viral in nature. These do NOT
Sore Throat require antimicrobial therapy. Antibiotic treatment of adult
pharyngitis benefits only those patients with GABHS infection. Four
clinical criteria (Centor criteria **) that predict infection with GABHS
include:
(a) history of fever
(b) tonsillar exudates
(c) absence of cough
(d) tender anterior cervical lymphadenopathy (lymphadenitis)
Antibiotic therapy is recommended only for patients who fulfil
THREE or FOUR criteria. See below for antibiotic
recommendations for pharyngitis.

Throat cultures are not recommended for the routine primary

evaluation of adults with pharyngitis or for confirmation of negative
results on rapid antigen tests.

Amoxicillin/Co-amoxiclav and glandular fever (Infectious mononucleosis): A

maculopapular rash often occurs following the administration of ampicillin or amoxicillin in
patients with IM, and therefore these agents should not be used for empiric treatment of
an acute sore throat. Development of a drug-related rash during IM does not appear to
represent a true drug allergy, as patients subsequently tolerate ampicillin without an
adverse reaction.

Pharyngitis / Mild 10 days Mild

Tonsillitis Phenoxymethyl Clarithromycin - IV to oral switch
penicillin oral oral 500mg 12 when clinically
500mg 6 hourly hourly suitable (24
48hrs)
Mod-Severe Mod-Severe
Benzylpenicillin Clindamycin IV Stop antibiotics if
IV 1.2g 6 hourly 900mg 8 hourly IM diagnosed and
AND no positive culture
Metronidazole Oral Step down if
IV 500mg no positive
8 hourly cultures:
Clindamycin oral
Oral Step down 450mg 6 hourly
if no positive
cultures:
Penicillin V oral
500mg 6 hourly
AND
metronidazole
oral 400mg
8hrly
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 Quinsy Benzylpenicillin 10 days Clindamycin IV
(peritonsillar IV 1.2g 6 hourly 900mg 8 hourly
abscess) AND
Metronidazole Oral Step down:
IV 500mg Clindamycin oral
8 hourly 450mg 6 hourly

Oral Step down:

Penicillin V oral
500mg 6 hourly
AND
metronidazole
oral 400mg
8hrly

Above regimen
may be
insufficient for
polymicrobial
infection.
If lack of clinical
response and
IM ruled out:

Co-amoxiclav IV
1.2g 8 hourly

Oral Step down

Co-amoxiclav
oral 625mg 8
hourly

Epiglottitis Ceftriaxone IV 7 10 Clindamycin IV - IV to oral switch

2g OD days 900mg when clinically
8 hourly AND suitable (24
Oral step down: Ciprofloxacin oral 48hrs)
Co-Amoxiclav 500mg 12 hourly
625mg TDS - Review culture
Oral Step down: and sensitivity
Clindamycin oral results
450mg QDS AND
Ciprofloxacin oral
500mg 12 hourly

Acute Laryngitis Antibiotics are - - -

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 NOT indicated

Retropharyngeal Ceftriaxone IV 10 14 IV Clindamycin -IV to oral switch

Abscess / 2g OD AND days 900mg when clinically
Lateral Metronidazole 8 hourly AND suitable (24
pharyngeal IV 500mg 8 Ciprofloxacin oral 48hrs)
Abscess hourly 500mg 12 hourly - Review culture
and sensitivity
Oral Step down: Oral Step down: results
Co-Amoxiclav Clindamycin oral - All cases to be
625mg TDS 450mg QDS AND discussed with
Ciprofloxacin oral microbiology
500mg 12 hourly

Lemierres Ceftriaxone IV 4-6 Clindamycin IV - IV to oral switch

Syndrome 2g OD AND weeks 900mg when clinically
Metronidazole 8 hourly suitable (24
(Suppurative IV 500mg 48hrs)
Jugular 8 hourly Oral Step down: - Review culture
Thrombophlebitis) Clindamycin oral and sensitivity
Oral Step down: 450mg 6 hourly results
Co-amoxiclav - All cases to be
625mg TDS discussed with
microbiology

Suppurative Co-Amoxiclav 10 14 IV Clindamycin - IV to oral switch

Parotitis IV 1.2g days 900mg when clinically
8-hourly 8 hourly suitable (24
(Salivary Gland 48hrs)
Infection) Oral Step down: Oral Step down:
Co-amoxiclav Clindamycin oral - Review culture
625mg TDS 450mg 6 hourly and sensitivity
results

Standards

Document the Indication/rationale for antimicrobial therapy, including clinical

criteria relevant to this.

Review and document the patients allergy status

Ensure the choice of antibiotic complies with the antibiotic guidelines and you
have documented any clinical criteria relevant to the choice of agent.

Document a management plan including a stop or review date.

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 Where relevant, consider drainage of pus or surgical debridement/removal of
foreign material.

Explanation of terms & Definitions

NA

Roles and responsibilities

All clinical staff involved in the prescribing of antimicrobials to adhere to this policy
including full documentation on EPMAR as detailed.

Appendices

Not applicable

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