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Dept of ENT Surgery - Antibiotic guidelines (May 2013)
Condition
First Line Intravenous Antibiotic
Penicillin allergy
Notes
Severe Tonsillitis
Benzyl Penicillin 1.2 g IV QDS plus
Metronidazole 400mg PO TDS (500mg IV
TDS if unable to swallow)
Clarithromycin 500mg IV BD plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to swallow)
If patient has had more than 5 days of oral Penicillin V then
use Co-amoxiclav 1.2g IV TDS.
If patient has infectious mononucleosis (glandular fever) and
>5 d oral Penicillin V use Cefuroxime 750mg IV TDS and
Metronidazole 500mg IV TDS
Peritonsillar abscess
(Quinsy)
Benzyl Penicillin 1.2 g IV QDS plus
Metronidazole 400mg PO TDS (500mg IV
TDS if unable to swallow)
Clarithromycin 500mg IV BD plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
If patient has had a course of oral Penicillin V then use
Cefuroxime 750mg IV TDS and
Metronidazole 500mg IV TDS
Acute Epiglottitis
(Paediatric)
Ceftriaxone IV once daily
(Dose calculation as per BNF)
D/W Microbiology only if type 1 anaphylaxis
Supraglottitis
(Adult)
Cefuroxime 1.5g IV TDS plus
Metronidazole 400mg PO TDS (500mg IV
TDS if unable to swallow)
D/W Microbiology only if type 1 anaphylaxis
Neck abscess
Co-amoxiclav 1.2g IV TDS
Clarithromycin 500mg IV BD plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
Orbital cellulitis
(Paediatric)
Cefotaxime IV plus Metronidazole IV
(Dose calculation as per BNF)
D/W Microbiology only if type 1 anaphylaxis
Pinna/Facial
Cellulitis (superficial
skin / soft tissue)
Flucloxacillin 1g IV QDS plus
BenzylPenicillin 1.2g IV QDS
Clarithromycin 500mg IV BD
Facial cellulitis –
odontogenic and
other deep soft
tissue infections
(Adult)
Co-amoxiclav 1.2g IV TDS
Cefuroxime 1.5g TDS IV plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
If severe type 1 hypersensitivity (anaphylaxis):
Teicoplanin 400mg once daily plus
Gentamicin 5mg/kg/day plus
Metronidazole (as above).
Severe pre-septal
cellulitis and ALL
orbital cellulitis
(Adult)
Co-amoxiclav 1.2g IV TDS
Cefuroxime 1.5g TDS IV plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
If severe type 1 hypersensitivity (anaphylaxis):
Teicoplanin 400mg once daily plus
Gentamicin 5mg/kg/day plus
Metronidazole (as above).
IV Clarithromycin - risk of phlebitis. Switch to PO as soon as
possible
Gentamicin – risks of nephrotoxicity and ototoxicity
Gentamicin duration should be kept <5 days wherever
possible – review results of cultures and switch antibiotics
according to sensitivities
In renal impairment (eGFR <60ml/min), Gentamicin can be
replaced with Ciprofloxacin 400mg IV BD (500mg BD PO if
able to take oral medications)
Gentamicin – risks of nephrotoxicity and ototoxicity
Gentamicin duration should be kept <5 days wherever possible
– review results of cultures and switch antibiotics according to
sensitivities
In renal impairment (eGFR <60ml/min), Gentamicin can be
replaced with Ciprofloxacin 400mg IV BD (500mg BD PO if
able to take oral medications)
Acute Parotitis
Co-amoxiclav 1.2g IV TDS
Clarithromycin 500mg IV BD plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
IV Clarithromycin - risk of phlebitis. Switch to PO as soon as
possible
Acute Mastoiditis
Co-amoxiclav 1.2g IV TDS
Cefuroxime 1.5g TDS IV plus
Metronidazole 400mg PO TDS (500mg IV TDS if
unable to take PO)
If severe type 1 hypersensitivity (anaphylaxis):
Teicoplanin 400mg once daily plus
Ciprofloxacin 500mg PO BD plus
Metronidazole (as above).
In paediatric patients consider Cefuroxime and Metronidazole
if patient has had Amoxycillin or Co-amoxiclav orally
Acute Otitis media
Consider 2 or 3 d
delayed antibiotics.
Amoxicillin 500mg PO TDS
For 5 days
Clarithromycin 250-500mg PO BD. For 5 days
Malignant Otitis
externa
Piperacillin/ tazobactam 4.5g IV TDS
D/W Microbiology
Acute Rhinosinusitis
Amoxicillin 500mg PO TDS
(double dose if severe)
For 7 days
Doxycycline 100mg PO BD.
If persistent infection: use agent to cover anaerobes Co-amoxiclav 625mg PO TDS OR
add Metronidazole 400mg PO TDS to Doxycycline
for 7 days
Chronic
Rhinosinusitis
Clarithromycin 500mg oral BD for 2 weeks
followed by Clarithromycin 250mg oral BD
for up to 8weeks
Consider Azithromycin or Doxycycline in patients
not tolerating / allergic to Clarithromycin.
Antibiotics for Surgical prophylaxis
Review microbiology results
Recommended as per EPOS-2012
(European Position Paper on Rhinosinusitis)
Oral Equivalent (see Trust guideline on IV to oral switching)
Procedure
Antibiotic
Alternative
Mastoid Surgery/
Ossiculoplasty
Septorhinoplasty/ Septal
reconstruction
Co-amoxiclav 1.2g IV (single
dose)
Co-amoxiclav 1.2g IV (single
dose)
*Cefuroxime 1.5g (single dose) plus
Metronidazole 500mg IV (single dose)
*Cefuroxime 1.5g (single dose) plus
Metronidazole 500mg IV (single dose)
Benzylpenicillin
Penicillin V 500mg
Cefuroxime plus
Metronidazole
Neck dissection
Co-amoxiclav 1.2g-3doses
IV (three doses)
*Cefuroxime 1.5g plus
Metronidazole 500mg IV (3 doses)
Cefotaxime
Co-amoxiclav 625mg, if no penicillin allergy
Cefalexin 500mg plus Metronidazole 400mg if penicillin
allergic (not type 1 hypersensitivity)
No oral equivalent
*Do not use cefuroxime if
there is a history of type1
anaphylaxis. In such cases
use:
Teicoplanin 400mg (single dose) plus
Gentamicin 160mg (single dose) plus
Mertronidazole 500mg IV (single
dose)
Ceftriaxone
IV antibiotic
Piperacillin/ tazobactam
Oral switch agent
No oral equivalent
No oral equivalent. Consider oral Ciprofloxacin for
pseudomonas if sensitive.
Malignant otitis externa –D/W Microbiology