HEENT

Common Culprits: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

First and Second line treatment

1. Trimethoprim-polymyxin B 0.1%-10,000 units/mL ophthalmic drops 1 to 2 drops 4 times daily for 5 to 7 days 

   • Preferred in noncontact lens wearers

2. Ofloxacin 0.3% 1 to 2 drops 4 times daily for 5 to 7 days 

   • Preferred agent in contact lens wearers

3. Erythromycin 1 cm ribbon into affected eye(s) 4 times daily for 7 days 

   • Infants

Special Considerations:

Neonatal C. trachomatis infections: Oral azithromycin 20 mg/kg per day given orally once daily for three days

Neonatal N. gonorrhoeae conjunctivitis: single dose of ceftriaxone 25 to 50 mg/kg (maximum dose 250 mg) given IV or IM. If being treated for hyperbilirubinemia use Ceftazidime – Given as a single dose (50 mg/kg) IV or IM

Common Culprits: Staphylococcus aureus and streptococci, h. influenzae, anaerobes

First and Second line treatment:

• Orbital Cellulitis initial IV treatment (inpatient condition)

  1. Vancomycin 40 to 60 mg/kg IV per day in three or four divided doses PLUS Ceftriaxone 50 mg/kg per dose IV once or twice per day, maximum dose 4g/day 

  2. Vancomycin (40 to 60 mg/kg IV per day in three or four divided doses PLUS levofloxacin 16 to 20 mg/kg IV per day divided every 12 hours (maximum daily dose 750 mg) for infants ≥6 months and children <5 years, and at a dose of 10 mg/kg IV per dose every 24 hours (maximum daily dose 750 mg) for children ≥5 years

     • PCN allergy

• Preseptal Cellulitis 

  1. Amoxicillin-clavulanic acid 45 mg/kg per day divided every 12 hours for 5-7 days

  2. Cefuroxime 30 mg/kg/day in divided doses every 12 hours; maximum dose: 500 mg/dose for 5-7 days 

  3. Levofloxaccin 10 to 20 mg/kg per day orally divided every 12 to 24 hours (maximum daily dose 500 mg) for 10-14 days 

     • Serious PCN allergy

Special Considerations:

Until the possibility of intracranial involvement has been assessed and excluded, metronidazole is also used 30 mg/kg IV or orally per day in divided doses every eight hours

Common Culprits: H. influenzae, S. pneumoniae , M. catarrhalis

First and Second line treatment:

1. Amoxicillin 80-90 mg/kg/day [high dose] for 10 days 

   • For patients≥2 years of age with mild to moderate, nonrecurrent disease without tympanic membrane perforation, shorter durations of 5 to 7 days may be sufficient

2. Amoxicillin-Clavulanate 90 mg/kg/day BID for 5-10 days (use if recently treated AOM w/ Amoxicillin)

Drug Alternatives:

Cefdinir 14 mg/kg/day BID or daily for 5-10 days if PCN allergy

Common Culprits: S. aureus, Pseudomonas aeruginosa

First and Second line treatment:

1. Ciprofloxacin and Dexamethasone Otic Ear Drops 4 drops in affected ear(s) BID x 7 days

2. Neomycin, polymyxin B, and hydrocortisone (otic) 3 drops 3-4 times daily

Common Culprits: Streptococcus pyogenes, Staphylococcus aureus, and respiratory anaerobes (including Fusobacteria, Prevotella, and Veillonella species), occasionally Haemophilus species 

First and Second line treatment:

1. Parenteral:

   1. Ampicillin-sulbactam intravenously (IV) (50 mg/kg per dose [maximum single dose 3 g] every six hours in children; 3 g every six hours in adults)

   2. Clindamycin IV (13 mg/kg per dose [maximum single dose 900 mg] every eight hours in children; 600 mg every six to eight hours in adults)

• Patients who present with moderate or severe disease (eg, toxic appearance, temperature >39°C, drooling, and/or respiratory distress) or who do not respond to initial treatment with ampicillin-sulbactam or clindamycin add one of the following to the chosen empiric regimen above:

1. 2. 1. IV vancomycin (in children and adolescents, 15 mg/kg per dose every six hours, maximum single dose 2 g; in adults, 15 to 20 mg/kg per dose every 8 to 12 hours); adjust dose based upon therapeutic monitoring if using for longer than two to three days

      2. IV linezolid (in children and adolescents, 10 mg/kg per dose every eight hours, maximum single dose 600 mg; in adults, 600 mg every 12 hours)

2. Oral:

   1. Amoxicillin-clavulanate: children – 45 mg/kg per dose (maximum single dose 875 mg) every 12 hours, adults – 875 mg every 12 hours for 14 days

   2. Clindamycin (for patients who have responded to parenteral clindamycin): children – 10 mg/kg per dose (maximum single dose 600 mg) every eight hours, adults – 300 to 450 mg every six hours for 14 days

Common Culprits: S. aureus, M. catarrhalis, S. pneumoniae, H. influenzae

First and Second line treatment:

1. Amoxicillin-clavulanate 45 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 1.75 g) for 10 days

2. levofloxacin 10 to 20 mg/kg/day divided every 12 to 24 hours for 10 to 14 days; maximum daily dose: 500 mg/day (PCN allergy option)

Special Consideractions:

In children with increased risk for drug resistance or severe sinusitis, use Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component orally in two divided doses (maximum daily dose 4 g) for 10 days

Common Culprits: Group A Strep, M. pneumoniae, C. diphtheriae, N. gonorrhea/meningitidis

Treatment:

1. Amoxicillin 50 mg/kg/day once daily or in divided doses every 12 hours for 10 days; maximum daily dose: 1,000 mg/day

2. Cephalexin 40 mg/kg/day divided every 12 hours for 10 days; maximum dose: 500 mg/dose 

   • Nonanyphalactic PCN allergy

3. Cefdinir 7 mg/kg/dose orally every 12 hours for 5 to 10 days or 14 mg/kg/dose every 24 hours for 10 days (maximum 600 mg/day) 

   • mild PCN allergy

4. Azithromycin 12 mg/kg/day (maximum 500 mg/dose) for 5 days 

   • SEVERE PCN ALLERGY