Antibiotic Guidelines

Chapter 9: Ear, Nose and Throat Infections

Antibiotic Guidelines

Chapter 9: Ear, Nose and Throat Infections

Acute Otitis Media (AOM)

Bacterial Pathogens

Common: Streptococcus pneumoniae, H. influenzae, Moraxella catarrhalis
Occasional: S. pyogenes, S. aureus
Special populations: Gram-negative bacilli, MRSA

First-Line Treatment`‍`

Drug	Dose (Children)	Dose (Adults)	Notes
Amoxicillin	90 mg/kg/day PO in 2–3 doses × 5–7 days	1 g PO 8-hourly	10-day course if <2 yrs or severe
Amox-clavulanate (14:1)	90 mg/kg/day amoxicillin component PO × 5–7 days	2 g SR PO 12-hourly	Use if recent amoxicillin or conjunctivitis
Cefuroxime	30 mg/kg/day PO in 2 doses	–	Penicillin allergy
Ceftriaxone	50 mg IM/IV daily × 3 days	–	Penicillin allergy

Otitis Media with Tympanostomy Tubes

Pathogens: P. aeruginosa, S. aureus, + usual pathogens
Topical ciprofloxacin drops preferred over oral therapy.

Otitis Externa

Pathogens: P. aeruginosa, Proteus, S. aureus, S. pyogenes

Treatment

Clean canal with acetic acid, suction, or dry swab.
Topical: Sofradex®, Ciprofloxacin + steroid drops
Systemic antibiotics only for cellulitis or invasive infection
Otomycosis: topical clotrimazole

Malignant Otitis Externa

Elderly diabetics/immunocompromised
Treatment:
- Piperacillin-tazobactam or ceftazidime or imipenem + aminoglycoside or quinolone
- Surgical debridement
- Urgent ENT referral

Mastoiditis

Same pathogens as AOM
If chronic: cover S. aureus, Gram-negatives
Cultures must be taken carefully
May require mastoidectomy
ENT referral recommended

Acute Viral Rhinitis (Common Cold)

Cause: rhinovirus, coronavirus, RSV, influenza, metapneumovirus
Symptoms: nasal congestion, rhinorrhoea, sore throat
Management:
- Supportive only: paracetamol, fluids
- Avoid antibiotics
- No evidence for vitamins, antihistamines, antivirals

Acute Bacterial Rhinosinusitis (ABRS)

Pathogens: H. influenzae, S. pneumoniae, M. catarrhalis, S. aureus
Diagnosis: clinical; sinus aspirate gold standard (rarely done)

First-Line Treatment`‍`

Drug	Dose (Adults)	Dose (Children)
Amoxicillin	1 g PO 8-hourly × 5–7 days	80–90 mg/kg/day in 2 doses × 10 days

Alternatives`‍`

Alternative	Adult Dose	Child Dose
Amox-clav (SR)	2 g PO 12-hourly × 5–7 days	90 mg/kg/day amoxicillin component × 10 days
Cefuroxime	1000 mg PO 12-hourly	30 mg/kg/day in 2 doses (max 250 mg/dose)
Cefpodoxime	400 mg PO 12-hourly	16 mg/kg/day in 2 doses

Failure After First-Line`‍`

Second-Line Agent	Dose
Moxifloxacin	400 mg PO daily × 5–7 days
Levofloxacin	500 mg 12-hourly or 750 mg daily × 5–7 days
Telithromycin	800 mg PO daily × 5–7 days

Chronic Rhinosinusitis (CRS)

Pathogens: S. aureus, Enterobacteriaceae, Pseudomonas
Avoid nasal swabs – use endoscopic middle meatus culture if needed
Empiric treatment:
- Amox-clavulanate or respiratory fluoroquinolone
- Duration often longer than ABRS

Pharyngitis / Tonsillitis

Group A Streptococcus (GAS) is most common treatable cause

Treatment Options`‍`

Antibiotic	Adult Dose	Child Dose
Penicillin VK	500 mg PO 12-hourly × 10 days	250–500 mg PO 12-hourly × 10 days
Benzathine Penicillin	1.2 MU IM once	600 000 U IM if <27 kg
Amoxicillin	500–1000 mg PO 12-hourly × 10 days	50 mg/kg/day once or divided × 10 days
Azithromycin	500 mg PO daily × 5 days	10–20 mg/kg/day PO daily × 5 days
Clarithromycin	250 mg PO 12-hourly × 10 days	15 mg/kg/day in 2 doses × 10 days

Oral Thrush (Candidiasis)

Severity	Treatment	Duration
Mild	Nystatin suspension or pastilles	7–14 days
Moderate–Severe	Fluconazole 100–200 mg PO	7–14 days
Oesophageal	Fluconazole 200–400 mg PO	14–21 days

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