Patient Population: Pediatric

Need for drainage/source control of head and neck infections should be evaluated carefully in consultation with Pediatric Otolaryngology, Head and Neck Surgery. If initial non-operative management is chosen, a narrow spectrum regimen (i.e. without vancomycin) is encouraged to facilitate transition to oral therapy. 

ID consultation is recommended for head and neck infections occurring in immunocompromised patients, and for those with atypical features, chronic course, or lack of response to first line therapy.  

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments

Mastoiditis - acute, immunocompetent patient          

(<1 month duration) 


Subacute (duration >= 1 month) but with the following distinctions from chronic mastoiditis:  
Develops as a complication of acute otitis media 

Patient does not have history of a chronically non-intact tympanic membrane 

Patient does not have history of chronic suppurative otitis media 

Streptococcus pneumoniae 

Group A streptococcus 

Staphylococcus aureus 

Ampicillin-sulbactam (Unasyn) 50 mg ampicillin/kg/dose (max 2000 mg ampicillin/dose) IV q6h  

If patient has history of documented MRSA infection or carriage within the last 6 months:

ADD Vancomycin  

(follow link for dosing & monitoring)  

Penicillin or cephalosporin allergy with higher risk for allergic reaction:  

Consult ID/ASP 

Urgent OHNS consult recommended to evaluate need for source control 

Consider ID consult (see details above) 

For confirmed or suspected intracranial extension, refer to Intracranial Abscess section for empiric therapy 

Therapy may be tailored based on cultures from I&D 

If Vancomycin was started and MRSA not recovered from drained abscess, discontinue Vancomycin 

Duration: Uncomplicated acute mastoiditis is typically treated first with IV therapy then converted to enteral therapy within days based on clinical improvement, with a total duration of 3-4 weeks (combined IV and enteral).  

A longer duration and more IV therapy is indicated for intracranial or other complications.  

Mastoiditis - chronic    

(months-years duration, arising as a complication of chronic suppurative otitis media, with chronically non-intact tympanic membrane) 

Variable depending on risk factors  


Individualized treatment guided in consultation with OHNS    

OHNS consult recommended (management is primarily surgical)  

ID consult recommended if patient is presenting with new severe local symptoms and/or signs in the context of history of chronic mastoiditis, or if not responsive to usual management 


American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.