Respiratory, Head, and Neck Infections

Rifampin*  
17.5 mg/kg (max 600 mg/dose) enterally daily 

Drug-drug interactions should be evaluated prior to starting therapy (use Lexi-Comp drug-drug interaction checker) 

Isoniazid and Rifapentine* weekly for 12 weeks is the shortest treatment option for children 2 years and older who meet criteria; refer to linked guidelines below and consider ID consultation or discussion with local public health department   

Patient with contraindication to Rifampin (e.g. drug-drug interaction): 

Isoniazid
12.5 mg/kg (max 300 mg/dose) enterally  daily 

AND 

Pyridoxine supplementation if exclusively breastfeeding or other risk factors for peripheral neuropathy (refer to linked guidelines below)  

A short course regimen is now preferred for all eligible patients due to higher likelihood of treatment completion and lower risk for adverse effects 

Duration: 

Rifampin: 4 months 

Isoniazid: 9 months 

Refer to linked guidelines below for detailed recommendations including LTBI diagnosis and monitoring during therapy 

Initiation of LTBI therapy is not recommended during pregnancy unless at high risk for progression - discuss with ID or local public health department as needed  

Acute bacterial sinusitis 

Diagnosed based on acute upper respiratory illness with: 

Persistent rhinorrhea or daytime cough lasting >=10 days and not improving  

OR 

Substantially worsening course after initial improvement 

OR 

Severe symptoms at onset:  

T >= 39C 

AND  

Purulent nasal discharge for at least 3 consecutive days 

Streptococcus pneumoniae 

Haemophilus influenzae 

Moraxella catarrhalis 

Recommend initial observation without antibiotic therapy if diagnosis is made only based on persistence of rhinorrhea or cough - many patients improve without antibiotic therapy 

Non-severe symptoms: 

Amoxicillin  
45 mg/kg/dose (max 1000 mg/dose)* enterally bid  

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Severe symptoms (see 1st  column): 

Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/dose (max 2000 mg amoxicillin/dose)*  enterally bid  

Penicillin allergy with lower risk for allergic reaction: 

Oral cephalosporin (follow link for options) 

--------------------- 

Penicillin allergy with higher risk for allergic reaction: 

Consult ID/ASP  

Azithromycin is not recommended for this indication. 

Duration: Typical treatment duration is 10 days 

*See guidance on maximum dosing of Amoxicillin and Amoxicillin-Clavulanate 

Refer to Intracranial Abscess section if intracranial complication or Orbital Cellulitis section if orbital extension 

Amoxicillin  
50 mg/kg/dose (max 1000 mg/dose) enterally daily  

------------------------ 

Anticipated difficulty tolerating or adhering to enteral therapy: 

Weight < 27 kg: Benzathine Penicillin G 600,000 units IM x 1 dose 

Weight > 27 kg: Benzathine Penicillin G 1.2 million units IM x 1 dose 

Penicillin allergy with lower risk for allergic reaction: 

Cephalexin  
25 mg/kg/dose (max 500 mg/dose) enterally bid  

------------------------- 

Penicillin allergy with higher risk for allergic reaction: 

Clindamycin  
7 mg/kg/dose (max 300 mg/dose) enterally tid 

Azithromycin is not recommended for this indication.  

Streptococcus pneumoniae 

Haemophilus influenzae 

Moraxella catarrhalis 

----------------------- 

Severe symptoms: moderate or severe otalgia or otalgia > 48 hours, or temperature 39C or higher 

Non-severe symptoms: mild otalgia < 48 hours, temperature <39C 

Recommend initial observation without antibiotic therapy for 48-72 hours in immunocompetent patients with the following criteria: 

6 months-2 years old: unilateral, no otorrhea, non-severe symptoms (see second column) 

OR 

>=2 years old: no otorrhea, non-severe symptoms (see second column) 

Ensure that reassessment and initiation of antibiotic will be feasible if symptoms do not improve during observation 

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For patients not meeting above criteria: 

Amoxicillin  
45 mg/kg/dose (max 1000 mg/dose)* enterally bid  

If patient meets criteria for treatment (same as 3rd column), and has received Amoxicillin within preceding 30 days, has purulent conjunctivitis, history of recurrent AOM not responsive to Amoxicillin, or does not respond to initial therapy with Amoxicillin x 48-72 hours: 

Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/dose (max 1000 mg amoxicillin/dose)* enterally bid   

Penicillin allergy with lower risk for allergic reaction: 

Oral cephalosporin (follow link for options) 

Penicillin allergy with higher risk for allergic reaction:  

Consult AAP/AAFP guidelines (linked below) or ASP. Azithromycin is not recommended for this indication. 

------------------------- 

Failed oral therapy:  

Consult AAP/AAFP guidelines (linked below) 

Duration for beta lactam therapy: 

< 2 years old or any age with severe symptoms: 10 days 

2-5 years old: 7 days 

> 5 years old: 5 days 

Pain control recommended for all patients 

*See guidance on Amoxicillin and Amoxicillin-clavulanate maximum dosing and formulation

Age < 6 months: 

Azithromycin 
10 mg/kg/dose enterally or IV daily x 5 days 

------------------------ 

Age >= 6 months: 

Azithromycin  
10 mg/kg/dose (max 500 mg/dose) once enterally or IV on day 1 , then 5 mg/kg/dose (max 250 mg/dose) enterally or IV daily on days 2-5  

Provided regimens can also be used for post-exposure prophylaxis 

Refer to CDC guidelines on post-exposure prophylaxis 

Enteral therapy is preferred once it can be tolerated 

Periorbital/preseptal cellulitis, suspected to be caused by skin flora (most common) 

Group A streptococcus 

Staphylococcus aureus 

Cephalexin
25 mg/kg/dose (max 500 mg/dose) enterally tid  

OR 

Cefazolin
25 mg/kg/dose (max 1000 mg/dose) IV q8h  

Choice of IV vs. enteral depending on illness severity; switch to enteral upon clinical improvement 

Penicillin or cephalosporin allergy with higher risk for allergic reaction:  

Clindamycin
10 mg/kg/dose (max 900 mg/dose) IV q8h  

OR  

Clindamycin
10 mg/kg/dose (max 600 mg/dose) enterally tid 

If patient is ill enough for inpatient care, consider evaluation for Orbital Cellulitis/Abscess, consider Ophthalmology consult 

Duration: 5-7 days or until resolution of inflammation 

Periorbital/preseptal cellulitis, suspected to be caused by sinus flora (patient has associated symptoms of sinusitis)  

Include coverage for:  

Streptococci 

Anaerobes 

Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/ dose (max 1000mg amoxicillin/dose)*  enterally bid 

OR 

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

Choice of IV vs. enteral depending on illness severity; switch to enteral upon clinical improvement 

Penicillin or cephalosporin allergy with higher risk for allergic reaction: 

Clindamycin
10 mg/kg/dose (max 900 mg/dose) IV q8h  

OR  

Clindamycin
10 mg/kg/dose (max 600 mg/dose) enterally tid 

If patient is ill enough for inpatient care, consider evaluation for Orbital Cellulitis/Abscess, consider Ophthalmology consult 

*See guidance on Amoxicillin-Clavulanate maximum dosing and formulations 

Duration: 5-7 days or until resolution of inflammation. Duration may need to be extended to treat associated sinusitis. See Sinusitis section.  

Streptococci 

Staphylococcus aureus 

Haemophilus influenzae 

Anaerobes 

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

If there is a large abscess (>10mm), anticipated to undergo surgical drainage, toxic appearance, rapidly progressive proptosis or ophthalmoplegia, or patient with history of documented MRSA infection or carriage within the last 6 months: 

ADD Vancomycin  

(follow link for dosing and monitoring)  

Penicillin or cephalosporin allergy with higher risk for allergic reaction:  

Consult ID/ASP 

Urgent OHNS and Ophthalmology consults recommended to evaluate need for source control   

ID consult recommended (see details above) 

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

Therapy may be tailored based on cultures from I&D. If Vancomycin was started but MRSA not recovered, Vancomycin should be discontinued.  

Duration: Uncomplicated orbital cellulitis/abscess is typically treated first with IV therapy then converted to enteral therapy within days based on clinical improvement, with a total duration of 14-21 days (combined IV and enteral).  

A longer duration may be indicated if there is significant bone destruction or a large abscess that is not drained. 

Conjunctivitis 

This section does not address infectious keratitis associated with contact lens wear (patients with this condition should be managed in consultation with an optometrist or ophthalmologist) 

Often viral 

Streptococcus pneumoniae 

Haemophilus influenzae 

Moraxella catarrhalis 

Staphylococcus aureus 

Supportive care without topical antibiotic therapy is recommended unless bacterial etiology is suspected based on clinical features 

If suspected bacterial etiology: 

Trimethoprim-Polymyxin B (Polytrim) 0.1%-10,000 units/ml ophthalmic drops 1-2 drops 4 times daily  

Commonly caused by viruses, consider supportive treatment such as warm compresses or cold saline drops 

Duration: 5-7 days 

Mastoiditis - acute, immunocompetent patient          

(<1 month duration) 

OR 

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  

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 

Lymphadenitis - acute, suppurative bacterial, usually unilateral 

Usual presentation, without suspected dental source (e.g. periodontal disease, poor dental hygiene) 

Staphylococcus aureus 

Group A streptococcus 

Cephalexin 25 mg/kg/dose (max 500 mg/dose) enterally tid  

OR 

Cefazolin 25 mg/kg/dose (max 1000 mg/dose) IV q8h  

Choice of IV vs. enteral depending on illness severity; switch to enteral route upon clinical improvement 

Penicillin or cephalosporin allergy with higher risk for allergic reaction OR history of documented MRSA infection or carriage within the last 6 months 

Please confirm clindamycin susceptibility if prior cultures are available, tailor antibiotics to past susceptibility:

Clindamycin
10 mg/kg/dose (max 600 mg/dose) enterally tid 

OR  

Clindamycin
10 mg/kg/dose (max 900 mg/dose) IV q8h 

Consider OHNS consult to evaluate need for source control 

If lack of response to empiric therapy, consider need for drainage, or alternative etiology besides typical bacteria - consider ID consult (also see details above) 

Duration: 10 days (or 5-7 days after abscess drainage if applicable) 

Lymphadenitis - acute, suppurative bacterial, usually unilateral 

With suspected dental source (e.g. concurrent periodontal disease) 

Amoxicillin-clavulanate (Augmentin) 22.5 mg amoxicillin/kg/ dose (max 875 mg amoxicillin/dose) enterally bid  

OR 

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

Choice of IV vs. enteral depending on illness severity, switch to enteral route upon clinical improvement

Penicillin or cephalosporin allergy with higher risk for allergic reaction OR history of documented MRSA infection or carriage within the last 6 months 

Please confirm clindamycin susceptibility if prior cultures are available, tailor antibiotics to past susceptibility: 

Clindamycin
10 mg/kg/dose (max 600 mg/dose) enterally tid 

OR 

Clindamycin
10 mg/kg/dose (max 900 mg/dose) IV q8h  

Consider OHNS consult to evaluate need for source control 

If lack of response to empiric therapy, consider need for drainage, or alternative etiology besides typical bacteria - consider ID consult (also see details above) 

Duration: 10 days (or 5-7 days after abscess drainage if applicable)