What is the treatment for Ludwig's angina (a severe infection of the submandibular space)?

From the Guidelines

Ludwig angina requires immediate treatment with antibiotics, airway management, and surgical drainage if necessary, with initial antibiotic therapy including broad-spectrum coverage such as ampicillin-sulbactam or piperacillin-tazobactam, as recommended by the most recent guidelines 1. The treatment of Ludwig angina should prioritize broad-spectrum antibiotic coverage, given the polymicrobial nature of the infection, which often includes both aerobic and anaerobic organisms.

Key Considerations

• Initial antibiotic therapy should include options such as ampicillin-sulbactam (3g IV every 6 hours) or piperacillin-tazobactam (3.37g IV every 6-8 hours), as these provide broad-spectrum coverage against the likely pathogens, including those that may be resistant to other antibiotics 1.
• For patients allergic to penicillin, alternative options such as clindamycin (600-900mg IV every 8 hours) plus a third-generation cephalosporin can be considered, although the choice should be guided by local resistance patterns and the specific clinical scenario 1.
• Airway assessment is critical, with early consideration for securing the airway via intubation or tracheostomy if there are signs of compromise, as airway obstruction is a significant risk in Ludwig angina.
• Surgical drainage is indicated for fluctuant collections, worsening symptoms despite antibiotics, or airway compromise, highlighting the need for a multidisciplinary approach to management.
• Supportive care includes IV fluids, pain management, and close monitoring, with treatment typically continuing for 7-14 days, and transition to oral antibiotics once clinical improvement occurs.

Antibiotic Selection

• The selection of antibiotics should be based on the most recent guidelines and local resistance patterns, with ampicillin-sulbactam and piperacillin-tazobactam being preferred options due to their broad-spectrum activity 1.
• The use of fluoroquinolones, such as ciprofloxacin or levofloxacin, may be considered in certain cases, although their effectiveness against anaerobic organisms may be limited 1.
• Clindamycin, with its good activity against staphylococci, streptococci, and anaerobes, is an alternative for patients with penicillin allergy, but its use should be guided by susceptibility patterns and clinical judgment 1.

From the Research

Treatment Overview

The treatment of Ludwig's angina is focused on early recognition, airway management, and infection control.

• Effective treatment is based on early recognition of the clinical process, with the appropriate use of parenteral antibiotics, securing the airway, and formal surgical drainage of the infection 2.
• The first line approach for airway intervention is flexible intubating endoscopy with preparation for a surgical airway 3.

Airway Management

Airway management is critical in the treatment of Ludwig's angina due to the risk of impending airway obstruction.

• Awake fiberoptic intubation under topical anesthesia may be the preferred method to secure the airway 2, 4.
• Flexible nasotracheal intubation requires skill and experience 2.
• When fiberoptic bronchoscopy is not feasible, not available, or has failed, an elective awake cricothyrotomy and tracheostomy are the options 2, 4.
• Video-assisted laryngoscopy may allow the clinician additional flexibility in nonsurgical airway management 2.

Infection Control

Infection control is achieved through the use of broad-spectrum antibiotics and surgical source control.

• Broad spectrum antibiotics and surgical source control are keys in treating the infection 3.
• Penicillin, clindamycin, or chloramphenicol were started initially in all cases, with judicious surgical intervention indicated in those patients who develop localized abscesses while on antibiotics or are unresponsive to medical management 5.

Conservative Measures

Conservative measures, such as close airway observation, may be effective in some cases.

• Management of Ludwig's angina has evolved from aggressive airway management into a more conservative one, based on close airway observation on a specialised airway unit and a serial clinical airway assessment 6.
• Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice 6.