From the Guidelines
Zosyn (piperacillin-tazobactam) is an appropriate antibiotic choice for Ludwig's angina, particularly in hospitalized patients requiring intravenous therapy, due to its broad-spectrum activity against gram-positive, gram-negative, and anaerobic bacteria. The typical dosing is 3.375g (3g piperacillin/0.375g tazobactam) IV every 6 hours or 4.5g (4g piperacillin/0.5g tazobactam) IV every 8 hours for adults with normal renal function, with dose adjustments needed for patients with impaired kidney function, as recommended by the Infectious Diseases Society of America 1. Ludwig's angina is a rapidly progressive cellulitis involving the submandibular, sublingual, and submental spaces, typically caused by polymicrobial infections including oral anaerobes and streptococci.
Key Considerations
- Airway management is critical as the condition can cause life-threatening airway obstruction.
- Surgical drainage is often necessary alongside antibiotic therapy.
- For optimal management, patients should be hospitalized for close monitoring, and consultation with otolaryngology and possibly infectious disease specialists is recommended.
- Alternative antibiotic regimens might include clindamycin plus a third-generation cephalosporin, or ampicillin-sulbactam, depending on local resistance patterns and patient factors.
Treatment Approach
The treatment of Ludwig's angina requires a comprehensive approach beyond antibiotics alone. According to the guidelines, piperacillin-tazobactam plus vancomycin is recommended for mixed infections, which is consistent with the polymicrobial nature of Ludwig's angina 1. However, the choice of antibiotic should be guided by local resistance patterns and patient factors.
Evidence Summary
The evidence from the Infectious Diseases Society of America guidelines supports the use of piperacillin-tazobactam as a first-line antimicrobial agent for mixed infections, including those that cause Ludwig's angina 1. While older guidelines also support this approach 1, the most recent and highest quality evidence should be prioritized in clinical decision-making.
From the FDA Drug Label
Skin and Skin Structure Infections caused by E. coli, Klebsiella spp., Serratia spp., Acinetobacter spp., Enterobacter spp., P. aeruginosa, Morganella morganii, Providencia rettgeri, Proteus vulgaris, P. mirabilis, Bacteroides spp., including B. fragilis, anaerobic cocci, or enterococci.
Zosyn (piperacillin-tazobactam) may be used for the treatment of skin and skin structure infections, but Ludwig's angina is a specific type of skin and skin structure infection.
- The drug label does mention that piperacillin-tazobactam is effective against various bacteria that can cause skin and skin structure infections.
- However, it does not specifically mention Ludwig's angina. Therefore, it can be used for the treatment of Ludwig's angina if the causative microorganism is susceptible to piperacillin-tazobactam 2 2.
From the Research
Treatment of Ludwig's Angina with Zosyn (Piperacillin-Tazobactam)
- Zosyn (piperacillin-tazobactam) is a broad-spectrum antibiotic that can be effective against a variety of bacterial infections, including those caused by Gram-positive and Gram-negative aerobic and anaerobic bacteria 3, 4.
- However, in the case of Ludwig's angina, the use of Zosyn may be limited by the potential for hypersensitivity reactions, as seen in a case report where a patient had to be treated with alternative antibiotics due to a hypersensitivity reaction to piperacillin/tazobactam 5.
- The most common cause of Ludwig's angina is dental, and the organism most often cultured is streptococcus, which may be susceptible to penicillin and other antibiotics 6.
- Piperacillin-tazobactam has been shown to be effective in the treatment of various infections, including intra-abdominal, skin and soft tissue, and lower respiratory tract infections, but its use in Ludwig's angina specifically is not well-documented 3, 7, 4.
- In general, the treatment of Ludwig's angina requires aggressive management, including securing the airway, administering antibiotics, and early surgical intervention, with penicillin remaining a preferred primary antibiotic 6.
Key Considerations
- The potential for hypersensitivity reactions to piperacillin/tazobactam should be considered when treating Ludwig's angina 5.
- Alternative antibiotics, such as clindamycin and metronidazole, may be effective in treating Ludwig's angina, especially in cases where hypersensitivity reactions to other antibiotics are a concern 5.
- The use of Zosyn (piperacillin-tazobactam) in Ludwig's angina should be approached with caution and careful consideration of the potential risks and benefits 5, 3, 4.