Treatment for Parotitis
The first-line treatment for acute bacterial parotitis is amoxicillin-clavulanate, which targets the most common pathogens including Staphylococcus aureus and anaerobic bacteria. For patients with penicillin allergies, clindamycin is an appropriate alternative.
Etiology and Microbiology
Parotitis can be classified as:
- Acute bacterial suppurative parotitis
- Viral parotitis (e.g., mumps)
- Chronic recurrent parotitis
The most common pathogens in acute bacterial parotitis include:
- Staphylococcus aureus (predominant)
- Anaerobic bacteria (Peptostreptococcus, Bacteroides, Prevotella, Porphyromonas)
- Streptococcus species
- Gram-negative organisms (particularly in hospitalized patients) 1
Treatment Algorithm
1. Acute Bacterial Parotitis
First-line antimicrobial therapy:
- Amoxicillin-clavulanate (high-dose formulation)
- Adults: 875 mg/125 mg twice daily or 2000 mg/125 mg twice daily
- Children: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate in two divided doses 2
For penicillin-allergic patients:
- Clindamycin (30-40 mg/kg/day in 3 divided doses for children; 300-450 mg four times daily for adults) 2
- Respiratory fluoroquinolones (adults only) such as levofloxacin or moxifloxacin 2
Duration of therapy:
- 10-14 days of oral antibiotics for uncomplicated cases
- May require longer treatment for complicated cases
2. Supportive Measures (for all types of parotitis)
- Hydration: Adequate fluid intake is essential to promote salivary flow 2, 1
- Warm compresses: Apply to affected area to relieve pain and promote drainage
- Parotid gland massage: Gentle massage toward the duct orifice
- Sialagogues: Use of agents that stimulate salivary flow (e.g., lemon drops, sugar-free candies)
- Oral hygiene: Maintain good oral hygiene to prevent ascending infection 1
3. Surgical Management
Indicated when:
- Abscess formation is present
- Failure to respond to appropriate antimicrobial therapy
- Recurrent episodes of chronic parotitis unresponsive to medical management 3
Procedures include:
- Incision and drainage of abscess
- Sialendoscopy with ductal irrigation and steroid instillation for chronic cases 4
- Parotidectomy as a last resort for severe chronic recurrent parotitis 3
Special Considerations
Viral Parotitis
- Primarily supportive care (hydration, analgesics)
- No specific antiviral therapy is typically required
- Antibiotics are not indicated unless secondary bacterial infection occurs
Chronic Recurrent Parotitis
- Conservative management with sialagogues and gland massage
- Antibiotics during acute exacerbations
- Sialendoscopy with ductal irrigation and steroid instillation for refractory cases 4
Hospital-Acquired Parotitis
- Consider broader spectrum antibiotics to cover gram-negative organisms
- Empiric therapy should include coverage for Pseudomonas in appropriate clinical settings 1
Pitfalls and Caveats
- Dehydration: Failure to address underlying dehydration can lead to treatment failure
- Beta-lactamase producers: Nearly 75% of isolates may produce beta-lactamase, necessitating coverage with beta-lactamase inhibitors 5
- Inadequate drainage: Failure to surgically drain a parotid abscess can lead to prolonged infection and complications
- Misdiagnosis: Confusing viral parotitis with bacterial parotitis can lead to unnecessary antibiotic use
- Ductal obstruction: Underlying sialolithiasis (stones) should be ruled out as they may require specific intervention
Penicillin alone has been shown to achieve higher concentrations in purulent saliva compared to healthy saliva, but amoxicillin-clavulanate is preferred due to the prevalence of beta-lactamase producing organisms 6.