What antibiotics are recommended for the treatment of epiglottitis?

Antibiotic Treatment for Epiglottitis

Ceftriaxone is the first-line antibiotic treatment for epiglottitis, administered as a single daily dose of 50 mg/kg (maximum 1-2 g) for 5-7 days, due to its excellent clinical outcomes and high efficacy against Haemophilus influenzae type b (Hib), the most common causative organism. 1

First-Line Treatment Options

Adults:

• Ceftriaxone: 1-2 g IV once daily for 5-7 days
• Cefotaxime: 2 g IV every 4-6 hours as an alternative third-generation cephalosporin

Children:

• Ceftriaxone: 50 mg/kg IV once daily (maximum 1-2 g) for 5-7 days
• Cefotaxime: 150 mg/kg/day divided every 8 hours as an alternative

Alternative Regimens for Penicillin Allergies

Non-severe Penicillin Allergy:

• Ceftazidime: 150 mg/kg/day divided every 8 hours 1

Severe Penicillin Allergy (Type I immediate hypersensitivity):

• Adults: Levofloxacin 750 mg IV once daily 1
• Children and Adults: Clindamycin 30-40 mg/kg/day divided every 8 hours (maximum 300 mg per dose) plus an aminoglycoside for gram-negative coverage 1

Special Considerations

For Suspected Resistant Organisms:

• Consider combination therapy with high-dose amoxicillin/clavulanate plus either cefixime or rifampin 1
• For MRSA coverage, add vancomycin 15 mg/kg IV every 12 hours 1

Important Caveats:

1. Rifampin should never be used as monotherapy due to rapid development of resistance 1
2. Fluoroquinolones are generally contraindicated in children but may be necessary in cases of severe allergy or resistant organisms 1
3. While a shorter course (2 days) of ceftriaxone has shown efficacy in some studies 2, the standard recommendation remains 5-7 days of therapy, with longer courses (10-14 days) for complicated cases 1

Microbiology Considerations

The microbiology of epiglottitis has evolved since the introduction of Hib vaccination:

• Historically, Haemophilus influenzae type b was the predominant pathogen
• In the post-vaccination era, there is greater diversity in causative organisms 3
• Blood cultures are frequently negative, making empiric coverage essential 4

Treatment Duration and Monitoring

• Standard course: 5-7 days of antibiotics
• Extended course (10-14 days): For complicated cases, immunocompromised patients, or persistent symptoms 1
• Clinical reassessment within 24-48 hours of discharge is essential to evaluate for:
  • Resolution of fever
  • Improvement in throat pain and dysphagia
  • Absence of stridor or respiratory distress
  • Adequate oral intake 1

While ampicillin has shown efficacy in some studies 4, third-generation cephalosporins like ceftriaxone remain the preferred first-line agents due to their broader coverage and excellent clinical outcomes in treating this potentially life-threatening condition.