What is the treatment for acute parotitis?

Treatment of Acute Parotitis

The treatment of acute bacterial suppurative parotitis requires prompt administration of parenteral antimicrobial therapy targeting Staphylococcus aureus and anaerobic bacteria, along with adequate hydration and surgical drainage if an abscess has formed. 1

Etiology and Risk Factors

Acute parotitis is an inflammatory condition of the parotid salivary gland that can be classified as:

• Bacterial (suppurative) parotitis: Most commonly caused by:

  • Staphylococcus aureus (predominant pathogen)
  • Anaerobic bacteria (Prevotella, Porphyromonas, Fusobacterium, Peptostreptococcus)
  • Streptococcus species
  • Gram-negative bacilli (especially in hospitalized patients) 1, 2

• Viral parotitis: Caused by paramyxovirus (mumps), Epstein-Barr virus, coxsackievirus, and influenza viruses 2

Key predisposing factors include:

• Dehydration
• Poor oral hygiene
• Malnutrition
• Immunosuppression
• Medications that reduce salivation
• Sialolithiasis (salivary stones)
• Post-surgical states
• Advanced age 2, 3

Diagnostic Approach

1. Clinical presentation:

   • Painful swelling of the parotid gland
   • Fever (often high, up to 39°C)
   • Purulent discharge from Stenson's duct (pathognomonic)
   • Signs of systemic illness in severe cases 3, 4

2. Laboratory investigations:

   • Culture and sensitivity testing of pus aspirated from the parotid gland
   • Complete blood count showing leukocytosis
   • Blood cultures if systemic infection is suspected 2

3. Imaging:

   • Computed tomography (CT) scan to identify abscess formation and extent of infection 3
   • Ultrasound can be used as an alternative, especially in children

Treatment Algorithm

1. Initial Management

• Hydration: Aggressive fluid resuscitation to correct dehydration 1, 3
• Oral care: Implement meticulous oral hygiene measures 1
• Analgesia: NSAIDs or acetaminophen for pain and fever management (similar to recommendations for other head and neck infections) 5

2. Antimicrobial Therapy

• Empiric antibiotic therapy should be started immediately, targeting both aerobic and anaerobic bacteria:

  First-line options:

  • Penicillinase-resistant penicillin (e.g., nafcillin or oxacillin) plus metronidazole
  • Amoxicillin-clavulanate (high-dose)
  • Ampicillin-sulbactam 1, 2

  For penicillin-allergic patients:

  • Clindamycin (covers both S. aureus and anaerobes)
  • Cephalosporin (if non-anaphylactic allergy) plus metronidazole 5, 2

  For severe infections or hospitalized patients:

  • Piperacillin-tazobactam
  • Carbapenem
  • Vancomycin plus metronidazole (for suspected MRSA) 2, 3

• Route of administration:

  • Initial therapy should be parenteral (IV) in moderate to severe cases
  • Switch to oral therapy once clinical improvement is observed 1, 6

• Duration of therapy:

  • 10-14 days total
  • Continue parenteral therapy until significant clinical improvement (usually 3-5 days) 1

3. Surgical Intervention

• Indications for surgical drainage:

  • Abscess formation confirmed by imaging
  • Failure to respond to medical therapy within 48-72 hours
  • Progressive clinical deterioration 1, 3

• Procedure:

  • Incision and drainage of the abscess
  • Collection of specimens for culture and sensitivity testing
  • Removal of necrotic tissue if present 3

4. Supportive Measures

• Local measures:

  • Warm compresses to the affected area
  • Gentle massage of the gland to promote drainage
  • Sialagogues (lemon drops, sugar-free candies) to stimulate saliva flow once acute phase resolves 2

• Nutritional support:

  • Ensure adequate caloric and protein intake
  • Soft diet as tolerated 3

Prevention

• Maintain good oral hygiene
• Ensure adequate hydration, particularly in elderly and post-surgical patients
• Early and proper treatment of oropharyngeal infections
• Proper management of conditions that reduce salivary flow 1, 2

Complications and Prognosis

Potential complications include:

• Abscess formation
• Facial nerve paralysis
• Sepsis and multiple organ dysfunction syndrome
• Salivary fistula
• Recurrent parotitis

With prompt and appropriate treatment, most patients recover completely. However, acute suppurative parotitis can be life-threatening, particularly in elderly and immunocompromised patients 3.