What antibiotics are used to treat secondary bacterial infections in perichondritis?

Antibiotic Treatment for Perichondritis

For secondary bacterial infections in perichondritis, fluoroquinolones (ciprofloxacin or levofloxacin) are the first-line treatment due to their excellent coverage of Pseudomonas aeruginosa, while anti-staphylococcal antibiotics should be used for non-abscess cases where Staphylococcus aureus predominates. 1

Pathogen Considerations

Common Pathogens

• Abscess-forming perichondritis: Predominantly Pseudomonas aeruginosa (58-69% of cases) 2, 3
• Non-abscess perichondritis: Predominantly Staphylococcus aureus (49% of cases) 2

Antibiotic Selection Based on Clinical Presentation

For Abscess-Forming Perichondritis:

• First-line: Fluoroquinolones (ciprofloxacin or levofloxacin) 1
  • Excellent coverage against Pseudomonas aeruginosa
  • Good tissue penetration
  • Available in both oral and IV formulations

For Non-Abscess Perichondritis:

• First-line: Anti-staphylococcal antibiotics 2
  • Clindamycin
  • First-generation cephalosporins (cefazolin)
  • Amoxicillin-clavulanate

Treatment Algorithm

Initial Assessment:

1. Determine if abscess is present (fluctuance, severe pain, pointing)
2. Assess severity (systemic symptoms, extent of involvement)
3. Evaluate risk factors (diabetes, immunosuppression)

Treatment Recommendations:

Mild to Moderate Non-Abscess Perichondritis:

• Oral therapy:
  • Amoxicillin-clavulanate 875/125 mg twice daily 4
  • Alternative for penicillin allergy: Clindamycin 300-450 mg four times daily

Severe Non-Abscess Perichondritis:

• IV therapy:
  • Cefazolin 1-2 g every 8 hours
  • Alternative: Clindamycin 600-900 mg every 8 hours

Abscess-Forming Perichondritis:

• IV therapy:
  • Ciprofloxacin 400 mg every 12 hours or Levofloxacin 750 mg daily 1
  • Alternative: Ceftazidime 2 g every 8 hours or Cefepime 2 g every 12 hours

Surgical Management:

• Incision and drainage for abscess formation 5
• Wide debridement may be necessary for necrotic cartilage

Duration of Therapy

• 7-10 days for uncomplicated cases
• 14-21 days for severe cases or those with abscess formation

Monitoring and Follow-up

• Clinical reassessment at 48-72 hours
• If no improvement after 72 hours:
  1. Consider changing antibiotics based on culture results
  2. Evaluate for abscess formation requiring drainage
  3. Consider imaging (CT or MRI) to assess extent of infection

Special Considerations

Adjunctive Therapies

• Removal of foreign bodies (jewelry, etc.) 1
• Oral antiseptic rinses for oral perichondritis 1
• Hyperbaric oxygen therapy may be beneficial in diabetic patients with recurrent perichondritis 6

Prevention

• Proper care after piercing procedures
• Early treatment of minor trauma to cartilaginous areas
• Avoidance of unnecessary manipulation of affected areas

Important Caveats

• Inadequate treatment can lead to permanent auricular deformity 5
• Pseudomonas infections often require longer treatment courses
• Repeated or prolonged courses of metronidazole should be avoided due to risk of cumulative neurotoxicity 1
• Consider local antibiotic resistance patterns when selecting empiric therapy

The key to successful management is early recognition, appropriate antibiotic selection based on likely pathogens, and surgical intervention when indicated to prevent cartilage destruction and permanent deformity.