What is the treatment for acute parotitis?

Treatment of Acute Parotitis

Acute bacterial parotitis requires immediate empiric antibiotic therapy targeting Staphylococcus aureus and anaerobic bacteria, with surgical drainage if abscess formation occurs.

Initial Assessment and Risk Stratification

Determine the clinical severity and patient context:

• Outpatient/mild cases: Painful parotid swelling without systemic toxicity 1
• Severe/hospitalized patients: High fever, systemic toxicity, or septic shock 2, 3
• High-risk populations: Elderly surgical patients, debilitated/dehydrated patients, immunocompromised states 3

Microbiology

The most common pathogens are:

• Staphylococcus aureus - most frequent cause 1, 4
• Anaerobic bacteria - including Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species 1
• Streptococcus species - including S. pneumoniae and Group B Streptococcus (particularly in infants) 1, 4
• Gram-negative bacilli - E. coli, Pseudomonas aeruginosa (especially in hospitalized/debilitated patients) 1, 2

Empiric Antibiotic Therapy

For Outpatient/Mild Cases:

Oral antibiotics covering S. aureus and anaerobes:

• Amoxicillin-clavulanate - provides coverage for S. aureus, streptococci, and anaerobes 1
• Alternative for penicillin allergy: Clindamycin 300 mg orally three times daily for 10 days 5, 1

For Hospitalized/Severe Cases:

Intravenous antibiotics with broader coverage:

• Ampicillin-sulbactam or piperacillin-tazobactam - covers S. aureus, anaerobes, and gram-negative organisms 1
• If Pseudomonas suspected (debilitated/hospitalized patients): Add an aminoglycoside or use ciprofloxacin 2
• Duration: 4-13 days IV followed by oral therapy to complete 10-16 days total 4

Supportive Management

Critical adjunctive measures to address underlying pathophysiology:

• Aggressive hydration - corrects dehydration that predisposes to parotitis 1, 3
• Oral hygiene optimization - reduces bacterial load 1
• Sialagogues - lemon drops or massage to promote salivary flow 1
• Analgesics/antipyretics - acetaminophen or NSAIDs for pain and fever control 5

Surgical Intervention

Immediate surgical drainage is required when:

• Abscess formation confirmed on ultrasound or CT imaging 1, 2, 3
• Clinical deterioration despite 48-72 hours of appropriate antibiotic therapy 2
• Severe pain, facial nerve palsy, or progressive swelling despite antibiotics 2

Surgical drainage should not be delayed - waiting beyond 9 days can lead to increased morbidity and mortality 2, 3

Imaging

Obtain imaging when:

• Diagnosis uncertain - ultrasound is first-line to confirm parotitis 4
• Abscess suspected - CT scan with contrast to identify fluid collections requiring drainage 3
• No improvement after 48-72 hours of antibiotic therapy 2

Common Pitfalls to Avoid

• Delaying surgical drainage when abscess is present - this can lead to necrotizing fasciitis, multiple organ dysfunction, and death 3, 6
• Using narrow-spectrum antibiotics without anaerobic coverage - anaerobes are major pathogens 1
• Inadequate hydration - dehydration is both a risk factor and perpetuating factor 1, 3
• Failing to consider Pseudomonas in hospitalized or debilitated patients - may require specific anti-pseudomonal coverage 2
• Underestimating severity in elderly surgical patients - ASP carries high mortality in this population despite aggressive treatment 3

Special Populations

Infants under 3 months:

• Consider Group B Streptococcus as a cause, which may present with septic shock 4
• Blood cultures are essential in this age group 4
• Early antibiotic therapy prevents progression to serious complications 4