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, immunosuppressed 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 antibiotic covering S. aureus and anaerobes:

• Amoxicillin-clavulanate as first-line therapy (covers S. aureus, anaerobes, and streptococci) 1
• Alternative for penicillin allergy: Clindamycin 300 mg orally three times daily (covers S. aureus and anaerobes) 5

For Hospitalized/Severe Cases:

Intravenous antibiotics with broader coverage:

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

Special Populations:

Infants under 3 months:

• Consider Group B Streptococcus as potential pathogen 4
• Use ampicillin plus gentamicin or cefotaxime for initial empiric coverage 4

Supportive Care

Essential non-antibiotic measures:

• Maintain adequate hydration - dehydration is a major risk factor 1, 3
• Improve oral hygiene - reduces bacterial load 1
• Analgesics/antipyretics - acetaminophen or NSAIDs for pain and fever control 5
• Sialagogues - lemon drops or massage to promote salivary flow 1

Surgical Management

Indications for surgical drainage:

• Abscess formation confirmed on imaging (ultrasound or CT) 1, 2, 3
• Clinical deterioration despite 48-72 hours of appropriate antibiotic therapy 2
• Severe cases with necrosis - may require debridement 3, 6

Timing is critical: Delayed surgical intervention when indicated can lead to multiple organ dysfunction and death 3

Imaging

Obtain imaging when:

• Diagnosis is uncertain or abscess is suspected 3, 4
• Ultrasound is first-line for confirming parotitis and detecting abscess 4
• CT scan for severe cases or suspected complications (necrotizing fasciitis) 3, 6

Monitoring and Reassessment

Reassess within 48-72 hours:

• If no clinical improvement (persistent fever, worsening swelling, increasing pain), consider imaging for abscess and surgical consultation 2, 3
• Adjust antibiotics based on culture results if available 1, 2
• Monitor for life-threatening complications including necrotizing fasciitis and septic shock 6, 3

Common Pitfalls to Avoid

• Delaying surgical drainage when abscess is present - this can lead to rapid deterioration and death 3
• Inadequate hydration - failure to address dehydration perpetuates the condition 1, 3
• Narrow-spectrum antibiotics - missing anaerobic coverage or gram-negative organisms in hospitalized patients 1, 2
• Underestimating severity in elderly or debilitated patients - ASP can be rapidly fatal in this population 3