What is the treatment for bacterial laryngitis?

Treatment of Bacterial Laryngitis

Most cases of laryngitis are viral and do not require antibiotics; however, when true bacterial laryngitis is confirmed, treatment should target the specific pathogen identified through culture, with prolonged antibiotic courses often necessary for bacterial eradication. 1

Distinguishing Viral from Bacterial Laryngitis

The vast majority of acute laryngitis is caused by viral pathogens (parainfluenza, rhinovirus, influenza, adenovirus) and is self-limited, resolving within 7-10 days without antibiotic therapy. 1 Routine empiric antibiotic use for dysphonia is unwarranted and exposes patients to unnecessary costs, side effects, and contributes to antibiotic resistance. 1

When to Suspect Bacterial Laryngitis

Antibiotics may be appropriate in select circumstances: 1

• Immunosuppressed patients (renal transplant recipients, HIV-positive patients with laryngeal tuberculosis or atypical mycobacterial infection) 1
• Bacterial laryngotracheitis secondary to Staphylococcus aureus with severe upper respiratory infection, mucosal crusting, cough, stridor, increased work of breathing, and dysphonia 1
• Pertussis outbreaks in adolescents and adults with waning immunity 1
• Epiglottitis (supraglottic laryngitis) caused by bacterial infections, historically Haemophilus influenzae type B, requiring emergency treatment 2, 3

Diagnostic Approach

Diagnostic laryngoscopy should be performed before initiating treatment to document laryngeal findings and establish the diagnosis. 1 For suspected infectious laryngitis with persistent dysphonia and laryngeal inflammation, culture via biopsy is recommended to identify the causative organism. 4

Treatment Based on Pathogen

Methicillin-Sensitive or Methicillin-Resistant Staphylococcus aureus (MSSA/MRSA)

MRSA has emerged as a significant pathogen in chronic bacterial laryngitis, accounting for approximately 30% of cases in recent series. 5

• First-line empiric therapy: Amoxicillin-clavulanate for minimum 21 days 5
• Treatment failure rate: 52% with amoxicillin-clavulanate, often due to unrecognized MRSA 5
• MRSA-directed therapy: Sulfamethoxazole-trimethoprim (Bactrim) demonstrated 100% resolution without recurrence in one series 5
• Duration: Multiple prolonged courses (often >21 days) may be necessary for MSSA or MRSA to achieve symptom improvement and resolution of laryngeal inflammation 4, 5

Other Bacterial Pathogens

Infections with Pseudomonas aeruginosa, Serratia marcescens, or other identified organisms typically resolve with a single appropriate antibiotic course. 4

Epiglottitis (Supraglottic Laryngitis)

This is a medical emergency requiring immediate hospitalization. 3

• Antibiotic therapy: Ampicillin or appropriate coverage for H. influenzae type B and other potential pathogens 3
• Corticosteroids: Hydrocortisone sodium succinate (Solu-Cortef) intramuscularly 3
• Airway management: Tracheotomy or intubation may be necessary for airway protection 3
• Supportive care: Intravenous fluids and humidified air 3

Bacterial Laryngotracheitis

This condition involves secondary bacterial invasion following viral infection, with prolonged clinical course and serious systemic effects. 3

• Treatment: Combination of antibiotics targeting secondary bacterial pathogens, corticosteroids, and often requires tracheotomy with bronchoscopic removal of viscous crusts 3
• Respiratory support: Mechanical ventilation may be required 3

Antibiotics NOT Recommended for Laryngitis

The following should NOT be used for routine treatment of dysphonia: 1

• Tetracyclines: High prevalence of resistant strains 1
• Sulfonamides and trimethoprim-sulfamethoxazole: Do not eradicate Group A Streptococcus (though note: effective for MRSA laryngitis specifically) 1
• Older fluoroquinolones (ciprofloxacin): Limited activity against typical pathogens 1
• Newer fluoroquinolones (levofloxacin, moxifloxacin): Unnecessarily broad spectrum and expensive 1

Treatment Algorithm for Suspected Bacterial Laryngitis

1. Perform diagnostic laryngoscopy to document findings 1
2. Obtain culture via biopsy if persistent dysphonia with laryngeal inflammation 4
3. For empiric treatment pending culture:
   • Start amoxicillin-clavulanate for minimum 21 days 5
   • Monitor response at 2-3 weeks 5
4. If treatment failure or recurrence:
   • Suspect MRSA (58% of treatment failures) 5
   • Switch to sulfamethoxazole-trimethoprim 5
   • Consider extended courses (>21 days) 4, 5
5. Culture-directed therapy: Adjust antibiotics based on sensitivities 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for acute dysphonia without evidence of bacterial infection, as most cases are viral and self-limited 1, 6
• Do not use short antibiotic courses for confirmed bacterial laryngitis; extended therapy (≥21 days) is often required 4, 5
• Do not assume treatment failure is due to non-compliance; consider MRSA as the underlying pathogen 5
• Do not overlook immunosuppression or inhaled steroid use as risk factors for atypical bacterial laryngeal infections 1

Special Considerations

Risk factors potentially associated with MRSA laryngitis include smoking and gastroesophageal reflux, though these associations did not reach statistical significance in available studies. 5