What is the recommended antibiotic treatment and duration for a child with a retropharyngeal abscess and a positive streptococcal (Strep) test?

From the Guidelines

For a child with retropharyngeal abscess and positive strep test, the recommended treatment is a combination of surgical drainage and antibiotics, with a total antibiotic duration of 10 days, as indicated by the Infectious Diseases Society of America guidelines 1. The initial empiric antibiotic therapy should include broad-spectrum coverage for both Group A Streptococcus and anaerobes.

• Clindamycin (10-13 mg/kg IV every 8 hours) or ampicillin-sulbactam (50 mg/kg IV every 6 hours) are suitable options.
• If MRSA is a concern, vancomycin (15 mg/kg IV every 6 hours) can be added. Surgical drainage is typically necessary for abscesses larger than 2 cm.
• After clinical improvement with IV antibiotics (usually 24-72 hours with defervescence and improved oral intake), transition to oral antibiotics such as amoxicillin-clavulanate (45 mg/kg/day divided twice daily) or clindamycin (30-40 mg/kg/day divided three times daily). Close follow-up is essential to monitor for complications such as airway compromise, sepsis, or extension to adjacent structures. Retropharyngeal abscesses require aggressive treatment because of their proximity to critical structures and potential for serious complications including airway obstruction, mediastinitis, and sepsis. The positive strep test confirms Group A Streptococcus as a causative organism, but polymicrobial infection with anaerobes is common in these deep neck infections, necessitating broad-spectrum coverage. The guidelines from the Infectious Diseases Society of America 1 support the use of penicillin or amoxicillin as the recommended drug of choice for those non-allergic to these agents, with a duration of 10 days to eradicate the organism from the pharynx. However, in the case of a retropharyngeal abscess, broader spectrum coverage is necessary due to the potential for polymicrobial infection. The BTS guidelines for the management of pleural infection in children 1 also emphasize the importance of broad-spectrum antibiotic coverage and the need for prolonged antibiotic treatment, but are not directly applicable to retropharyngeal abscesses. Therefore, the recommended treatment should be based on the most recent and relevant guidelines, which prioritize the use of broad-spectrum antibiotics and surgical drainage for retropharyngeal abscesses.

From the FDA Drug Label

For the treatment of serious miscellaneous infections other than meningitis, the recommended total daily dose is 50 to 75 mg/kg, given in divided doses every 12 hours. When treating infections caused by Streptococcus pyogenes, therapy should be continued for at least 10 days.

The recommended antibiotic treatment and duration for a Retropharyngeal abscess with a positive strep test in a child is ceftriaxone 50 to 75 mg/kg per day for at least 10 days 2.

From the Research

Antibiotic Treatment for Retropharyngeal Abscess

• The choice of antibiotic treatment for retropharyngeal abscess in children often involves intravenous antibiotics such as clindamycin, ampicillin/sulbactam, or ceftriaxone, followed by oral antibiotics like amoxicillin/clavulanate or clindamycin 3, 4.
• A study from 2004 suggests that empirical intravenous clindamycin can be started for a trial of conservative medical therapy, with 75% of patients responding to medical treatment alone 3.
• Another study from 2006 recommends treatment with i.v. antibiotics including ampicillin/sulbactam or clindamycin plus either cefuroxime or ceftriaxone, followed by oral amoxicillin/clavulanate or clindamycin, especially given the emerging role of group A beta hemolytic streptococcus in retropharyngeal abscesses 4.

Duration of Antibiotic Treatment

• The duration of antibiotic treatment can vary, but it is often continued until the patient shows significant improvement, which can be several days to a week or more, depending on the severity of the infection and the patient's response to treatment 3, 5.
• A study from 1999 notes that nearly two thirds of practitioners recommended a trial of intravenous antibiotics at least occasionally for suspected retropharyngeal abscess before operative drainage was considered, with 51% indicating that 20% to 40% of cases may resolve with antibiotics alone 5.

Positive Strep Test Considerations

• In cases where a positive strep test is obtained, the antibiotic treatment should be effective against group A beta hemolytic streptococcus, such as penicillin or ampicillin, in addition to coverage for other potential pathogens 4, 6.
• The presence of a positive strep test may influence the choice of antibiotic and the duration of treatment, with a focus on ensuring adequate coverage against streptococcal infections 4.