Treatment of Infected Tongue Piercing
For an infected tongue piercing, use amoxicillin-clavulanate 875/125 mg orally twice daily as first-line therapy, or clindamycin 300-450 mg orally three times daily if penicillin-allergic. 1
Rationale for Antibiotic Selection
The oral cavity harbors vast amounts of bacteria, making tongue piercings susceptible to polymicrobial infections involving both aerobic and anaerobic organisms from normal oral flora. 1, 2 The most common pathogens include:
- Streptococcus viridans and other oral streptococci 2, 3
- Staphylococcus aureus 1
- Anaerobic bacteria (Prevotella, Fusobacterium, Peptostreptococcus species) 2, 4
- Gemella species 2
First-Line Treatment
Amoxicillin-clavulanate provides optimal coverage for the mixed aerobic-anaerobic flora typical of oral infections, covering streptococci, staphylococci, and oral anaerobes. 5, 6, 7 This combination is superior to penicillin alone because:
- The clavulanate component inhibits beta-lactamases produced by oral bacteria 7
- It provides broader anaerobic coverage than penicillin V 5, 4
- It covers potential staphylococcal pathogens 1, 5
Dosing: 875/125 mg orally twice daily for 5-7 days 5, 6
Alternative Options for Penicillin Allergy
For mild penicillin allergy (non-anaphylactic):
- Cefuroxime 500 mg orally twice daily 5
For severe penicillin allergy (anaphylaxis, angioedema, urticaria):
- Clindamycin 300-450 mg orally three times daily is the preferred alternative 1, 8, 4
- Clindamycin provides excellent coverage against oral streptococci, staphylococci, and anaerobes 8, 4
- Doxycycline 100 mg twice daily is another option but has less robust anaerobic coverage 5, 4
Critical Warning Signs Requiring Escalation
Ludwig angina is a life-threatening complication of tongue piercing infections that requires immediate recognition. 1 This rapidly spreading oral cellulitis presents with:
- Bilateral submandibular swelling 1
- Tongue elevation and posterior displacement 1
- Drooling and difficulty swallowing 1
- Potential airway compromise 1
Management of Ludwig angina requires:
- Immediate airway assessment and securing if compromised 1
- IV antibiotics (ampicillin-sulbactam or piperacillin-tazobactam) 1, 9
- Surgical drainage of abscesses 1
- Hospital admission 1
Additional Serious Complications
Infective endocarditis has been reported following tongue piercing, particularly in patients with underlying valve disease. 1, 2, 3 Eight cases of endocarditis from tongue piercings have been documented, caused by oral flora including Streptococcus viridans and Gemella species. 2, 3
Other severe complications include:
- Glossal abscess 2
- Submandibular lymphadenitis 2
- Cerebellar abscess 2
- Airway obstruction from tongue swelling 1
Treatment Duration and Monitoring
Standard duration: 5-7 days for uncomplicated infections 5, 6
Extend treatment to 7-10 days if: 6
- Significant tissue involvement
- Delayed response to initial therapy
- Presence of abscess requiring drainage
Reassess within 48-72 hours for signs of treatment failure, including increasing pain, swelling, erythema, or purulent drainage. 5
Essential Adjunctive Management
Beyond antibiotics, proper wound care is critical:
- Remove the jewelry if infection is present 1
- Oral rinses with antiseptic mouthwash (e.g., chlorhexidine or Listerine) 1
- Maintain good oral hygiene 1
- Avoid manipulation of the piercing site 1
Common Pitfalls to Avoid
- Do not use penicillin V alone for established infections, as it lacks adequate coverage for staphylococci and some anaerobes 4
- Do not use first-generation cephalosporins (e.g., cephalexin) as they provide inadequate anaerobic coverage 5
- Do not delay treatment in patients with systemic symptoms or signs of deep space infection 1, 2
- Do not ignore airway concerns - tongue swelling can rapidly compromise the airway 1
When to Obtain Cultures
Cultures are recommended in: 1