What are the treatment options for bacterial laryngitis with antibiotics?

Antibiotic Treatment for Laryngitis

Antibiotics should NOT be routinely prescribed for laryngitis, as the vast majority of cases are viral and self-limited, resolving within 7-10 days without antibiotic therapy. 1

General Approach to Laryngitis

The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation against routine antibiotic use for dysphonia/laryngitis, based on systematic reviews and randomized trials showing ineffectiveness and a preponderance of harm over benefit. 1

Why Antibiotics Are Not Recommended

• Most laryngitis is viral: Acute upper respiratory infections caused by parainfluenza, rhinovirus, influenza, and adenovirus are the primary causes of acute laryngitis. 1
• Self-limited course: Most patients experience symptomatic improvement within 7-10 days irrespective of treatment. 1
• Cochrane review evidence: Antibiotics do not appear effective in treating acute laryngitis in terms of objective outcomes. 1, 2
• Significant harms: Antibiotics expose patients to unnecessary costs (accounting for 30% of medication costs in laryngeal disorders), side effects (rash, abdominal pain, diarrhea, vomiting), and contribute to antibiotic resistance. 1
• Risk of laryngeal candidiasis: Antibiotic use can increase the risk of or exacerbate laryngeal candidiasis. 1

When Antibiotics MAY Be Appropriate

Antibiotics should only be considered in select circumstances where bacterial infection is documented or highly suspected. 1

Specific Bacterial Infections Requiring Antibiotics

1. Bacterial Laryngotracheitis

• Pathogen: Staphylococcus aureus (including MSSA and MRSA) and other bacteria. 1
• Clinical presentation: Severe upper respiratory infection with mucosal crusting, cough, stridor, increased work of breathing, and dysphonia. 1
• Treatment approach:
  • Diagnosis must be established prior to therapy through laryngoscopy and culture (biopsy if needed). 1, 3, 4
  • For MSSA/MRSA-associated laryngitis, multiple courses of prolonged antibiotics are often necessary for symptom improvement and resolution of laryngeal inflammation. 4
  • Infections with Pseudomonas aeruginosa or Serratia marcescens typically resolve with a single course of targeted antibiotics. 4

2. Immunocompromised Patients

• Laryngeal tuberculosis: In patients with renal transplants or HIV. 1
• Atypical mycobacterial infections: Particularly in patients on inhaled steroids. 1, 3
• Treatment: Targeted antibiotic therapy based on culture results. 1, 3

3. Pertussis

• Context: Community outbreaks attributed to waning immunity in adolescents and adults. 1
• Treatment: Appropriate antibiotics when diagnosis is confirmed. 1

4. Epiglottitis (Supraglottic Laryngitis)

• Pathogen: Primarily Haemophilus influenzae type B, though other bacteria can be causative. 5
• Clinical presentation: Severe dyspnea, requires emergency management. 5
• Treatment: Antibiotics in combination with high-dose systemic and inhaled glucocorticoids (>0.3 mg/kg dexamethasone for 48 hours). 5

Diagnostic Algorithm Before Antibiotic Use

Before prescribing antibiotics for suspected bacterial laryngitis, the following steps are mandatory: 1, 3

1. Perform diagnostic laryngoscopy to document laryngeal findings and establish the diagnosis. 1, 3
2. Obtain culture through biopsy if bacterial infection is suspected, particularly looking for:
   • MSSA or MRSA 4
   • Pseudomonas aeruginosa 4
   • Serratia marcescens 4
   • Mycobacterial species in immunocompromised patients 1, 3
3. Initiate targeted therapy only after diagnosis is established. 1, 3

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics empirically for acute dysphonia without evidence of bacterial infection, as this contributes to resistance and exposes patients to unnecessary harm. 1, 3
• Do NOT assume bacterial infection based on symptom duration alone; viral laryngitis can persist for 7-10 days. 1
• Do NOT use antibiotics to treat pharyngitis-associated dysphonia unless Group A Streptococcus is documented by rapid antigen test or culture. 1
• Consider immunosuppression or inhaled steroid use as risk factors for atypical bacterial laryngeal infections requiring culture-directed therapy. 1, 3
• Recognize that "normal respiratory flora" on culture does not indicate bacterial laryngitis requiring treatment. 4

Evidence Quality Note

The evidence against routine antibiotic use is based on systematic reviews and randomized controlled trials showing no benefit for objective outcomes and only modest, inconsistent benefits for subjective outcomes that do not outweigh the harms. 1, 2 The Cochrane review found that antibiotics like erythromycin showed some subjective benefit at one week but no objective voice improvement. 2 However, these modest benefits are insufficient to justify routine use given the significant individual and societal harms of antibiotic overuse. 1