What is the recommended treatment for parotitis (inflammation of the parotid gland) following influenza?

Treatment of Post-Influenza Parotitis

Post-influenza parotitis should be managed supportively with hydration and symptomatic care, while considering antiviral therapy if within 48 hours of symptom onset, and reserving antibiotics only for cases with clear evidence of secondary bacterial superinfection.

Initial Assessment and Diagnosis

When evaluating parotitis following influenza, distinguish between viral parotitis (directly caused by influenza virus) and bacterial suppurative parotitis (secondary bacterial infection):

• Viral parotitis presents with bilateral or unilateral parotid swelling, mild symptoms, and typically resolves within 5 days without complications 1
• Bacterial suppurative parotitis presents with severe pain, purulent discharge from Stensen's duct, fever, and systemic toxicity 2, 3
• Influenza A (particularly H3N2) can directly cause parotitis, often presenting with concurrent influenza-like illness (fever, myalgia, cough) 1, 4

Antiviral Therapy

Consider neuraminidase inhibitors if the patient presents within 48 hours of symptom onset:

• Oseltamivir 75 mg every 12 hours for 5 days (reduce to 75 mg once daily if creatinine clearance <30 mL/min) 5
• Treatment can be initiated beyond 48 hours in severely ill or immunocompromised patients, though evidence for benefit is limited 5
• Patients unable to mount adequate febrile response (immunocompromised, elderly) may still benefit despite lack of documented fever 5

Supportive Care

Primary management focuses on:

• Maintenance of adequate hydration to promote salivary flow 2, 3
• Analgesics for pain control
• Good oral hygiene 2
• Warm compresses and massage of the gland
• Sialagogues (lemon drops, sugar-free gum) to stimulate salivary flow

Antibiotic Therapy - When to Initiate

Antibiotics are NOT routinely indicated for viral parotitis but should be considered when:

• Purulent discharge is expressed from Stensen's duct 2, 3
• Severe pain with systemic toxicity (high fever, rigors) suggests bacterial superinfection 2, 3
• Symptoms worsen or fail to improve after 3-5 days of supportive care
• Patient has risk factors: dehydration, immunosuppression, poor oral hygiene, or hospitalization 2, 3

Antibiotic Selection for Bacterial Superinfection

If bacterial parotitis is suspected, empiric therapy must cover:

• Staphylococcus aureus (most common pathogen) 2, 3
• Anaerobes including Prevotella, Porphyromonas, Peptostreptococcus 2, 3
• Beta-lactamase producing organisms (present in ~75% of cases) 3

Recommended empiric regimens:

• Co-amoxiclav (amoxicillin-clavulanate) 625 mg three times daily orally provides coverage for both aerobic and anaerobic pathogens 2, 3
• Alternative: Clindamycin for penicillin-allergic patients (covers anaerobes and S. aureus)
• If hospitalized or severely ill: IV co-amoxiclav 1.2 g three times daily 2, 3

Key Clinical Pitfalls

Common errors to avoid:

• Do not automatically prescribe antibiotics for all post-influenza parotitis—most cases are viral and self-limited 1, 4
• Do not assume mumps in vaccinated patients; influenza is an important differential diagnosis 4
• Do not delay antiviral therapy while awaiting confirmatory testing if within the 48-hour window 5
• Beta-lactamase producing organisms are common; avoid amoxicillin alone 3

Indications for Surgical Drainage

Surgical intervention is required when:

• Abscess formation is confirmed (by palpation or imaging) 2, 3
• No clinical improvement after 48-72 hours of appropriate antibiotic therapy 3
• Obtain pus for culture (aerobic, anaerobic, mycobacterial, fungal) to guide targeted therapy 3

When to Refer or Escalate Care

Urgent referral to ENT or hospital admission indicated for:

• Suspected abscess formation requiring drainage 2, 3
• Severe systemic toxicity or sepsis
• Inability to maintain oral hydration
• Immunocompromised patients with worsening symptoms
• Failure to respond to appropriate outpatient management within 48-72 hours