What is the recommended treatment for a patient with perichondritis (inflammation of the tissue surrounding the cartilage) without an abscess?

Treatment of Perichondritis Without Abscess

For perichondritis without abscess formation, initiate oral fluoroquinolones (ciprofloxacin or levofloxacin) immediately as first-line therapy, or alternatively use intravenous antibiotics covering Staphylococcus aureus if the patient requires hospitalization or has contraindications to fluoroquinolones. 1, 2

Antibiotic Selection Algorithm

First-Line Therapy for Outpatient Management

• Oral fluoroquinolones are the recommended first-line treatment for mild to moderate perichondritis without abscess 1, 2
• Levofloxacin 500-750 mg orally once daily 1
• Ciprofloxacin is an equally effective alternative 1, 2
• These agents provide coverage against Pseudomonas aeruginosa, which accounts for 58-69% of perichondritis cases overall 2

Alternative Therapy Based on Recent Evidence

However, recent research challenges the universal need for anti-pseudomonal coverage in non-abscess cases. A 2019 study of 112 patients found that Staphylococcus aureus was the predominant pathogen in non-abscess perichondritis (49% of cases), while P. aeruginosa was more common in abscess cases (58%) 3. Importantly, patients with non-abscess perichondritis treated with antibiotics covering S. aureus (rather than P. aeruginosa) showed no significant differences in clinical progress, treatment alterations, hospitalization duration, relapse rates, or sequelae 3.

This evidence suggests a practical two-tiered approach:

• For non-abscess perichondritis, intravenous antibiotics covering S. aureus (such as cefazolin or nafcillin) may be sufficient as initial empirical therapy 3
• Expand coverage to include P. aeruginosa if clinical response is disappointing after 48-72 hours or if cultures grow P. aeruginosa 3

For Patients with Fluoroquinolone Contraindications

• Clindamycin combined with ceftazidime or cefepime provides dual coverage for S. aureus and P. aeruginosa in severe cases requiring hospitalization 2
• Clindamycin alone is insufficient as monotherapy due to unreliable Pseudomonas coverage 2

Treatment Duration and Monitoring

Duration

• Continue antibiotics for 7-10 days or until clinical resolution 1
• Monitor specifically for resolution of pain, swelling, and erythema 1

Clinical Monitoring Parameters

• Acute tenderness on deflecting the auricular cartilage distinguishes perichondritis from superficial skin infection 1, 2
• The characteristic presentation includes painful swelling, warmth, and redness of the auricle that spares the earlobe (which lacks cartilage) 1, 2
• Perichondritis typically occurs within the first month after ear piercing or trauma, especially during warm weather 1, 2

Critical Pitfalls to Avoid

Delayed Treatment Consequences

• Delaying treatment can lead to cartilage necrosis and permanent auricular deformity 1, 4
• The infection can progress rapidly from minor infection to perichondritis, abscess formation, and cartilage necrosis 2
• Once cartilage damage occurs, good cosmetic preservation is difficult to maintain 1, 2

Failure to Recognize Abscess Formation

• If an abscess develops, surgical incision and drainage become necessary 1, 2
• Antibiotics alone are insufficient for abscess resolution 2
• Approximately 7-11% of perichondritis cases require surgical intervention 5

Medication Safety

• Avoid aminoglycoside-containing eardrops if tympanic membrane perforation is suspected, as these can cause ototoxicity 1

Special Considerations

Severe Cases Requiring Hospitalization

• Intravenous fluoroquinolones (ciprofloxacin or levofloxacin) are recommended for severe perichondritis 1
• P. aeruginosa was found to be associated with more advanced clinical presentation and longer hospitalization 5

Adjunctive Therapies

• Nonsteroidal anti-inflammatory drugs may be used for symptom management 4
• In diabetic patients with recurrent perichondritis, hyperbaric oxygen therapy has shown benefit as adjunctive treatment 6