Otitis externa

Swab and treat as per culture results. If no response after 7 days of treatment, consider referral to ENT

If suspected / confirmed tympanic membrane perforation or grommet in situ - discuss with ENT

Remove hearing aids for duration of treatment if feasible (or ensure daily cleaning if not)

1st line

Analgesia and localised heat, such as a warm cloth

2nd line

ACETIC ACID 2% 1 spray 8 hourly

3rd line 

OTOMIZE 1 spray 8 hourly

Duration: 7 days

Fungal otitis externa

1st line

CLOTRIMAZOLE 1% Solution

Apply 2-3 times daily

2nd line

FLUMETASONE PIVALATE WITH CLIOQUINOL

2-3 drops 12 hourly

Duration: 7-14 days

Pinna cellulitis

ORAL:

FLUCLOXACILLIN 1g 6 hourly

Penicillin allergy

DOXYCYCLINE 100mg 12 hourly

IV

FLUCLOXACILLIN 2g 6 hourly

Penicillin allergy

VANCOMYCIN As per calculator

Duration: 7 days

Pinna perichondritis

Refer to ENT

ORAL

CIPROFLOXACIN 750mg 12 hourly (caution - risk of C difficile infection) Please review MHRA Safety Advice before prescribing.

Otitis media

1st line

AMOXICILLIN 500mg 8 hourly

Penicillin allergy

DOXYCYCLINE 100mg 12 hourly

Pregnancy

ERYTHROMYCIN 500mg 6 hourly or 1g 12 hourly

2nd line

COAMOXICLAV 625mg 8 hourly

Penicillin allergy

Discuss with Microbiology

Duration: 5 days

Shingles

1st line

ACICLOVIR PO 800mg 5 times daily

2nd line

FAMCICLOVIR PO 500mg 8 hourly OR 750mg 12 hourly

or VALACICLOVIR 1g 8 hourly

Duration: 7 days

If immunocompromised, continue until 48h after lesions have crusted

Mastoiditis

Acute

IV

CEFTRIAXONE 2g once daily

If true penicillin allergy:

VANCOMYCIN as per calculator,

target trough 15-20

PLUS

CIPROFLOXACIN 500mg 12 hourly (ORAL) or 400mg 12 hourly (IV) (Please review MHRA Safety Advice before prescribing).

IVOS

COAMOXICLAV 625mg 8 hourly

If true penicillin allergy:

COTRIMOXAZOLE 960mg 12 hourly

Duration: 10-14 days

Chronic

IV

CEFTAZIDIME 2g TDS

PLUS

METRONIDAZOLE 400mg 8 hourly (ORAL) or 500mg 8 hourly (IV)

If true penicillin allergy:

VANCOMYCIN as per calculator,

target trough 15-20

PLUS

CIPROFLOXACIN

750mg 12 hourly (ORAL) or 400mg 8 hourly (IV) (please review MHRA Safety Advice before prescribing).

PLUS

METRONIDAZOLE 400mg 8 hourly (ORAL) or 500mg 8 hourly (IV)

Duration: Discuss with Microbiology

Parotitis

Consider mumps or non-infective causes.

Refer to ENT if symptoms have been present for more than 2 weeks, or if there is unexplained parotid swelling

IV (septic)

FLUCLOXACILLIN 2g 6 hourly

PLUS

METRONIDAZOLE (PO) 400mg 8 hourly

True penicillin allergy or known previous MRSA:

VANCOMYCIN dose as per calculator

PLUS

METRONIDAZOLE (PO) 400mg 8 hourly

ORAL

FLUCLOXACILLIN 1g 6 hourly

PLUS

METRONIDAZOLE 400mg 8 hourly

True penicillin allergy or known previous MRSA:

DOXYCYCLINE 100mg 12 hourly

PLUS

METRONIDAZOLE 400mg 8 hourly

Duration: 7 days

Epiglottitis / Supraglottitis

IV

CEFTRIAXONE 2g Once Daily

PLUS

METRONIDAZOLE 500mg 8 hourly

True penicillin allergy or known previous MRSA:

VANCOMYCIN dose as per calculator

aim for trough 15-20

PLUS

CIPROFLOXACIN 400mg 12 hourly (please review MHRA Safety Advice before prescribing)

PLUS

METRONIDAZOLE 500mg 8 hourly

Discuss with Microbiology regarding duration and ongoing treatment options depending on severity and results of cultures

ORAL STEP DOWN (EMPIRICAL)

COAMOXICLAV 625mg 8 hourly

True penicillin allergy or known previous MRSA:

DOXYCYCLINE 100mg 12 hourly

PLUS

METRONIDAZOLE 400mg 8 hourly

Tonsillitis

IV (septic, or oral route unavailable)

BENZYLPENICILLIN 1.2g 6 hourly

True penicillin allergy:

CLARITHROMYCIN 500mg 12 hourly

ORAL

PHENOXYMETHYLPENICILLIN 500mg 6 hourly or 1g 12 hourly

True penicillin allergy:

CLARITHROMYCIN 500mg 12 hourly

Pregnant

ERYTHROMYCIN 500mg 6 hourly or 1g 12 hourly

Duration: 5 days

Peritonsillar abscess or cellulitis

IV (septic, or oral route unavailable)

BENZYLPENICILLIN 1.2g 6 hourly

Consider adding METRONIDAZOLE if no improvement after 48 hours

True penicillin allergy

CLINDAMYCIN 600mg - 1.2g 6 hourly

ORAL

PHENOXYMETHYLPENICILLIN 500mg 6 hourly or 1g 12 hourly

Consider adding METRONIDAZOLE if no improvement after 48 hours

True penicillin allergy:

CLINDAMYCIN 300-450mg 6 hourly

Duration: 10 days

Glandular fever

Bacterial tonsillitis can co-exist with EBV - use clinical judgement as to whether or not antibacterials are required.

Avoid Amoxicillin. Treat as Tonsillitis (above)

Halitosis (secondary to ENT tumour)

METRONIDAZOLE (oral) 400mg 8 hourly

Duration: 14 days, repeated for recurrence. May need to consider indefinite dosing (200mg 12 hourly)

Post-tonsillectomy bleed

With evidence of infection:

IV

AMOXICILLIN 1g 8 hourly

True penicillin allergy:

CLARITHROMYCIN 500mg 12 hourly

ORAL

AMOXICILLIN 500mg 8 hourly

True penicillin allergy:

CLARITHROMYCIN 500mg 12 hourly

Duration: 7 days

Deep neck space infection

IV

COAMOXICLAV 1.2g 8 hourly

True penicillin allergy:

CLINDAMYCIN 600mg - 1.2g 6 hourly

Duration depends on severity, source control and organism. Discuss with Microbiology.

Acute sinusitis

< 10 days and systemically well: usually no antibiotics required

If symptoms persist > 10 days with no improvement, consider high-dose nasal corticosteroid

High risk of complications:

ORAL

PHENOXYMETHYLPENICILLIN 500mg 6 hourly or 1g 12 hourly

If true penicillin allergy:

DOXYCYCLINE 200mg on day 1 then 100mg daily

Pregnant

ERYTHROMYCIN 500mg 6 hourly or 1g 12 hourly

Persistent symptoms or systemically unwell

COAMOXICLAV PO 625mg 8 hourly

Duration: 5-7 days

Orbital / peri-orbital / pre-septal cellulitis

See under skin and soft tissue infection Periorbital or Preseptal Cellulitis

Facial cellulitis (dental / mandibular / sinus source)

(See under skin and soft tissue infection for other presentations of facial cellulitis)

ORAL

COAMOXICLAV 625mg 8 hourly

If true penicillin allergy:

CLINDAMYCIN 300-450mg 6 hourly

Duration: 7 days

Skull base osteomyelitis

All cases should be discussed with Microbiology

Duration: at least 6 weeks