Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

airway compromise

1st line – intravenous corticosteroid + nebulized epinephrine

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ACUTE
|
airway compromise
1st line – 

intravenous corticosteroid + nebulized epinephrine

If there is a strong suspicion of RPA and the airway is compromised, the patient should be admitted to the hospital immediately. Initial medical management includes the use of intravenous corticosteroids and nebulized epinephrine. If this is not rapidly effective, the patient should be taken to the operating room promptly for examination under anesthesic with a view to surgical drainage. Fiberoptic intubation is sometimes favored in these cases to prevent bursting of the abscess and to gain a good view of the airway.[21][32]

Primary options

dexamethasone sodium phosphate: children and adults: 0.5 to 2 mg/kg/day intravenously given in divided doses every 6 hours

and

racepinephrine (racemic epinephrine) inhaled: consult local protocols for guidance on dose

Plus – surgery

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ACUTE
|
airway compromise
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

If intravenous corticosteroids + nebulized epinephrine are not rapidly effective, the patient should be taken to the operating room promptly for examination under anesthesic with a view to surgical drainage.

Intubation (by an experienced pediatric or adult anesthetist) or a surgical airway such as a tracheostomy will be required. Fiberoptic intubation is sometimes favored in these cases to prevent bursting of the abscess and to gain a good view of the airway.[21][32] If the tube is uncuffed, it is helpful to insert a pack allowing a view of the posterior pharyngeal wall for surgical access.[32]

If an RPA is confirmed on surgical exam, the patient should undergo transoral incision and drainage.

Cultures are taken and sent to the laboratory.

In cases where there is extension to the posterior mediastinum, drainage of purulent discharge and debridement of necrotic material from the pericardial area and pleural space may be required, possibly in conjunction with a cardiothoracic team.[33]

Plus – empiric antibiotic therapy

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ACUTE
|
airway compromise
Plus – 

empiric antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotics should be started after surgery and should cover the most common implicated organisms: Streptococcus viridans, Staphylococcus aureus (including MRSA), Streptococcus epidermidis, and beta-hemolytic streptococci. Less common causes include Veillonella species, Bacteroides melaninogenicus, Haemophilus parainfluenzae, and Klebsiella pneumoniae. Normal commensals of the upper respiratory tract can become pathologically offending organisms in an RPA.[13][14][15]

Metronidazole provides necessary cover for anaerobic bacteria (there may be a connection with the parapharyngeal space and therefore the oral cavity).

Clinical improvement should be seen within 24 to 48 hours; if this is not the case, the patient should be re-evaluated. The antibiotic spectrum may need to be broadened. In refractory cases, atypical mycobacteria or MRSA should be suspected.

Intravenous treatment should be continued until the patient is afebrile or is able to tolerate an oral antibiotic (e.g., amoxicillin/clavulanate) to complete a 14-day course.

Patients may be switched to targeted therapy based on cultures from incision and drainage if performed.

Primary options

ampicillin/sulbactam: children >1 month of age: 100-200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 1-2 g intravenously every 6-8 hours, maximum 12 g/day

More

OR

ceftriaxone: children >1 month of age: 50-80 mg/kg/day intravenously given in divided doses every 12-24 hours; adults: 1-2 g intravenously every 12-24 hours

and

clindamycin: children >1 month of age: 25-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 1.2 to 2.7 g/day intravenously given in divided doses every 6-12 hours

OR

cefuroxime sodium: children >1 month of age: 75-150 mg/kg/day intravenously given in divided doses every 8 hours; adults: 750-1500 mg intravenously every 8 hours

and

metronidazole: children >1 month of age: 22.5 mg/kg/day intravenously given in divided doses every 6 hours; adults: 500 mg intravenously every 8 hours

Plus – supportive care + analgesia

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ACUTE
|
airway compromise
Plus – 

supportive care + analgesia

Treatment recommended for ALL patients in selected patient group

Patients who still have an unstable airway after surgery should be monitored closely in an intensive care unit. These patients may require prolonged intubation or tracheostomy.

Adequate intravenous hydration and nutrition should be given until the patient is able to tolerate oral intake of food and drink.

Some patients may require analgesia.

Patients should be monitored closely for development of complications.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 4-6 hours when required, maximum 40 mg/kg/day; adults: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

no airway compromise

1st line – empiric antibiotic therapy

Back
ACUTE
|
no airway compromise
1st line – 

empiric antibiotic therapy

If the airway is not an immediate concern, initial treatment should be with empiric intravenous antibiotics. This can cause resolution or prevention of disease progression, in some patients with an early presentation (e.g. where there is only cellulitis, rather than true abscess formation), thereby avoiding the need for surgical drainage.

Antibiotics should cover the most common organisms: Streptococcus viridans, Staphylococcus aureus, Streptococcus epidermidis, and beta-hemolytic streptococci. Less common causes include Veillonella species, Bacteroides melaninogenicus, Haemophilus parainfluenzae, and Klebsiella pneumoniae. Normal commensals of the upper respiratory tract can become pathologic organisms in an RPA.[13][14][15]

Metronidazole would cover for anaerobic bacteria as there may be a connection with the parapharyngeal space and therefore the oral cavity.

Clinical improvement should be seen within 24 to 48 hours; if this is not the case, the patient should be re-evaluated. The antibiotic spectrum may need to be broadened or surgery considered. In refractory cases, atypical mycobacteria or MRSA should be suspected.

Intravenous treatment should be continued until the patient is afebrile or patient is able to tolerate an oral antibiotic (e.g., amoxicillin/clavulanate) to complete a 14-day course.

The patient may be switched to targeted therapy based on cultures from incision and drainage if performed.

Primary options

ampicillin/sulbactam: children >1 month of age: 100-200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 1-2 g intravenously every 6-8 hours, maximum 12 g/day

More

OR

ceftriaxone: children >1 month of age: 50-80 mg/kg/day intravenously given in divided doses every 12-24 hours; adults: 1-2 g intravenously every 12-24 hours

and

clindamycin: children >1 month of age: 25-40 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 1.2 to 2.7 g/day intravenously given in divided doses every 6-12 hours

OR

cefuroxime sodium: children >1 month of age: 75-150 mg/kg/day intravenously given in divided doses every 8 hours; adults: 750-1500 mg intravenously every 8 hours

and

metronidazole: children >1 month of age: 22.5 mg/kg/day intravenously given in divided doses every 6 hours; adults: 500 mg intravenously every 8 hours

Consider – intravenous corticosteroids

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ACUTE
|
no airway compromise
Consider – 

intravenous corticosteroids

Treatment recommended for SOME patients in selected patient group

Intravenous corticosteroids may also be used in conjunction with intravenous antibiotics.[31]

Primary options

dexamethasone sodium phosphate: children: 150 micrograms/kg intravenously given in divided doses every 12 hours; adults: 4-8 mg intravenously every 8 hours

Consider – surgery

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ACUTE
|
no airway compromise
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Failure of initial medical treatment (i.e., no symptomatic improvement, continuing swinging pyrexia, deterioration of vital signs) and/or the presence of a defined abscess on imaging should prompt the need for examination under anesthesic with a view to peroral surgical drainage. Although the general rule of thumb is to consider drainage for abscesses over the size of 2 cm, it is important to value clinical presentation and initial response to intravenous antibiotics even in larger abscesses.[34] Repeat CT imaging may be necessary to precisely locate the abscess. In pediatric patients, it is usually preferable to anesthetize prior to the CT scan, whereas adults can generally undergo imaging without the need for anesthesia. Intravenous antibiotics are continued after surgical drainage, either as an empiric regimen or according to sensitivities when available.

Plus – supportive care + analgesia

Back
ACUTE
|
no airway compromise
Plus – 

supportive care + analgesia

Treatment recommended for ALL patients in selected patient group

Patients should have their airway monitored throughout treatment.

Adequate intravenous hydration and nutrition is given until the patient is able to tolerate oral intake of food and drink.

Some patients may require analgesia.

Patients should be monitored closely for development of complications.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5-10 mg/kg orally every 4-6 hours when required, maximum 40 mg/kg/day; adults: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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