Intravenous antibiotic therapy for acute epiglottitis
For patients with acute epiglottitis who have sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock, immediately after blood samples are taken for culture. Collect other samples (eg swab of epiglottis, pus) as soon as possible; however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.
Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure for patients with septic shock or requiring intensive care support, modified dosages of cefotaxime, ceftriaxone, flucloxacillin and piperacillin+tazobactam are recommended. Once the critical illness has resolved, consider switching to the standard dosage.
For patients without immune compromise who have acute epiglottitis, use initially:
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily. For patients with septic shock or requiring intensive care support, use ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) intravenously, 12-hourly. Switch to oral therapy when the patient improves1 ceftriaxone ceftriaxone ceftriaxone
PLUS
flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For patients with septic shock or requiring intensive care support, use flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. Switch to oral therapy when the patient improves flucloxacillin flucloxacillin flucloxacillin
OR as a single drug
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For patients with septic shock or requiring intensive care support, use cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. Switch to oral therapy when the patient improves. cefotaxime cefotaxime cefotaxime
For patients with immune compromise who have acute epiglottitis, use initiallyAbdul-Aziz 2024Dulhunty 2024:
patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) 6-hourly
patients with septic shock or requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g (child: 400+50 mg/kg up to 16+2 g) administered over 24 hours2.
Patients at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection require treatment with vancomycin. In the ceftriaxone-based regimen, replace flucloxacillin with vancomycin; in the cefotaxime- or piperacillin+tazobactam-based regimens, add vancomycin. Use initially:
vancomycin intravenously; switch to oral therapy when the patient improves vancomycin vancomycin vancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing for critically ill adults
child: for initial vancomycin dosing, see Intermittent vancomycin dosing for young infants and children.
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use cefotaxime alone or ceftriaxone plus vancomycin (see dosages above).
For patients who have had severe immediate3 hypersensitivity reaction to a penicillin, cefotaxime alone or ceftriaxone plus vancomycin (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin in whom cefotaxime or ceftriaxone plus vancomycin is not used, or for patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, use initially:
moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, daily. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. Switch to oral therapy when the patient improves5. moxifloxacin moxifloxacin moxifloxacin