Mediastinitis following oesophageal rupture in patients with low risk of gram-negative bacteria or Candida species

To determine whether a patient with mediastinitis following oesophageal rupture is at low risk of gram-negative bacteria or Candida species, see Approach to managing mediastinitis following oesophageal rupture.

For treatment regimens in patients with sepsis or septic shock, see Mediastinitis following oesophageal rupture in patients with sepsis or septic shock, or at high risk of gram-negative bacteria or Candida species.

For mediastinitis following oesophageal rupture in adults and children 2 months or older with low risk of gram-negative bacteria or Candida species, use the results of culture and susceptibility testing to guide initial therapy. If microbiological results are not available, use:

1amoxicillin+clavulanate intravenously; see below for modification and duration of therapy amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate

2+0.2 g formulation

adult, or child 40 kg or more: 2+0.2 g 8-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

1+0.2 g formulation

adult, or child 40 kg or more: 1+0.2 g 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

child younger than 3 months and less than 4 kg: 25+5 mg/kg 12-hourly

child younger than 3 months and 4 kg or more: 25+5 mg/kg 8-hourly

child 3 months or older and less than 40 kg: 25+5 mg/kg up to 1+0.2 g 8-hourly

OR as a 2-drug regimen

2cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See below for modification and duration of therapy cefazolin cefazolin cefazolin

PLUS

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. See below for modification and duration of therapy. metronidazole metronidazole metronidazole

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use cefazolin plus metronidazole (see dosage above).

For patients who have had severe immediate¹ hypersensitivity reaction to a penicillin, cefazolin plus metronidazole (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 immediate¹ hypersensitivity reaction to a penicillin in whom cefazolin is not used, or for patients who have had a severe delayed² hypersensitivity reaction to a penicillin, use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly³. See below for modification and duration of therapy. clindamycin clindamycin clindamycin

Modification and duration of therapy: Seek expert advice for ongoing management and duration of therapy. Treatment for 4 to 6 weeks (intravenous + oral) may be requiredMcMullan, 2016.

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return