Approach to managing retropharyngeal abscess

Retropharyngeal abscess is a potentially life-threatening condition. Initial management involves:

urgent transfer to hospital with airway management
referral to an otolaryngologist for consideration of surgical drainage – if the abscess is small (eg less than 2 cm), surgical drainage may not be required
intravenous antibiotic therapy.

For empirical treatment of retropharyngeal abscess in adults and children without sepsis or septic shock, use:

1amoxicillin+clavulanate intravenously; switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous 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 1 month to younger than 3 months and less than 4 kg: 25+5 mg/kg 12-hourly

child 1 month to 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 6-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. Switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous therapy cefazolin cefazolin cefazolin

PLUS

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. Switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous therapy. metronidazole metronidazole metronidazole

For empirical treatment of retropharyngeal abscess in adults and children with sepsis or septic shock, use:

cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For patients with septic shock or requiring intensive care support, consider dosing cefazolin 6-hourly¹. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. Switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous therapy cefazolin cefazolin cefazolin

PLUS

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

For patients who have had a severe immediate² 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 immediate² hypersensitivity reaction to a penicillin in whom cefazolin plus metronidazole is not used, or for patients who have had a severe delayed³ hypersensitivity reaction to a penicillin, use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly; switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous therapy⁴. clindamycin clindamycin clindamycin

For patients who have had a hypersensitivity reaction to a penicillin, consider adding metronidazole (see dosage above) to clindamycin because of increasing resistance to clindamycin in gram-negative anaerobes (especially Bacteroides species).

If the patient is at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, or is not improving despite adequate drainage, add to the above regimens:

vancomycin intravenously; switch to oral therapy once the patient improves, after a minimum of 3 days of intravenous therapy 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 dosing, see Intermittent vancomycin dosing for young infants and children.

Consider replacing vancomycin with clindamycin (see dosage above) if local epidemiology indicates that MRSA is likely to be susceptible to lincosamides and the patient is not severely unwell.

Modify therapy based on the results of culture and susceptibility testing. If MRSA is not identified by culture, consider stopping additional therapy for MRSA. If MRSA is identified, modify therapy based on susceptibility results.

Limited evidence suggests adjunctive corticosteroid therapy accelerates overall improvement. Although corticosteroid therapy is frequently prescribed, the dose and duration are unclear – seek expert adviceKent 2019.

¹ 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, a modified dosage of cefazolin is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ 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

⁴ 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