Peritonsillar abscess: Initial empiric parenteral antibiotic regimens

Antibiotic	Adults	Children and infants >28 days
Nontoxic appearance
Ampicillin-sulbactam (preferred)^*	3 g IV every 6 hours	50 mg/kg (based upon ampicillin component) IV every 6 hours (maximum single dose 2 g ampicillin)
or, for patients with penicillin-allergy:
Linezolid	600 mg IV every 12 hours	<12 years: 10 mg/kg IV every 8 hours (maximum total daily dose 1200 mg) ≥12 years: 600 mg IV every 12 hours
plus
Metronidazole	500 mg IV every 8 hours	10 mg/kg IV every 8 hours (maximum single dose 500 mg)
or
Clindamycin^¶	600 mg IV every 6 to 8 hours	10 to 13 mg/kg IV every 8 hours (maximum single dose 600 mg)
Moderate or severe disease^Δ or MRSA coverage desired^◊ give:
Vancomycin^§	Loading dose (optional for severe disease): 20 to 35 mg/kg IV once (maximum single dose 3 g) Maintenance dose: 15 to 20 mg/kg IV every 8 to 12 hours for most patients	15 mg/kg IV every 6 hours
plus
Ampicillin-sulbactam	Dosing as above	Dosing as above
or
Linezolid	Dosing as above	Dosing as above
plus
Ampicillin-sulbactam	Dosing as above	Dosing as above

This table provides initial antibiotic regimens for patients with peritonsillar abscess. The doses provided are intended for patients with normal kidney and liver function; refer to drug information monographs for dose adjustments in patients with reduced kidney or liver function. Antibiotic regimens should be tailored to culture and susceptibility data (if drainage is performed) or based upon clinical response to treatment. When tailoring therapy based upon culture results, a key consideration is that peritonsillar abscesses are frequently polymicrobial, and not all microbes are consistently cultured. Once parenteral therapy has resulted in defervescence and clinical improvement, oral therapy should be used to complete a 14-day course; refer to the separate UpToDate content for oral regimens.

IV: intravenous; MRSA: methicillin-resistant Staphylococcus aureus.

* Ampicillin-sulbactam is a combination product formulated in a 2:1 ratio (eg, each vial contains 2 g of ampicillin and 1 g of sulbactam). Adult dosing is provided as total grams of ampicillin and sulbactam. Pediatric dosing is expressed as mg of ampicillin component.

¶ For patients with penicillin allergy and whose cultures indicate susceptibility to clindamycin. Otherwise, we generally avoid clindamycin, if possible, due to risk for Clostridioides difficile infection. In addition, depending upon local susceptibility patterns, clindamycin may not be active against methicillin susceptible S. aureus, MRSA, or group A streptococcus (refer to UpToDate content for details).

Δ Patients with moderate to severe disease have toxic appearance, temperature >39°C, drooling, and/or respiratory distress.

◊ In addition to individuals with moderate or severe disease, MRSA coverage is also appropriate as initial therapy for patients with peritonsillar abscess and other risk factors for MRSA such as:

Prevalence of MRSA in the community >10% of S. aureus isolates
High likelihood of patient colonization (eg, prior hospitalizations, comorbid conditions, recent broad-spectrum antibiotic coverage, and/or history of frequent skin abscesses)
Although not immediately available to guide antibiotic therapy, results of a swab of the nose and axilla

§ Vancomycin dose selection and monitoring is generally determined by institutional protocol and is based upon disease severity, patient-specific characteristics (eg, kidney function, presence of obesity), anticipated duration of therapy, and clinical resources (eg, pharmacist availability for therapeutic drug monitoring). Refer to UpToDate topic reviews of vancomycin dosing in adults and invasive staphylococcal infections in children for further details.

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Peritonsillar abscess: Initial empiric parenteral antibiotic regimens