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 + nebulised adrenaline (epinephrine)

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ACUTE
|
airway compromise
1st line – 

intravenous corticosteroid + nebulised adrenaline (epinephrine)

If there is a strong suspicion of RPA and the airway is compromised, the patient should be admitted to hospital immediately. Initial medical management includes the use of intravenous corticosteroids and nebulised adrenaline (epinephrine). If this is not rapidly effective, the patient should be taken to theatre promptly for examination under anaesthesic with a view to surgical drainage. Fibre-optic intubation is sometimes favoured in these cases to prevent bursting of the abscess and to gain a good view of the airway.[21][32]

Primary options

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

and

adrenaline 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 + nebulised adrenaline (epinephrine) are not rapidly effective, the patient should be taken to theatre promptly for examination under anaesthesic with a view to surgical drainage.

Intubation (by an experienced paediatric or adult anaesthetist) or a surgical airway such as a tracheostomy will be required. Fibre-optic intubation is sometimes favoured 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 examination, 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 – empirical antibiotic therapy

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ACUTE
|
airway compromise
Plus – 

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotics should be started after surgery and should cover the most common organisms: Streptococcus viridans, Staphylococcus aureus (including MRSA), Streptococcus epidermidis, and beta-haemolytic 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: 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

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 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: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

no airway compromise

1st line – empirical antibiotic therapy

Back
ACUTE
|
no airway compromise
1st line – 

empirical antibiotic therapy

If the airway is not an immediate concern, initial treatment should be with empirical 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-haemolytic streptococci. Less common causes include Veillonella species, Bacteroides melaninogenicus, Haemophilus parainfluenzae, and Klebsiella pneumoniae. Normal commensals of the upper respiratory tract can become pathological 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: 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

Additional treatment recommended for SOME patients in selected patient group

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

Primary options

dexamethasone: 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

Additional 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 anaesthesic 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 paediatric patients, it is usually preferable to anaesthetise prior to the CT scan, whereas adults can generally undergo imaging without the need for anaesthesia. Intravenous antibiotics are continued after surgical drainage, either as an empirical 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

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 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: 300-400 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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