Tratamentul antibiotic in

infectiile ORL
The Sanford Guide To Antimicrobial Therapy

Ruxandra Moroti, PhD

Medic primar Boli Infectioase INBI Matei Bals
S.L. Boli Infectioase UMF Carol Davila
 Betalactamine
• Peniciline
• Cefalosporine
• Carbapeneme

Actioneaza pe peretele bacterian 

NU au activitate pe germenii intermediari!!
(Mycoplasme, Chlamydii, Rickettsii)
• Peniciline naturale •coci+ (Strepto spp,
– PeniV inclusiv Pneumococ)
– PeniG •Anaerobi+ si
– Moldamin Fusobacterium
•Spirochete
• Peniciline antistafilococice (Oxacilina)

• Amoxicilina (Amoxi), Ampicilina (Ampi):

Strepto spp, inclusiv Pneumococ, Haemoph Infl

• Peniciline antipiocianic: Piperacilina (Pip)

Piocianic, alti bacili gram-

!! Antibiotice timp-dependente: se administreaza la 4-6 ore

(max 8)!!!
• Inhibitorii de betalactamaza (iBL):
– Clavulanat (Clav)
– Sulbactam (Sb)
– Tazobactam (Taz)

In plus:
combinatii cu iBL: Stafilococ MetiS
• Amox/Clav Haemoph Infl Rez
• Amp/Sb Bacili gram-
Anaerobi+ si -
• Pip/Taz
Cefalosporine clase:

• CI: Cefalexin Nu intra in LCR •Coci+ (Strepto,

• CII: Cefuroxim incl Pneumococ,
Staf metiS)
•Haemoph infl
• CIII: Ceftriaxona •Bacili gram-
LCR
Ceftazidim •Unii anaerobi
Cefotaxim
• CIV: Cefepim

Carbapeneme:
• Meropenem (Mero)
• Imipenem
Varia
• Macrolide:
– Eritromicina (Eritro)
– Claritromicina (Claritro)
– Azitromicina (Azitro)
• Clindamicina
alternative pt SBHA la alergici
(30% Rez la macrolide, clinda)
Germeni intermediari!!
Nu intra in LCR!

• Vancomicina
• Linezolid coci+ multiRez

• F-chinolone “antipneumococice”:
– Levofloxacin (Levo)
LCR
– Moxifloxacin (Moxi)
Bacili gram-, Pneumococ, Intermediari

• Metronidazol: anaerobi+si-

• Aminoglicozidele: NU-si justifica locul in infectiile ORL!!!

 Angine
• Virale
– 60-90%
– EBV
– !HIV
• Bacteriene Penicilina
– 10-40% SBHA Cefalosporine gen I, II
– SBH C,G
– Fuzo-spirili (!Lemierre) Macrolide (Eritro, Azitro, Claritro)
– Difterie Clindamicina
– Sifilis, gonococ
• Fungice Ceftriaxona pt gonococ
• Non-infectioase Ser antidifteric pt difterie (+PeniG)
– Cancere amigdaliene
– Hemopatii maligne
– Boli autoimune
• Epiglotita la copii: Haemoph infl, Strepto piogen,
Pneumococ, Staf auriu
spitalizare,
Cefalosporina III, Amox/Clav, Amp/Sb
trusa de traheostoma

• Colectii parafaringiene: polimicrobiene: strepto spp,

anaerobi
PeniG 24MU(sau Clindamicina) + Metronidazol iv

• Flebita septica/tromboza vena jugulara (sdr Lemierre):

fusobacterium
PeniG 24MU sau Clindamicina iv
 Rino-faringite
• Virale: NU se trateaza cu AB!
(autolimitate 4-5 zile febra, tuse</=10 zile)

• Febra inalta>39:
– Rinofaringita este cauza?
– Rinofaringita face parte dintr-un prodrom?
– Suprainfectie bacteriana?
(pneumococ, HI, moraxella, alti strepto, stafilococ)

• Complicatii:
– Otita medie acuta
– Sinuzita acuta
– Bronsita acuta
 Sinuzite
Acute:

• Virale (majoritatea)

• Bacteriene (suprainfectie germeni “locali”):

– Haemophillus influenzae
– Pneumococ
– Moraxella
– Alti streptococi
– Stafilococ
– Anaerobi (!focar dentar)

Cronice:
+ Anaerobi
+ BGN (bacili gram negativi aerobi)
 Sinuzita acuta  ? AB
• Cand?
– durere faciala/ maxilara + secretii purulente apar/ persista > 5-7z
– febra inalta/ stare generala alterata trat. simptomatic

• De ce?
– Rezolvare infectie, prevenire cronicizare
– Prevenire complicatii: empiem subdural, abces epidural, abces
cerebral, meningita, tromboza sinus cavernos

• Cu ce?
– NU AB ultima luna  Amox/Clav, Cefalo II (7-10z)
– AB ultima luna  FQ (5z): Levo 750mg/z; Moxi 400mg/z
– Spitalizat + tub nazogastric/ nazotraheal !! BGN (piocianic,
acinetobacter, E Coli), Stafilococ auriu, levuri, polimicrobian
Mero/Imipenem + Vanco +/- Fluconazol
– DZ, neutropenic, deferoxamin !! fungi filamentosi (aspergillus,
mucor)  antifungic + chirurgie
 Sinuzita cronica

• De regula NU AB!: exacerbarile se trat ca

sinuzitele acute
 Otita medie acuta
• Otita medie acuta:
– Virusuri
– Pneumococ
– Haemophillus infl
– Moraxella

• >2 ani, afebril, fara durere otica  temporizare AB 48 ore

• <2 ani: tratament AB (10 z); (>2ani: trat 5-7z)
– Fara AB ultima luna Amoxicilina doza mare
– AB ultima luna  Amox/Clav/ Cefalo II
– esec 72h  Ceftriaxona/ Clindamicina(!) +/-timpanocenteza

• La >48h de la intubare naso-traheala Piocianic, Klebsiella,

Enterobacter Ceftazidim, Pip/Taz, Mero/Imipenem

• Profilaxia otitei medii AB a crescut Rez Pneumococ la Blactamine!

vaccin pneumococic
 Mastoidita
• Acuta
– Pneumococ
– Streptococi piogeni
– Stafilococ auriu
– Haemophillus infl
– Piocianic
trat otitei acute +/- Vancomicina/ Oxacilina
imagistica!

• Cronica
– Polimicrobiana: anaerobi, staf, enterobacterii, piocianic
 imagistica (RMN, CT: colectii intracraniene!)
chirurgie + prelevare probe pt laborator
AB: Meropenem/ Pip/Taz
 Complicatii intracraniene
• Meningita acuta
• Empiem subdural (60-90%=extensii sinuzite/ otite medii)
• Abces cerebral (contiguitate focare ORL, meningita,
posttraumatic/postchir; hematogen)
• Tromboze/tromboflebite intracraniene

Tratament si etiologie in functie de surse:

-otomastoidita: Pneumococ, HI, Enterobacterii, Anaerobi
Meropenem/ Cefalo IV
-dentar, pulmonar: Anaerobi, Actinomyces  Ceftrixona + Metronidazol
-cardiac: Staf, Pneumococ, HI Linezolid/ Ceftriaxona/ Meropenem
-trauma, postchir: Staf, Enterobacterii, Piocianic: Meropenem+Linezolid