Critical Care Medicine-Infections and Immunologic Disease>>>>>Head and Neck, Upper Airway Infections
Question 3#

A 28-year-old woman presents with increasing pain and progressive swelling of her neck over the last day. She recently underwent a dental extraction for an abscess but did not complete her course of antibiotics. She denies any respiratory difficulty or distress. On examination, her neck is inflamed, erythematous, with areas of fluctuance and crepitus on palpation. She is to be taken emergently for surgical debridement.

After cultures are obtained in the operating room, what is the MOST appropriate antibiotic regimen to administer? 

A. Vancomycin and clindamycin
B. Meropenem
C. Piperacillin-tazobactam and vancomycin
D. Meropenem and vancomycin and clindamycin

Correct Answer is D


Correct Answer: D

The finding of severe pain, fluctuance, and crepitus in the setting of recent infection is typical of a necrotizing soft-tissue infection. Necrotizing soft-tissue infection is a surgical emergency that requires immediate debridement. Necrotizing soft-tissue infections of the head and neck infection can rapidly spread leading to mediastinitis and possibly death from associated complications. These infections can result from a disruption in the oropharyngeal mucus membrane such as following surgery for a dental infection. The infection is usually polymicrobial caused by mouth anaerobes (fusobacteria, anaerobic streptococci, Bacteroides). Monomicrobial infections due to group A Streptococcus can also occur. Empiric treatment of a necrotizing infection is three-pronged and should include:

  1. coverage for gram-positive, gram-negative, and anaerobic organisms with a carbapenem (meropenem) or beta-lactam-betalactamase inhibitor (piperacillin-tazobactam, or ampicillin-sulbactam)
  2. coverage for methicillin-resistant Staphylococcus aureus (vancomycin)
  3. clindamycin for its antitoxin effects against streptococci and staphylococci


  1. Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck. Lung. 2009;187:271.
  2. Vincent JL, Abraham E, Moore FA., et al, eds. Textbook of Critical Care. 7th ed. Philadelphia, PA: Elsevier; 2017.