Ludwig angina
- Bilateral infection of the floor of the mouth that involves the submandibular, sublingual, and submental spaces
- Infection typically follows infected 2nd/3rd molar tooth. Tooth extraction recommended.
- Represents rapidly spreading cellulitis (not abscess) that can progress to airway obstruction
Diagnosis:
- Blood cultures
- CT scan
Management:
- Airway management
Usual Pathogens
Polymicrobial:
S. anginosus group
Mixed anaerobes
Sometimes S. aureus/MRSA
| Empiric Therapy | Dose |
Duration |
|---|---|---|
| Ceftriaxone | 2g IV daily |
10-14 days |
| + |
|
|
| Metronidazole | ||
| If MRSA risk factors, add: | ||
| Vancomycin | 15mg/kg IV q12h | 10-14 days |
Ceftriaxone allergy
| Empiric Therapy | Dose |
Duration |
|---|---|---|
| Levofloxacin | 750mg IV daily | 10-14 days |
| + | ||
| Metronidazole | 500mg IV q12h | |
| If MRSA risk factors, add: | ||
| Vancomycin | 15mg/kg IV q12h | 10-14 days |
| Alternative: | ||
| Ertapenem | 1g IV daily | 10-14 days |
| If MRSA risk factors, add: | ||
| Vancomycin | 15mg/kg IV q12h | 10-14 days |
Immunocompromised/ICU admission
| Empiric Therapy | Dose |
Duration |
|---|---|---|
| Piperacillin-tazobactam | 4.5g IV q6h |
14 days |
| + | ||
| Vancomycin | 15mg/kg IV q12h |