›Ceftriaxone 2 g IV every 24 hours
›Severe illness or immunocompromised regimens
›Piperacillin-tazobactam
›4.5 g IV every 6-8 hours
›Extended infusion 4 hours per local protocol for severe sepsis
›Covers gram-negatives and anaerobes
›Meropenem
›1-2 g IV every 8 hours
›Reserve for critically ill, prior antibiotic failure, or resistant organisms
›MRSA coverage — add when risk factors present
›Vancomycin IV
›15-20 mg/kg IV every 8-12 hours
›AUC-guided monitoring — target AUC/MIC 400-600
›Trough monitoring if AUC unavailable — target 15-20 mcg/ml
›Linezolid IV or PO alternative
›600 mg IV or PO every 12 hours
›Monitor CBC — thrombocytopenia with prolonged use
›Duration of IV antibiotics
›3-7 days IV followed by oral step-down when improving
›Total course 10-14 days typical
›Longer course when mediastinitis, necrotizing component, or immunocompromise
›Corticosteroids — controversial adjunct
›Dexamethasone 0.15 mg/kg IV (typical adult dose 10-12 mg)
›May reduce tissue edema and potentially decrease need for surgical drainage
›Evidence limited to case reports and case series — no RCT evidence
›All published cases used steroids alongside antibiotics and most still required surgery
›Administer only after airway secured or in mild-moderate disease without compromise
›Contraindicated as sole therapy or substitute for surgical source control
›NSAIDs — avoid
›Associated with worsening necrotizing cervical cellulitis in case series
›Do not use for analgesia in Ludwig's angina
›Analgesia
›IV opioids — morphine 2-4 mg IV every 4 hours PRN or fentanyl 25-50 mcg IV
›Titrate cautiously — avoid respiratory depression
›IV acetaminophen 1 g IV every 6 hours — opioid-sparing
›Surgical drainage principles
›Trans-cervical approach — standard for moderate to severe cases
›Small incisions with blunt dissection through fascial spaces
›Irrigation with saline or dilute antiseptic solution
›Drain placement — passive or active suction
›Intraoral approach — for limited submandibular collections
›Less morbidity but limited access
›Tooth extraction — at time of drainage or staged shortly after
›Definitive source control
›Fasciotomy — when necrotizing fasciitis identified
›Wide debridement of necrotic tissue
›Hyperbaric oxygen — adjunct for necrotizing component
›Limited evidence; used in specialized centers
›IV fluids
›Normal saline or lactated Ringer's 30 ml/kg initial bolus if septic
›Reassess fluid responsiveness before further boluses
›Avoid fluid overload — may worsen airway edema
›Maintenance IV fluids while NPO
›Titrate to urine output >= 0.5 ml/kg/hr
›Vasopressors — norepinephrine for refractory hypotension
›Norepinephrine 0.1-0.3 mcg/kg/min — titrate to MAP >= 65 mmHg