II. Epidemiology
- Rare, serious infection
III. Pathophysiology
- Mechanism
- Bacterial Infection with seeding via retrograde infection from the oral cavity
- Stasis due to volume depletion or Xerostomia allows for Salivary GlandBacterial parenchymal infection
- Most common in age >50 years
- Contrast with Viral Sialoadenitis
-
Parotid Gland is most commonly affected Salivary Gland
- Less bacteriostatic secretions than submandibular
IV. Causes: Bacterial
- See Viral Sialoadenitis
- Staphylococcus aureus (most common, cultured in >50% of cases)
- Streptococcus species (esp. Streptococcus Pyogenes, Streptococcus viridans)
- Gram Negative Bacteria (e.g. Escherichia coli)
- Anaerobic Bacteria
- Other rare causes
V. Risk Factors
- Advanced age
- Volume depletion
- Diabetes Mellitus
- Hypothyroidism
- Renal Failure
- Sjogren Syndrome
- Debilitated or recently post-operative or post-hospitalization
- Anticholinergic Medications causing Xerostomia
- Secondary to Salivary Gland Calculus
- Known as Obstructive Sialadenitis
VI. Symptoms
- Acute pain and swelling localized over affected Salivary Gland
- High fever with chills often present
VII. Signs
- Ill appearing patient
- Exquisitely tender, warm, swollen Salivary Gland (usually Parotid Gland)
- Regional Lymphadenopathy
- Pus at affected Salivary duct orifice
- Affected gland may be massaged to express pus for culture
- Parotid duct (Stensen's Duct) at upper second molar
- Submandibular duct (Wharton's Duct) at frenulum
VIII. Labs
- Gram Stain and culture of Salivary duct discharge
IX. Imaging
- CT Scan if not improving within 3-4 days
- Avoid sialography in acute Bacterial Sialoadenitis
X. Differential Diagnosis
XI. Management
- Precautions
- Acute Parotitis and other severe Sialadenitis may require initial inpatient ParenteralAntibiotics
- Start Antibiotic coverage for Staphylococcus aureus and other Gram Positive organisms (as well as Anaerobes)
- Total treatment course: 10-14 days
- Oral agents (non-toxic patient)
- Amoxicillin-Clavulanate (Augmentin) 875/125 mg every 12 hours OR
- Cefuroxime (Ceftin) 500 mg every 12 hours and Metronidazole 500 mg every 8 hours
- Penicillin and Cephalosporin allergy
- Clindamycin 300 to 450 mg orally three to four times daily OR
- Macrolide (e.g. Azithromycin) with Metronidazole 500 mg every 8 hours
- Parenteral agents
- Indications
- First-line Antibiotics if no risk for Pseudomonas
- Ampicillin-Sulbactam (Unasyn) 3 g every 6 hours OR
- Ceftriaxone 1 to 2 grams IV daily AND Metronidazole 500 mg every 8 hours OR
- Clindamycin 600 to 900 mg IV every 8 hours
- First-line Antibiotics if Pseudomonas risk (recent Antibiotics, hospitalized, NH resident, DM, Hemodialysis, Immunocompromised)
- Piperacillin-Tazobactam (Zosyn) 3.375 g every 6 hours (or 4.5 g every 8 hours) OR
- Meropenem 1 g every 8 hours (os substitute other carbopenem)
- Add MRSA coverage if needed
- MRSA coverage should be considered in cases failing to improve or Immunocompromised patients
- Vancomycin 20 to 25 mg/kg load, then 15 mg/kg every 12 hours (max 3 g/dose) OR
- Linezolid 600 mg every 12 hours
- Increase Saliva production
- Increase fluid intake
- Stop Anticholinergics and other Xerostomia causes
- Sialologues induce Salivation (help clear stone)
- Lemon drops
- Vitamin C lozenges
- Citric acid or malic acid (lemons, limes, apples, grapes)
- Symptomatic therapy
- Analgesics
- Warm compresses over affected Salivary Gland
- Attempt to milk gland of discharge
- Otolaryngology Consultation
- Surgical drainage of abscess (with culture) may be required
- Consider early intervention or if no improvement in 3-4 days
XII. Complications
- Acute Suppurative Parotitis mortality can approach 40% in some cohorts
- Salivary Gland abscess (rare)
XIII. References
- (2018) Sanford Guide, accessed on IOS 12/24/2019
- Fedok in Noble (2001) Primary Care Medicine, p. 1770-1
- Chow in Mandell (2000) Infectious Disease, p. 699-700
- Walner in Cummings (1998) Otolaryngology, p. 5-121
- Kim (2024) Am Fam Physician 109(6): 550-9 [PubMed]
- Wilson (2014) Am Fam Physician 89(11): 882-8 [PubMed]