Empiric systemic antibiotics for hospitalized patients with severe odontogenic infections

https://doi.org/10.1016/j.jcms.2016.05.019Get rights and content

Abstract

Introduction

Odontogenic infections may lead to severe head and neck infections with potentially great health risk. Age, location of purulent affected sites and beta-lactam allergy are some mentionable factors regarding patients' in-hospital stay and course of disease. Are there new challenges regarding bacteria' antibiotic resistance for empiric treatment and what influences do they have on patients' clinical course?

Methods

We analyzed in a 4-year retrospective study the medical records of 294 in-hospital patients with severe odontogenic infections. On a routine base bacteria were identified and susceptibility testing was performed. Length of stay in-hospital was evaluated regarding patients' age, beta-lactam allergy profile, affected sites and bacteria susceptibility to empiric antibiotics.

Results

Length of stay in-hospital was detected to be associated with affected space and penicillin allergy as well (p < 0.05). Isolates presented large amounts of aerobic gram-positive bacteria (64.2%), followed by facultative anaerobic bacteria (gram+/15.8%, gram−/12.7%). Tested ampicillin in combination with sulbactam (or without) and cephalosporins displayed high susceptibility rates, revealing distinguished results regarding clindamycin (p < 0.05). Co-trimoxazol and moxifloxacin showed high overall susceptibility rates (MOX: 94.7%, COTRIM: 92.6%).

Discussion

This study demonstrates ampicillin/sulbactam in addition to surgical intervention is a good standard in treatment of severe odontogenic neck infections. Cephalosporins seem to be a considerable option as well. If beta-lactam allergy is diagnosed co-trimoxazol and moxifloxacin represent relevant alternatives.

Conclusion

Age, allergic profile and bacteria' resistance patterns for empiric antibiotics have an influence on patients in-hospital stay. Ampicillin/sulbactam proves itself to be good for empiric antibiosis in severe odontogenic infections. Furthermore cephalosporins could be considered as another option in treatment. However moxifloxacin and co-trimoxazol deserves further investigation as empiric antibiosis in odontogenic infections if beta-lactam allergy is diagnosed.

Introduction

In the field of head and neck surgery, severe odontogenic infections remain potentially life-threatening events (Wang et al., 2003). Initially caused by pericoronitis of an emerging tooth, a cariogenic necrosis of the dental pulp, and subsequent infection of the root canal, odontogenic cysts or an infection of the periodontal tissues by bacteria of the subgingival microflora, these infections evolve to major purulent health risks (Dahlen, 2002, Boscolo-Rizzo and Da Mosto, 2009). Infections spreading in the facial planes through communicating lodges may endanger sensitive tissues such as the patient's orbita or brain (Al-Nawas and Maeurer, 2008, Azenha et al., 2012, Tavakoli et al., 2013). Likewise, a purulent fluid collection may travel the fascial layers deep into the neck (Daramola et al., 2009). This compromises the patient's health by secondary infection or compression of anatomical landmarks, such as the upper airways, major blood vessels, or the mediastinum (Garatea-Crelgo and Gay-Escoda, 1991, Biasotto et al., 2004, DeAngelis et al., 2014).

Infection expansion and tissue infection largely depend on the patient's immunological response (Lin et al., 2006, Lee et al., 2007, Tzermpos et al., 2013). Predisposing factors for severe progression of an odontogenic infection are deficiencies of immunological competence, such as human immunodeficiency virus positivity, long-term diabetes mellitus, chronic alcohol abuse, hepatitis and liver cirrhosis, systemic lupus erythematosus, and history of immunosuppression after transplant surgery (Peters et al., 1996, Whitesides et al., 2000, Seppanen et al., 2008, Sandner and Börgermann, 2011).

Patients with severe odontogenic abscesses benefit most from a biphasic treatment, incision, and drainage combined with intravenous antibiotic therapy (Wang et al., 2003, Islam et al., 2008, Walia et al., 2014). Additionally, immediate or secondary removal of the odontogenic focus is inevitable for sufficient therapy (Jundt and Gutta, 2012).

Commonly, intravenous antibiosis is administered using a peripherally inserted venous catheter (Islam et al., 2008), and penicillin derivatives are administered as the empirical drug of choice for odontogenic infections (e.g., Ampicillin plus sulbactam) (Rega et al., 2006). One in 10 patients report a history of a penicillin allergy; however, up to 90% of these patients are able to tolerate penicillin treatment, and consequently, they are falsely considered to be allergic to penicillin (Sogn et al., 1992, Gadde et al., 1993, American Academy of Allergy, 2010). Odontogenic infections are not specific, but usually involve a variety of different bacteria. The infections involve strictly anaerobic Gram-positive cocci and Gram-negative rods, along with facultative and microaerophilic streptococci that are implicated in purulent odontogenic infections (Stefanopoulos and Kolokotronis, 2004). Nevertheless, streptococci seem to be predominant in early stages of infection, corresponding to cellulitis and abscess formation. Streptococci species' susceptibility to β-lactam drugs, including penicillin V, ampicillin, and amoxicillin, largely remains; but an emerging resistance to erythromycin and clindamycin has been reported (Limeres et al., 2005). Viridans streptococci have been isolated in vast amounts from purulent odontogenic infections, representing a group of aerobic facultative anaerobic bacteria; likewise, Prevotella species (spp) have been frequently detected as anaerobic bacteria (Warnke et al., 2008). Additionally, in severe odontogenic head and neck infections, the involvement of Fusobacterium species and Bacteroides fragilis must be considered in therapy regimens (Boyanova et al., 2006).

The aim of this study was to evaluate the efficiency of frequently applied empiric antibiosis and to investigate alternatives in antibiotic treatment if needed.

Section snippets

Patients

A 4-year retrospective study evaluated hospital records of 294 patients with severe odontogenic infections who received medical attention from the Department of Oral and Maxillofacial Plastic Surgery of the University Cologne, Germany. All patients in this study underwent extraoral incision and drainage under general anesthesia. They received intravenous antibiotics and underwent culture and sensitivity testing. Patients' clinical data were reviewed, including sex, age, medical record, involved

Results

A total of 294 subjects (176 male, 59%, and 118 female, 41%) from 1 to 88 years of age were enrolled in this study. The patients' mean age was 41.1 (±1.17 standard deviation [SD]). Patients were divided into groups according to age (Fig. 1). The distribution was normal according to the Shapiro–Wilk-test (p < 0.05). Hospitalized patients were analyzed by their length of stay (LOS), the location of abscess, and microbial resistance regarding the different antibiotics.

Subjects were further sorted

Discussion

In our retrospective study, we investigated the clinical course of patients with odontogenic deep neck or facial infections. All patients enrolled faced a severe health risk leading to a potentially life-threatening situation requiring hospitalization (Seppanen et al., 2008, Daramola et al., 2009, DeAngelis et al., 2014).

We observed a maximum of incidences in the submandibular (n = 83, 28.2%) and perimandibular (n = 177, 60.2%) spaces within three decades of life (20–30, 31–40, and 41–50

Conclusion

Age, allergic profile, and bacterial resistance patterns for empiric antibiotics have an influence on patients' in-hospital stay. Ampicillin/sulbactam has been demonstrated to be good for empiric antibiosis in severe odontogenic infections. Cephalosporins could be considered as another option in treatment. However, moxifloxacin and co-trimoxazol deserves further investigation for empiric antibiosis in odontogenic infections if β-lactam allergy is diagnosed.

Financial disclosure

There are no financial disclosures or commercial interests from any authors.

Conflict of interest

There were no conflicts of interest.

Acknowledgments

None.

References (45)

  • E.S. Peters et al.

    Risk factors affecting hospital length of stay in patients with odontogenic maxillofacial infections

    J Oral Maxillofac Surg

    (1996)
  • A.J. Rega et al.

    Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin

    J Oral Maxillofac Surg

    (2006)
  • F.R. Sato et al.

    Eight-year retrospective study of odontogenic origin infections in a postgraduation program on oral and maxillofacial surgery

    J Oral Maxillofac Surg

    (2009)
  • L. Seppanen et al.

    Analysis of systemic and local odontogenic infection complications requiring hospital care

    J Infect

    (2008)
  • P.K. Stefanopoulos et al.

    The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections

    Oral Surg Oral Med Oral Pathol Oral Radiol Endod

    (2004)
  • W. Storoe et al.

    The changing face of odontogenic infections

    J Oral Maxillofac Surg

    (2001)
  • F. Tzermpos et al.

    Function of blood monocytes among patients with orofacial infections

    J Craniomaxillofac Surg

    (2013)
  • J. Wang et al.

    A five-year retrospective study of odontogenic maxillofacial infections in a large urban public hospital

    Int J Oral Maxillofac Surg

    (2005)
  • L.F. Wang et al.

    Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases

    Am J Otolaryngol

    (2003)
  • P.H. Warnke et al.

    Penicillin compared with other advanced broad spectrum antibiotics regarding antibacterial activity against oral pathogens isolated from odontogenic abscesses

    J Craniomaxillofac Surg

    (2008)
  • L. Whitesides et al.

    Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases

    J Oral Maxillofac Surg

    (2000)
  • B. Al-Nawas et al.

    Severe versus local odontogenic bacterial infections: comparison of microbial isolates

    Eur Surg Res

    (2008)
  • Cited by (29)

    • Evolution of the treatment of severe odontogenic infections over 50 years: A comprehensive review

      2023, Journal of Taibah University Medical Sciences
      Citation Excerpt :

      The rate of anaerobic resistance to metronidazole is approximately 6%.76 Penicillin resistance due to extensive previous use is associated with more severe cases of odontogenic infections and is a major cause of a need for re-drainage and longer hospitalization times.41,73,78 Genetic analysis could improve upon traditional and molecular methods for routine diagnosis.74

    • Surgical side infections of the tracheostomy – A retrospective cohort study of patients with head and neck cancer in intensive care

      2022, Journal of Cranio-Maxillofacial Surgery
      Citation Excerpt :

      All in all, surgical infection prophylaxis guideline recommendations fail to account for the complexity of head and neck surgery with the excision of an oral tumor, microvascular tissue transfer and tracheostomy (Veve et al., 2017; Zirk et al., 2019). Adventitiously, limited data are available in regard to risk factors for SSI; this hampers surgeons in therapeutic decisions and in prevention of potential antibiotic overuse, which can ultimately lead to antibiotic resistance or antibiotic related adverse effects (Zirk et al., 2016; Veve et al., 2017; Zirk et al., 2019). Moreover, despite antimicrobial prophylaxis for oncologic head and neck patients, tracheostomy may also increase microbial colonization of the wound due to the permanent communication between the respiratory tract and the skin of neck wounds (Lee et al., 2011).

    • Are routine microbiological samplings in acute dental infections justified? Our 10-year real-life experience

      2019, Journal of Stomatology, Oral and Maxillofacial Surgery
      Citation Excerpt :

      In France, non-severe odontogenic infections are managed by the dentist while hospitals deal with all severe cases involving trismus, extensive cellulitis, dysphagia, dysphonia, dyspnoea and refractory pain. Various reports state that odontogenic infection is due to the interdependent and synergistic metabolism of a variety of mixed aerobic and anaerobic microorganisms whose collection and culture are complex [2–15]. Empirically and in our everyday experience, we have observed that the probabilistic antibiotic therapy is rarely modified during a hospital stay.

    View all citing articles on Scopus
    View full text