Empiric systemic antibiotics for hospitalized patients with severe odontogenic infections
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)
- et al.
Odontogenic infections and descending necrotising mediastinitis: case report and review of the literature
Int Dent J
(2004) - et al.
Submandibular space infection: a potentially lethal infection
Int J Infect Dis
(2009) - et al.
Diagnosis and treatment of deep neck space abscesses
Otolaryngol Head Neck Surg
(2009) - et al.
Detection and genetic characterization of beta-lactamases in Prevotella intermedia and Prevotella nigrescens isolated from oral cavity infections and peritonsillar abscesses
Anaerobe
(2015) - et al.
Mediastinitis from odontogenic infection. Report of three cases and review of the literature
Int J Oral Maxillofac Surg
(1991) - et al.
Use of peripherally inserted central catheters in the management of recalcitrant maxillofacial infection
J Oral Maxillofac Surg
(2008) - et al.
Characteristics and cost impact of severe odontogenic infections
Oral Surg Oral Med Oral Pathol Oral Radiol
(2012) - et al.
Empirical antimicrobial therapy for odontogenic infections
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2005) - et al.
Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study
J Allergy Clin Immunol
(2014) - et al.
Incidence and management of severe odontogenic infections ─ a retrospective analysis from 2004 to 2011
J Craniomaxillofac Surg
(2015)
Risk factors affecting hospital length of stay in patients with odontogenic maxillofacial infections
J Oral Maxillofac Surg
Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin
J Oral Maxillofac Surg
Eight-year retrospective study of odontogenic origin infections in a postgraduation program on oral and maxillofacial surgery
J Oral Maxillofac Surg
Analysis of systemic and local odontogenic infection complications requiring hospital care
J Infect
The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
The changing face of odontogenic infections
J Oral Maxillofac Surg
Function of blood monocytes among patients with orofacial infections
J Craniomaxillofac Surg
A five-year retrospective study of odontogenic maxillofacial infections in a large urban public hospital
Int J Oral Maxillofac Surg
Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases
Am J Otolaryngol
Penicillin compared with other advanced broad spectrum antibiotics regarding antibacterial activity against oral pathogens isolated from odontogenic abscesses
J Craniomaxillofac Surg
Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases
J Oral Maxillofac Surg
Severe versus local odontogenic bacterial infections: comparison of microbial isolates
Eur Surg Res
Cited by (29)
Antimicrobial therapy in the management of odontogenic infections: the penicillin-allergic patient
2024, International Journal of Oral and Maxillofacial SurgeryPoorly controlled diabetes mellitus is strongly associated with descending necrotizing mediastinitis of odontogenic origin
2024, Oral Surgery, Oral Medicine, Oral Pathology and Oral RadiologyEvolution of the treatment of severe odontogenic infections over 50 years: A comprehensive review
2023, Journal of Taibah University Medical SciencesCitation 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 SurgeryCitation 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).
Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine
2021, Journal of Cranio-Maxillofacial SurgeryAre routine microbiological samplings in acute dental infections justified? Our 10-year real-life experience
2019, Journal of Stomatology, Oral and Maxillofacial SurgeryCitation 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.