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Klug TE, Andersen C, Hahn P, Danstrup CS, Petersen NK, Mikkelsen S, Døssing H, Christensen AL, Rusan M, Kjeldsen A, Greve T. Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study. Eur Arch Otorhinolaryngol 2021; 279:2057-2067. [PMID: 34196735 DOI: 10.1007/s00405-021-06962-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress). METHODS Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear-nose-throat departments. RESULTS Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients. CONCLUSION The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin-tazobactam.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Camilla Andersen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Pernille Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Lillebaelt, Vejle, Denmark
| | - Christian Sander Danstrup
- Department of Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Krintel Petersen
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Sophie Mikkelsen
- Department of Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Helle Døssing
- Department of Otorhinolaryngology, Head and Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Anne-Louise Christensen
- Department of Otorhinolaryngology, Head and Neck Surgery, Regional Hospital, Holstebro, Denmark
| | - Maria Rusan
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anette Kjeldsen
- Department of Otorhinolaryngology, Head and Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
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Klug TE, Greve T, Andersen C, Hahn P, Danstrup C, Petersen NK, Ninn-Pedersen M, Mikkelsen S, Pauli S, Fuglsang S, Døssing H, Christensen AL, Rusan M, Kjeldsen A. Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens. Eur J Clin Microbiol Infect Dis 2021; 40:1461-1470. [PMID: 33566204 PMCID: PMC8205900 DOI: 10.1007/s10096-021-04180-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/01/2021] [Indexed: 12/28/2022]
Abstract
We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients (n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum, Prevotella spp., SAG, and S. pyogenes. SAG, Prevotella spp., F. necrophorum, S. pyogenes, and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum, Prevotella, and S. pyogenes are significant pathogens in PPA development.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Andersen
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Pernille Hahn
- Department of Otorhinolaryngology, Head & Neck Surgery, Hospital Lillebaelt, Kolding, Denmark
| | - Christian Danstrup
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Krintel Petersen
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Mirjana Ninn-Pedersen
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Sophie Mikkelsen
- Department of Otorhinolaryngology, Head & Neck Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Pauli
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Simon Fuglsang
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Helle Døssing
- Department of Otorhinolaryngology, Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Anne-Louise Christensen
- Department of Otorhinolaryngology, Head & Neck Surgery, Regional Hospital West Jutland, Herning, Denmark
| | - Maria Rusan
- Department of Otorhinolaryngology, Head & Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Anette Kjeldsen
- Department of Otorhinolaryngology, Head & Neck Surgery, Odense University Hospital, Odense, Denmark
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Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob 2020; 19:32. [PMID: 32731900 PMCID: PMC7391705 DOI: 10.1186/s12941-020-00375-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Background The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications. Methods Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited. Results Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%). Conclusion Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Malene Hentze
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark
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Suri P, Aurora TK. Care of Infectious Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:647-671. [PMID: 28711129 DOI: 10.1016/j.emc.2017.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Infectious conditions such as skin and soft tissue infections (SSTIs), Urogenital infections and peritonsillar abscesses frequently require care beyond emergency stabilization and are well-suited for short term care in an observation unit. SSTIs are a growing problem, partly due to emergence of strains of methicillin-resistant S. aureus (MRSA). Antibiotic choice is guided by the presence of purulence and site of infection. Purulent cellulitis is much more likely to be associated with MRSA. Radiographic imaging should be considered to aid in management in patients who are immunosuppressed, have persistent symptoms despite antibiotic therapy, recurrent infections, sepsis or diabetes.
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Affiliation(s)
- Pawan Suri
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 1200 E Marshall Street, Richmond, VA 23298, USA.
| | - Taruna K Aurora
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 1200 E Marshall Street, Richmond, VA 23298, USA
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Klug TE, Fischer ASL, Antonsen C, Rusan M, Eskildsen H, Ovesen T. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. Eur Arch Otorhinolaryngol 2013; 271:1701-7. [PMID: 23982668 DOI: 10.1007/s00405-013-2667-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/16/2013] [Indexed: 11/30/2022]
Abstract
To characterize patients with parapharyngeal abscess admitted to a Danish tertiary care centre and evaluate our management. This is a retrospective chart review. All records of patients with parapharyngeal abscess admitted to the Ear-Nose-Throat Department at Aarhus University Hospital, Denmark, from January 2001 through December 2011 were reviewed. In total, 63 patients (41 males), aged 4-89 years (median, 45 years) were included in the study. The mean annual incidence of parapharyngeal abscess was 0.9 cases/100,000 population. Thirty-three (52%) patients had concomitant peritonsillar abscess. In two patients the parapharyngeal abscess was accompanied by necrotizing fasciitis. The most frequent surgical approach used was intrapharyngeal incision in combination with tonsillectomy. The most commonly used antibiotic regimen was benzylpenicillin plus metronidazole. Seven (13%) patients returned to the operating theatre due to post-tonsillectomy haemorrhage or insufficient abscess drainage. Tonsillectomy and internal incision of the abscess in combination with a narrow-spectrum intravenous penicillin and metronidazole is a safe and efficient approach for managing parapharyngeal abscesses. This approach, however, carries a relatively high complication rate, requiring close surveillance in the early post-operative period. This is especially true for parapharyngeal abscess patients without peritonsillar abscess. In our series, these patients were more ill, more likely to experience complications, require intensive care, intubation, and tracheotomy, than parapharyngeal abscess patients with concurrent peritonsillar abscess. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tonsillectomy to intrapharyngeal incision.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus C, Denmark,
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