Management of odontogenic space infection with microbiology study

Rising incidence of severe maxillofacial space infections in Germany

OBJECTIVES

Severe maxillofacial space infection (MSI) as an end stage of dentoalveolar diseases or complication of sialadenitis is a potentially life-threatening disease accompanied by complications including airway obstruction, jugular vein thrombosis, descending mediastinitis, sepsis and acute respiratory distress syndrome. The aim of this study was to analyze the incidence and time trends of severe MSI and potentially influencing factors in the German healthcare system over time.

MATERIALS AND METHODS

Nationwide data regarding the national diagnosis-related-group (DRG) inpatient billing system was received from the German Federal Statistical Office. A retrospective analysis of incidence and time trends of MSI-associated procedures classified with the Operation and Procedure Classification System (OPS), were statistically evaluated using Poisson regression analysis between 2005 and 2022 and were associated with different epidemiological factors.

RESULTS

The total standardized incidence rate of MSI-associated procedures in the observational period 2005-2022 was 9.8 (♀8.2; ♂11.4) per 100,000 person years. For all age groups a significant increase of 46.1% in severe MSI - related surgical interventions was registered within the observational period. The largest increase (120.5%) was found in elderly patients over 80 years. There were significant differences of the incidences of MSI-associated surgeries between the different federal states in Germany.

CONCLUSIONS

Severe MSI are a growing challenge in German health care especially among elderly patients over 80 years.

CLINICAL RELEVANCE

Severe MSI is a promising target for prevention. There should be more focus in primary dental and medical care especially in groups depending on social support.

Use of pus metagenomic next-generation sequencing for efficient identification of pathogens in patients with sepsis

The positive detection rate of blood metagenomic next-generation sequencing (mNGS) was still too low to meet clinical needs, while pus from the site of primary infection may be advantageous for identification of pathogens. To assess the value of mNGS using pus in patients with sepsis, thirty-five samples were collected. Pathogen identification and mixed infection diagnosis obtained by use of mNGS or cultivation methods were compared. Fifty-three aerobic or facultative anaerobes, 59 obligate anaerobes and 7 fungi were identified by the two methods. mNGS increased the accuracy rate of diagnosing aerobic or facultative anaerobic infections from 44.4% to 94.4%; mNGS also increased the sensitivity of diagnosing obligate anaerobic infections from 52.9% to 100.0%; however, mNGS did not show any advantage in terms of fungal infections. Culture and mNGS identified 1 and 24 patients with mixed infection, respectively. For obligate anaerobes, source of microorganisms was analyzed. The odontogenic bacteria all caused empyema (n = 7) or skin and soft tissue infections (n = 5), whereas the gut-derived microbes all caused intra-abdominal infections (n = 7). We also compared the clinical characteristics of non-obligate anaerobic and obligate anaerobic infection groups. The SOFA score [9.0 (7.5, 14.3) vs. 5.0 (3.0, 8.0), P = 0.005], procalcitonin value [4.7 (1.8, 39.9) vs. 2.50 (0.7, 8.0), P = 0.035], the proportion of septic shock (66.7% vs. 35.3%, P = 0.044) and acute liver injury (66.7% vs. 23.5%, P = 0.018) in the non-obligate anaerobic infection group were significantly higher than those in the obligate anaerobic infection group. In patients with sepsis caused by purulent infection, mNGS using pus from the primary lesion may yield more valuable microbiological information.

To Evaluate the Efficacy of Biomarkers as Monitoring Tool in Patients with Fascial Space Infections of Odontogenic Origin: A Clinical Study

Introduction

The objective was to evaluate the efficacy of biochemical markers (WBC, CRP and fibrinogen) and the course of odontogenic space infections in 50 patients.

Material and Methods

Blood samples were taken preoperatively and postoperatively at day 0, day 4, day 8 and day 12 for measuring the levels of all three biomarkers. The trends of the biomarkers were observed and compared with assessment parameters such as dental etiology, number of teeth involved, number of spaces involved, mouth opening and pain. Active pus discharge, dysphagia, hoarseness and swelling were assessed and scored accordingly.

Results

The data were subjected to paired 't' test, McNemar's and Pearson's bivariate correlation as appropriate. Statistical analysis found strong correlation between laboratory values of markers and parameters used to measure severity of infection. All three biomarkers (WBC, CRP and fibrinogen) are significant markers for hospital stay (p < 0.01). Prospective analysis indicates that only one biomarker cannot be used to rule out specific diagnosis.

Conclusion

The combination of three biochemical markers assessed in the present study (WBC, CRP and fibrinogen) should be used as prognostic factor in assessment, clinical severity and efficacy of treatment regime for patients as these can reliably predict the clinical course of odontogenic infection.

Maxillofacial infections in lithuanian hospitalised children and adolescents: a 17-years retrospective study

PURPOSE

To analyse the epidemiology, treatment, and microbiological findings of hospitalised Lithuanian children and adolescents admitted due to maxillofacial infections over a 17-years period.

METHODS

428 medical records of paediatric (under the age of 18) patients hospitalised at Vilnius University Hospital from 2003 to 2019 due to a maxillofacial infection were reviewed. The data concerning patient sociodemographic characteristics, aspects related to a hospital stay, treatment modalities, microbiological findings, and sensitivity to antibiotics, were collected and analysed.

RESULTS

The most prevalent condition was odontogenic maxillofacial space infection (28.7%), followed by lymphadenitis (21.7%). The mean (sd) age was 10.86 (4.8) years and the male-to-female ratio was 1.37:1. The majority of patients (83.4%) underwent surgical treatment. The mean (sd) hospital stay was 5.49 (2.9) days. The longest hospital stay was observed in the case of odontogenic maxillofacial space infections. A longer period of hospitalisation was generally associated with the presence of anaerobes and their resistance to antibiotics as well as multiple space involvement in deep neck space infections and a permanent causative tooth in odontogenic cases. The most commonly isolated microbiological species was Staphylococcus aureus spp.

CONCLUSION

The most common origin of maxillofacial infection was odontogenic among investigated Lithuanian children and adolescents. In the majority of cases, a penicillin group antibiotic was prescribed. Streptococci were the predominant bacteria in the cases of odontogenic infection, while Staphylococci were the most prevalent among non-odontogenic cases. Nearly 40.0% of isolated microorganisms were resistant to penicillin. High resistance to metronidazole was identified among anaerobic bacteria.

Diagnostic Value and Clinical Application of Metagenomic Next-Generation Sequencing for Infections in Critically Ill Patients

Objective

To evaluate the diagnostic value and clinical application of metagenomic next-generation sequencing (mNGS) for infections in critically ill patients.

Methods

Comparison of diagnostic performance of mNGS and conventional microbiological testing for pathogens was analyzed in 234 patients. The differences between immunocompetent and immunocompromised individuals in mNGS-guided anti-infective treatment adjustment were also analyzed.

Results

The sensitivity and specificity of mNGS for bacterial and fungal detection were 96.6% (95% confidence interval [CI], 93.5%-99.6%) and 83.1% (95% CI, 75.2%-91.1%), and 85.7% (95% CI, 71.9%-99.5%) and 93.2% (95% CI, 89.7%-96.7%), respectively. Overall, 152 viruses were detected by mNGS, but in which 28 viruses were considered causative agents. The proportion of mNGS-guided beneficial anti-infective therapy adjustments in the immunocompromised group was greater than in the immunocompetent group (48.5% vs 30.1%; P=0.008). In addition, mNGS-guided anti-infective regimens with peripheral blood and BALF specimens had the highest proportion (39.0%; 40.0%), but the proportion of patients not helpful due to peripheral blood mNGS was also as high as 22.0%.

Conclusion

mNGS might be a promising technology to provide precision medicine for critically ill patients with infection.

Should preoperative computed tomography be routine examination for cervicofacial space infections?

Background

Cervicofacial space infections are potentially life-threatening, which require accurate diagnosis, early incision, and adequate drainage. The utilization of computed tomography (CT) in cervicofacial space infections has significantly increased for its advantages in the evaluation of abscesses, its availability, and low cost. However, the clinical value of preoperative CT imaging in cervicofacial space infections remains controversial for its poor specificity, radiation exposure, potential complications, and extra cost. We, therefore, investigated whether CT examination should be used as a routine examination in the treatment of patients with cervicofacial space infections.

Methods

A retrospective study of all patients affected by cervicofacial space infections that received incision and drainage surgery from Jan 2016 to Dec 2020 was performed at West China Hospital of Stomatology at Sichuan University. Patients were divided into two groups: the group with preoperative CT and without preoperative CT. Outcomes, including reoperation rate, missed diagnosis rate, days of symptom relief, length of stay, duration of surgery, and total cost of hospitalization, were analyzed.

Results

Out of n = 153 patients, 108 patients underwent surgery with preoperative CT and 45 patients without preoperative CT. The reoperation rate in the preoperative CT group (6/108, 5.6%) was significantly lower (P = 0.00) than that in the group without preoperative CT (10/45, 22.2%). Significant reduction of missed diagnosis rate (P = 0.00), days of symptom relief (P = 0.01), length of stay(P = 0.03), and duration of surgery (P = 0.01) were detected in the preoperative CT group. The results demonstrated that the utilization of preoperative CT can reduce the missed diagnosis rate and repeated surgery complications.

Conclusions

We recommend preoperative CT as a routine examination in cervicofacial space infections.

Odontogenic Head and Neck Region Infections Requiring Hospitalization: An 18-Month Retrospective Analysis

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We retrospectively reviewed 85 patients treated at the Chair and Clinic of Maxillofacial Surgery of the University Hospital in Wrocław between January 2018 and June 2019. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward (SOR) by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination. The course of infection was monitored by means of laboratory parameters such as leukocyte counts and c-reactive protein levels. Odontogenic infections in the head and neck region are a persistent and common problem. Rapid, accurate diagnosis and treatment minimizes the risk of life-threatening complications, shortens the hospitalization period, and lowers treatment costs.

Mapping the microbiological diversity of odontogenic abscess: are we using the right drugs?

OBJECTIVES

The aim of this study was categorizing the microbial flora and susceptibility to antibiotics and to clarify to which degree the empiric administered antibiotics are suitable for therapy.

MATERIALS AND METHODS

A 3.5-year retrospective study evaluated hospital records of 206 patients who suffered from head and neck infections of odontogenic origin. All patients underwent surgical incision and drainage and received intravenous antibiotics and inpatient treatment. The specimens were obtained by performing a swab.

RESULTS

Two hundred six patients were included with 251 strains isolated (1.22 per patient). One hundred eight strains showed antibiotic resistance. Eighty-seven patients showed at least one bacterial strain that showed antibiotic resistance (42.2%). The most frequent isolated bacteria were Streptococcus spp. (n = 116), with a high rate of antibiotic resistance (50.8%). We investigated 205 cases of antibiotic resistance in 87 subjects. Nine bacterial strains showed no susceptibility to unacid (4.3%) and 36 strains to clindamycin (17.5%).

CONCLUSION

Antibiotic resistance against clindamycin was rather high. The distribution of the afflicted spaces and isolated bacteria was alike recent findings. It is mandatory to understand that immediate surgical treatment in terms of incision and drainage is the basis in abscess treatment. Antibiotic treatment is adjunct therapy.

CLINICAL RELEVANCE

Streptococcus species were the most frequently identified bacteria presenting antibiotic resistance in more than 50%. Increased resistant rates for clindamycin require reconsiderations regarding an empiric antibiotic treatment.

The pathogenic microbial flora and its antibiotic susceptibility pattern in odontogenic infections

Suppurative head and neck infections of odontogenic origin are the most frequent type of head and neck infections. According to the literature, 7-10% of all antibiotics are currently prescribed for their treatment. Since penicillin was invented, the overall antibiotic sensitivity and resistance pattern of the isolated pathogenic microflora has continuously changed. The response of microorganisms to antibiotics and the development of resistance to their action is a purely evolutive process characterized by genetic mutations, acquisition of genetic material or alteration of gene expression and metabolic adaptations. All this makes challenging and difficult the correct choice of empirical antibiotic treatment for head and neck space infections even today. The aim of this paper was to evaluate the literature and to evidence the most frequent locations of odontogenic head and neck infections, the dominant pathogenic microbial flora, the genetic mutations and metabolic changes necessary for bacteria in order to aquire antibiotic resistance and as well its susceptibility and resistance to common antibiotics. We also aimed to highlight the possible changes in bacterial resistance to antibiotics over time, and to assess whether or not there is a need for fundamental changes in the empirical antibiotic treatment of these infections and show which these would be.

Aerobic and anaerobic microorganisms and antibiotic sensitivity of odontogenic maxillofacial infections

This study aimed to identify the aerobic and anaerobic causal microorganisms of odontogenic infections and their antibiotic sensitivity. Purulent exudates were taken from patients with odontogenic infections by transdermal puncture, and aerobic and anaerobic microorganisms were identified using biochemical tests. Susceptibility to antibiotics was tested using the Kirby-Bauer method; the inhibition halos were measured according to NCCLS, and based on the results, the microorganisms were classified as susceptible, intermediate or resistant to each antibiotic. Frequencies of species and percentages of resistance were calculated. The microorganisms associated with odontogenic infections were principally anaerobic (65.3% anaerobic vs. 35.7% aerobic), and the susceptibility to antibiotics was higher in anaerobic than in aerobic microorganisms. The majority of isolated microorganisms (82%) showed susceptibility to amoxicillin/clavulanic acid. The causal agents of odontogenic infections were anaerobic microorganisms, which exhibited high resistance to antibiotics.

Odontogenic orbital abscess with intracranial and pulmonary involvement

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

Epidemiology, Microbiology and Antibiotic Sensitivity of Odontogenic Space Infections in Central India

Introduction

Odontogenic infections are the most commonly encountered orofacial infections, which may spread into the adjacent anatomical spaces along the contiguous fascial planes, leading to involvement of multiple spaces which can progress to life-threatening situations.

Materials and Methods

A prospective study was carried out on 100 consecutive cases of odontogenic infections treated at our institute over a period of 18 months by surgical intervention and intravenous antibiotics. Morphologic study of the isolates and antibiotic sensitivity testing was performed.

Results

Caries was the most frequent dental disease (53.27%), and the mandibular first molar was the most frequently involved tooth (41.9%) associated with the etiology of odontogenic infections. A total of 158 spaces were involved in 100 patients. In subjects with single space odontogenic infections (n = 61), submandibular space was most commonly affected (44.26%) followed by buccal space (27%). In subjects with multiple space infections (n = 39), submandibular space (30.19%) was most frequently involved followed by buccal space (17.92%). In the aerobic group/microaerophilic group, 17 different species were isolated in a total of 102 aerobic isolates. A total of 18 species were identified in 65 anaerobic isolates sampled.

Conclusion

Amoxicillin possess antimicrobial activity against major pathogens in orofacial odontogenic infections, but β-lactamase production has restricted the effectiveness of amoxicillin against the resistant strains of Staphylococcus aureus, Bacteroides, Prevotella and Porphyromonas. For the management of orofacial infections, the use of amoxicillin/clavulanate and clindamycin is recommended because of stability against β-lactamases.

Antibiotic Resistance in Severe Orofacial Infections

PURPOSE

This study assessed the antibiotic resistance profile in patients with severe orofacial infections treated at a single institution from 2009 through 2014. Factors contributing to resistance were studied. The resistance profile was compared with that of a cohort of similar patients treated a decade previously to identify changes in antibiotic resistance. In addition, the effect of antibiotic resistance on in-hospital course was studied.

MATERIALS AND METHODS

This was a 5-year retrospective cohort study. Patients were identified through the oral and maxillofacial surgery data registry. Inclusion criteria were patients treated for orofacial infection requiring hospital admission, surgical drainage, and availability of complete medical, surgical, and microbiological data. Patients with incomplete data or treated as outpatients or nonsurgically were excluded. Sixty patient charts were identified for review. Demographic data; medical, dental, and surgical histories; and hospital course and treatment specifics were obtained for each patient. Linear regression and logistic analyses were used to analyze the data.

RESULTS

Men composed 60% of the cohort (mean age, 45 yr). Average hospital stay was 5.5 days. Penicillin resistance was found in 32.5% of aerobic isolates and clindamycin resistance was found in 29.3%. Streptococcus viridans and Staphylococcus species showed increased resistance to clindamycin and erythromycin compared with historic controls. Younger patient age, surgical history, and number of cultured aerobes showed a relevant correlation to antibiotic resistance. The need for changes in antibiotics, repeat surgical drainage, and increased serum urea nitrogen levels correlated with longer hospital stay.

CONCLUSION

A serious increase in clindamycin and erythromycin resistance was found for S viridans and Staphylococcus species. Age, surgical history, and number of cultured aerobes showed a statistically meaningful correlation to antibiotic resistance. Presence of antibiotic resistance failed to show statistically relevant correlations to prolongation of hospital stay. Rather, the need for change in antibiotic regimen, the need for re-drainage, and increased serum urea nitrogen level were associated with longer hospital stay.

Characterization and Antibiotic Sensitivity Profile of Bacteria in Orofacial Abscesses of Odontogenic Origin

BACKGROUND

Odontogenic infections range from peripheral abscess to superficial and deep infections leading to severe infections in head and neck region. This study was aimed to assess bacterial isolates responsible for orofacial infection of odontogenic origin and their drug susceptibility patterns so as to provide better perceptive for the management of odontogenic infections.

METHODS

The study was made in a selected cohort of patients, irrespective of age and gender having moderate and severe orofacial infections of odontogenic origin admitted to Yenepoya University Hospital. Pus samples were collected and identification of bacteria was performed by 16S rRNA gene sequencing. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion method.

RESULT

A total of 37 study subjects were included, with bacterial isolation rate of 31 (83.7 %). The mean age presented of all patients was 40.62. Of all, 24 (64.9 %) were males. Staphylococcus aureus, Enterobacter claocae subsp. dissolvens, Klebsiella quasipneumoniae subsp. similipneumoniae, Staphylococcus aureus subsp. anaerobius and Klebsiella pneumoniae subsp. ozaenae were the most prevalent isolates. Result showed that 58.6 % of the isolates were resistant to gentamicin, 52.5 % for ampicillin, 51.3 % for piperacillin; least resistant being 18.9 % for azithromycin.

CONCLUSION

High prevalence of bacterial isolates was found, Staphylococcus aureus being the dominant. Most of the bacteria were resistant to different classes of antibiotics. Appropriate antibiotics should be given based on the bacterial isolates, culture sensitivity and clinical course of the disease.

Empiric systemic antibiotics for hospitalized patients with severe odontogenic infections

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.

Moxifloxacin versus Clindamycin/Ceftriaxone in the management of odontogenic maxillofacial infectious processes: A preliminary, intrahospital, controlled clinical trial

Background

The aim of this study was to compare the days of hospitalization length between patients treated with Moxifloxacin with that of patients treated with a Clindamycin/Ceftriaxone combination and additionally, to isolate and identify the oral pathogens involved in orofacial odontogenic infections.

Material and Methods

A pilot-controlled-clinical-trial was carried out on hospitalized patients with cervicofacial odontogenic abscesses or cellulitis, who were randomly asigned to two study groups: 1) patients who received Moxifloxacin, and 2) patients receiving Clindamycin/Ceftriaxone combination. Infiltrate samples were collected through transdermic or transmucosal punction and later cultured on a media specific for aerobic and anaerobic microorganisms. Mean hospitalization duration in days until hospital discharge and susceptibility assessment in rates were established.

Results

Mean hospitalization time in days of patients treated with Moxifloxacin was 7.0 ± 1.6 days, while in the Clindamycin/Ceftriaxone group, this was 8.4 ± 1.8 days, although significant difference could not be demonstrated (p=0.074). A total of 43 strains were isolated, all of these Gram-positive. These strains appeared to be highly sensitive to Moxifloxacin (97.5%) and Ceftriaxone (92.5%).

Conclusions

Moxifloxacin and Ceftriaxone appear to be potential convenient and rational alternatives to traditional antibiotics, for treating severe odontogenic infections, in conjunction with surgical extraoral incision, debridement, and drainage.

Key words:Orofacial odontogenic infections, antimicrobial susceptibility, antimicrobial resistance.

Antibiotic susceptibility of 33 Prevotella strains isolated from Romanian patients with abscesses in head and neck spaces

The purpose of this study was to investigate the susceptibility of a series of 33 Prevotella strains isolated from patients with abscesses in the head and neck spaces, presented to one Romanian hospital. The Etest was applied to determine the value of the minimum inhibitory concentrations for: penicillin G, ampicillin, amoxicillin-clavulanate, metronidazole and clindamycin. In addition, the beta-lactamase activity was detected by the chromogenic cephalosporin disc method. The results indicated that 11 isolates were resistant to both penicillin G and ampicillin due to the beta-lactamase production. All the 33 Prevotella strains were susceptible to the other 3 antimicrobial agents tested, except for only one penicillin G - ampicillin resistant isolate of Prevotella buccae (MIC > 32 and MIC = 12 mg/L, respectively), which showed high resistance to clindamycin (MIC > 256 mg/L) too. Our data underline the necessity for antimicrobial testing including monitoring of beta-lactamase production in cases of oro-maxillo-facial mixed anaerobic infections where antimicrobial treatment is required in addition to the surgical drainage. The results of the study indicated that amoxicillin-clavulanate, like metronidazole, was fully active against the tested Prevotella strains. However, local and multicentre surveys on drug resistance among the clinically significant anaerobic isolates should be carried out periodically.