Risk Factors for Reoperation in Patients Hospitalized for Odontogenic Infections

When is surgical intervention needed in oral and maxillofacial space infection patients? A retrospective case control study in 46 patients

OBJECTIVE

Patients with mild oral and maxillofacial space infection (OMSI) usually need only antimicrobial therapy. However, surgical intervention is eventually needed after using antibiotics for a period. The objective of this study was to explore the risk factors for drug therapy failure in OMSI.

SUBJECTS AND METHODS

A retrospective case‒control study was designed. From August 2020 to September 2022, patients at Shanghai Jiao Tong University Affiliated Ninth People's Hospital who were diagnosed with OMSI were retrospectively reviewed. The outcome variable was surgical intervention after the use of antibiotics. We collected common biological factors, including demographic characteristics, routine blood test results, C-reactive protein (CRP) levels and composite indicators, such as neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The χ2 test and binary logistic regression were used to examine the association between biological factors and the outcome variable.

RESULTS

Forty-six patients were included in this study. Further surgical intervention was needed in 20 patients (43.5%). The NLR showed a significant association with further surgical drainage (p = 0.01). A binary logistic regression equation was found by using stepwise regression based on the Akaike information criterion (R2 = 0.443), which was associated with sex (odds ratio [OR], 0.216; p = 0.092), NLR (OR, 1.258; p = 0.045), red blood cell (RBC) count (OR, 4.372; p = 0.103) and monocyte (MONO) count (OR, 9.528, p = 0.023). Receiver operating characteristic analysis produced an area under the curve for NLR of 0.725 (p = 0.01) and for the binary logistic regression model of 0.8365 (p < 0.001).

CONCLUSION

Surgical interventions are needed in some mild OMSI patients when antimicrobial therapy fails to stop the formation of abscesses. The binary logistic regression model shows that NLR can be used as an ideal prognostic factor to predict the outcome of antimicrobial therapy and the possibility of requiring surgical intervention.

STATEMENT OF CLINICAL RELEVANCE

Using simple, inexpensive, and easily achieved biological parameters (such as routine blood test results) and composite indicators calculated by them (such as NLR) to predict whether surgical intervention is needed in the future provides a reference for clinical doctors and enables more cost-effective and efficient diagnosis and treatment.

Antimicrobial therapy in the management of odontogenic infections: the penicillin-allergic patient

This retrospective analysis was performed to investigate whether clindamycin remains the preferred antibiotic for penicillin-allergic patients with odontogenic infections. The medical records of 311 patients admitted to the study department with odontogenic infections between 2018 and 2022 and treated with either intravenous amoxicillin-clavulanic acid (Augmentin) or intravenous clindamycin were analyzed. The Augmentin-treated group included 268 patients (86.2%) and the clindamycin-treated group included 43 patients (13.8%). Severity parameters did not differ significantly between the two groups, except for a higher prevalence of abscesses in the clindamycin-treated group (58.1% vs 41.0% in the Augmentin-treated group; P = 0.035). The clindamycin-treated group required a longer duration of intravenous antibiotics (P = 0.001) and had a higher rate of treatment failure (14.0% vs 2.2%; P = 0.002) when compared to the Augmentin-treated group, with a seven-fold increased risk of treatment failure. Moreover, significantly more isolated organisms in the clindamycin-treated group were resistant to clindamycin (P = 0.015); these were all Streptococcus anginosus group. Given the higher risk of treatment failure with clindamycin, it is necessary to choose the antibiotic treatment for penicillin-allergic patients carefully. A detailed history and allergy testing followed by combination therapy is recommended, especially in severe cases.

Does thePenicillin Allergy Label Affect Outcomes of Complicated Odontogenic Infections?

PURPOSE

Penicillins are a potent antibiotic in managing odontogenic infections, but 10% of the population is labelled as allergic to these drugs. This has limited their use and resulted in increased utilization of health care resources as well as complications associated with alternative antibiotics. The purpose of the study was to measure the association between patients labeled as penicillin allergic and treatment outcomes in a sample of patients treated for complicated odontogenic infections. Additionally, we sought to investigate antibiotic resistance patterns in these patients.

MATERIALS AND METHODS

A retrospective cohort study was performed at the Michigan Medicine health care system to include patients who were treated for complicated odontogenic infections by oral and maxillofacial surgery between 2016 and 2020. Complicated odontogenic infection was defined as any odontogenic infection requiring admission and surgical management in the operating room. The primary predictor variable was the penicillin allergy label, which was determined by chart review and not confirmed with formal testing. Outcomes were measures of disease severity. The primary outcome variable was hospital length of stay. Secondary outcome variables were ICU admission (yes/no), repeat computed tomography scan(s), repeat surgery (yes/no), and re-admission (yes/no). Co-variates included were age, sex (male/female), tobacco use status, diabetes, immunocompromised state, number of spaces involved, white blood cell count upon admission and insurance status. For our secondary aim, the primary predictor variable was again penicillin allergy and outcome variable was antibiotic resistance as determined by wound culture results following surgical intervention. Negative binomial regression and logistic regression analyses were performed. P < .05 was considered significant.

RESULTS

A total of 150 patients met the inclusion criteria and of those 17.3% reported as penicillin allergic. Patients labelled as penicillin allergic did not differ significantly from patients without penicillin allergy label in terms of treatment outcomes. Age, diabetes, and immunosuppression were associated with an increased length of stay. Patients labelled as penicillin allergic were at significantly higher risk for antibiotic resistance (relative risk = 2.34; 95% confidence interval, 1.66 to 3.32; P < .001), specifically clindamycin resistance (relative risk = 3.17; 95% confidence interval, 1.93 to 5.18; P < .001).

CONCLUSIONS

Penicillin allergy was significantly associated with clindamycin resistance. There were similar outcomes amongst patients with and without a penicillin allergy label despite antibiotic differences. Delabeling efforts for patients with a reported penicillin allergy must be considered and local nomograms for antibiotic selection should be used by providers when seeking alternative antibiotics.

Does Preoperative Surgical Delay Lead to Increased Postsurgical Length of Stay or Reoperation in Patients With Severe Odontogenic Infections?

BACKGROUND

While severe odontogenic infections can be life-threatening and emergent surgery can be required more often, surgical management in the operating room (OR) is completed as soon as feasible. However, provider schedules and OR availability can occasionally lead to longer delays before surgery, but their effect on outcomes is unknown.

PURPOSE

The purpose of this study was to determine the association of preoperative surgical delay with postsurgical length of stay (LOS) and reoperation in patients with severe odontogenic infections.

STUDY DESIGN, SETTING, SAMPLE

The authors conducted a retrospective cohort study consisting of all adult patients treated in the OR with incision and drainage for odontogenic infections from 1/1/2015 to 7/30/2021 at a large, urban academic hospital.

PREDICTOR VARIABLE

The primary predictor variable was the length of presurgical delay-the number of hours between arrival in the emergency department and the start of surgery.

MAIN OUTCOME VARIABLES

The primary outcome variable was the postsurgical LOS and the secondary outcome variable was the rate of reoperation.

COVARIATES

Demographics, medical history, exam findings, diagnosis, and treatment-related variables were also analyzed.

ANALYSES

Descriptive and bivariate analyses were performed along with multivariable linear and logistic regression. A P value of < .05 was considered significant.

RESULTS

There were 401 patients included in the study with 50.9% men and a mean age of 39.1 years. Increased length of presurgical delay (hours) was associated with a decreased postsurgical LOS (β = -0.05 days, P = .01) and length of presurgical delay was not associated with reoperation (P = .51) in the unadjusted analyses. However, length of presurgical delay was not found to be associated with either LOS (β = -0.02, 95% confidence interval (CI) -0.05 to 0.01, P = .12) or reoperation (adjusted odds ratio (aOR) 1.0, 95% CI 0.96 to 1.02, P = .67) in the adjusted analyses.

CONCLUSIONS AND RELEVANCE

The association of decreased length of presurgical delay with increased postsurgical LOS in the unadjusted analysis could reflect the practice of rapid intervention for the most ill patients. After adjusting for number of spaces, a primary indicator of infection severity, length of presurgical delay was not associated with either LOS or return to the operating room.

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.

Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery?

PURPOSE

The selection of perioperative antibiotics for prevention of surgical site infection (SSI) is often limited by the presence of a reported penicillin allergy. The purpose of this study was to determine if oral and maxillofacial surgery patients who report allergy to penicillin are at an increased risk of developing SSI.

METHODS

A retrospective cohort study was performed of patients who underwent oral and maxillofacial surgical procedures in the operating room setting at a single institution between 2011 and 2018. The following categories of procedures were investigated: dentoalveolar, orthognathic, orthognathic with third molar extraction, pathology and reconstruction, and temporomandibular joint. The primary predictor and outcome variables were reported penicillin allergy and surgical site infection, respectively. Bivariate and multiple logistic regression analysis were performed. P < .05 was considered to be significant.

RESULTS

The cohort was composed of 2,058 patients of which 318 (15.5%) reported allergy to penicillin. Beta-lactam antibiotics were administered less frequently to penicillin allergic patients perioperatively compared with those without penicillin allergy (7.9 vs 97.1%, P < .001), while clindamycin was more commonly administered (76.4 vs 2.5%, P < .001). Clindamycin was associated with a higher SSI rate compared with beta-lactam antibiotics (5.6 vs 1.4%, P < .001). Penicillin allergy was significantly associated with SSI at an adjusted odds ratio of 2.61 (95% CI 1.51 to 4.49, P = .001). After holding perioperative antibiotic usage equal between the 2 groups, penicillin allergy per se was no longer associated with SSI (P = .901), suggesting that the outcome was mediated by antibiotic selection.

CONCLUSIONS

Penicillin allergy was associated with development of SSI due to receipt of non-beta-lactam antibiotics as perioperative prophylaxis. Formal allergy evaluation should be considered for patients with putative penicillin allergy.

Redrainage in odontogenic orofacial infections: Risk factors and analysis

OBJECTIVES

The objective of this study was to determine the incidence of redrainage in odontogenic orofacial infections and evaluate possible risk factors. The investigators hypothesized that wait times to first surgery >48 hours and clinical risk factors may predispose patients to higher rates of redrainage.

STUDY DESIGN

Two hundred nineteen patients who underwent surgical drainage for odontogenic orofacial infections over an 8-year period were identified through Western Health electronic medical records. The primary outcome measure was the rate of redrainage. Secondary outcomes included total length of hospital stay and intensive care unit admission and length of stay. Stratified risk factors were analyzed using the Cochran-Mantel-Haenszel test to produce a total overall estimate risk ratio (forest plot).

RESULTS

Of 219 patients, 16 (7.3%) required at least 1 return to theater for redrainage. First surgery wait times >48 hours, multispace infection, C-reactive protein ≥150, trismus, and immunosuppression were associated with a significantly increased risk of redrainage (88%; combined risk ratio = 1.88; 95% confidence interval, 1.31-2.69; P = .001).

CONCLUSIONS

To minimize the risk of redrainage, patients with orofacial infections requiring surgery should undergo surgery within 48 hours of presentation to hospital, particularly when presenting with an elevated C-reactive protein ≥150, trismus, immunosuppression, or multispace involvement.