High Risk of Deep Neck Infection in Patients with Type 1 Diabetes Mellitus: A Nationwide Population-Based Cohort Study

Innovative Continuous Wound Irrigation Approach for Postoperative Treatment of Masticator Space Abscess

This is a case of an innovative method of continuous irrigation approach for wound care following surgical drainage. Compared with the traditional labor-intensive irrigation, this novel handy method is not only reducing the workload but is also less time-consuming and inexpensive. This continuous irrigation approach is an efficient alternative approach for wound care in deep infection of the head and neck.

The Bacterial Compositions of Nasal Septal Abscess in Patients with or without Diabetes

The nasal septal abscess (NSA) is a rare but potentially fatal disease causing intracranial infection. Treatments for NSA include antibiotics, surgical incision and drainage. Diabetes mellitus (DM) is a risk factor for NSA. Therefore, we assessed the pathogenic bacterial composition of NSA in diabetic patients. We analyzed the Chang Gung Memorial Hospital database to collect 79 NSA patients who received surgical incisions and drainage from 2004 to 2015. We divided them into DM and non-DM groups for analysis. We integrated the bacteria cultured from each patient, listed the top three with the highest frequency and divided the bacterial species into facultative anaerobes or aerobes and anaerobes. The microbiological cultures revealed mono-microbial infection in most of the cases. The top three facultative anaerobes or aerobes with the highest frequency of NSA-DM were Klebsiella pneumoniae (37.5%), methicillin-sensitive Staphylococcus aureus (MSSA; 25%) and methicillin-resistant Staphylococcus aureus (MRSA; 12.5%). The top three for NSA-non-DMs were MSSA (24%), MRSA (20%) and Pseudomonas aeruginosa (16%). The top three anaerobes causing NSA were Prevotella intermedia (25%), Peptostreptococcus species (12.5%) and Propionibacterium acnes (12.5%) in DM patients. The top three in non-DM patients were P. intermedia (25%), P. acnes (16.7%) and Fusobacterium nucleatum (12.5%). When treating NSA in diabetic patients, clinicians should choose empirical antibiotics for K. pneumoniae and P. intermedia, and when treating patients with NSA-non-DM, MSSA and P. intermedia should be considered first.

Historical Review and Modern Case of Spontaneous Laryngeal Abscess

OBJECTIVE

Laryngeal abscesses are rare in the modern antibiotic era. Historically, they were associated with systemic infections including typhoid fever, measles, gonorrhea, syphilis, and tuberculosis. More recent authors have described cases resulting from iatrogenic injury and immunosuppression. This report presents a novel case of laryngeal abscess in the setting of uncontrolled diabetes and a detailed review of modern, reported cases of spontaneous laryngeal abscess.

METHODS

Report of a single case. Also, PubMed was queried for cases of laryngeal abscess since 1985.

CASE REPORT

A 58-year-old male with poorly controlled diabetes presented with odynophagia, dysphagia, and dyspnea. He had biphasic stridor, and flexible laryngoscopy showed reduced mobility of bilateral vocal folds and narrowed glottic airway. He was taken urgently for awake tracheostomy and microdirect laryngoscopy. Laryngoscopy demonstrated fullness and fluctuance of the right hemilarynx. The abscess cavity was entered endoscopically via paraglottic incision extending into the subglottis. The patient was treated with an 8-week course of ampicillin-sulbactam with resolution of infection.

RESULTS

Seven additional cases of spontaneous laryngeal abscesses published after 1985 were identified. In total, 6 of 8 had some form of immunodeficiency (75%). The most common presenting symptoms were dysphonia (8/8, 100%), odynophagia (5/8, 62.5%), and dyspnea/stridor (4/8, 50%). All cases were treated with surgical incision and drainage.

CONCLUSIONS

Laryngeal abscesses are rare in the era of modern antibiotics. This review confirms that the majority of recent episodes occurred in the setting of immunodeficiency and are caused by non-tubercular bacteria. These infections are commonly associated with impaired vocal fold mobility which may contribute to dyspnea, stridor, and airway compromise. Surgical intervention is necessary for treatment and culture-directed antimicrobial therapy. Poorly controlled diabetes is a newly described context for development of spontaneous laryngeal abscess.

Sleep Apnea and Risk of Influenza-Associated Severe Acute Respiratory Infection: Real-World Evidence

PURPOSE

We executed the presented retrospective cohort study with the purpose of probing the risk of severe acute respiratory infection (SARI) following influenza in patients with sleep apnea.

MATERIALS AND METHODS

We executed this real-world study by gathering Taiwan National Health Insurance Research Database (NHIRD) data. From a database containing 1 million individuals sampled at random from the NHIRD, we identified all patients aged 20 years or older with a sleep apnea diagnosis between 1997 and 2013 as the study group. We established a comparison cohort of individuals without sleep apnea by randomly matching patients with respect to monthly income, gender, urbanization level, and age at a 1:4 ratio. Follow-up was performed until death or the end of 2015 for both groups. We determined the study outcome to be the occurrence of influenza-associated SARI.

RESULTS

We enrolled 6508 and 26,032 patients into the study and comparison groups, respectively. A significantly higher cumulative incidence of influenza-associated SARI was discovered in the study group (p < 0.001). In our multivariate analysis, sleep apnea, chronic obstructive pulmonary disease, and coronary artery disease were independent risk factors for influenza-associated SARI. The hazard ratio of sleep apnea for influenza-associated SARI was 1.98 (95% CI: 1.26-3.10) after adjustment for all comorbidities, gender, age, monthly income, and urbanization level.

CONCLUSION

Sleep apnea increased the risk of influenza-associated SARI. We suggest that physicians be cautious about the development of severe influenza illness in patients with sleep apnea. Vaccination and early oseltamivir administration should be actively considered in this group of patients.

Pathogens and Prognosis of Deep Neck Infection in End-Stage Renal Disease Patients

OBJECTIVES/HYPOTHESIS

To examine the pathogenic bacterial spectra and prognosis of deep neck infection (DNI) in end-stage renal disease (ESRD) patients.

STUDY DESIGN

Retrospective study.

METHODS

Patients diagnosed with DNI between 2004 and 2015 in Chang Gung Memorial Hospital were enrolled and divided into three groups, namely ESRD-DNI, chronic kidney disease (CKD)-DNI, and non-CKD-DNI. Differences in pathogenic bacteria, treatment, and prognosis were compared across the three groups.

RESULTS

The bacterial spectra differed among the three groups. The main three facultative anaerobic or aerobic bacteria causing ESRD-DNIs were methicillin-resistant Staphylococcus aureus (MRSA; 25.4%), methicillin-susceptible S. aureus (MSSA; 14.1%), and Klebsiella pneumoniae (KP; 12.7%). For CKD-DNIs, they were KP (23.5%), Viridans streptococci (VS; 23.5%), and MSSA (14.7%). For non-CKD-DNIs, they were VS (31.7%), KP (17.2%), and coagulase-negative staphylococci (8.0%). Compared with the other groups, the ESRD-DNI group had higher white blood cell and C-reactive protein levels, longer hospital stays, more frequent admissions to the intensive care unit, more mediastinal complications, and a significantly higher mortality rate.

CONCLUSIONS

The ESRD-DNI group exhibited more severe disease activity and higher mortality compared with those of the CKD-DNI and non-CKD-DNI groups. MRSA was the leading pathogen for patients with ESRD-DNI. Physicians must implement strategies for the early detection of MRSA to accurately prescribe antibiotics and prevent nosocomial transmission.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

The Pathogenic Bacteria of Deep Neck Infection in Patients with Type 1 Diabetes, Type 2 Diabetes, and Without Diabetes from Chang Gung Research Database

Deep neck infection (DNI) is a lethal emergent condition. Patients with types 1 and 2 diabetes mellitus (T1DM and T2DM, respectively) are predisposed to DNI and have poorer prognoses. The mainstay of the treatment is surgical drainage and antibiotics; however, the pathogenic bacteria of T1DM-DNI have not been studied before. We obtained the data of 8237 patients with DNI who were hospitalized from 2004 to 2015 from the Chang Gung Research Database, which contains multi-institutional medical records in Taiwan. Using diagnostic codes, we classified them into T1DM-DNI, T2DM-DNI, and non-DM-DNI and analyzed their pathogenic bacteria, disease severity, treatment, and prognosis. The top three facultative anaerobic or aerobic bacteria of T1DM-DNI were Klebsiella pneumoniae (KP, 40.0%), Viridans Streptococci (VS, 22.2%), and methicillin-sensitive Staphylococcus aureus (MSSA, 8.9%), similar for T2DM (KP, 32.2%; VS, 23.3%; MSSA, 9.5%). For non-DM-DNI, it was VS (34.6%), KP (9.8%), and coagulase-negative Staphylococci (8.7%). The order of anaerobes for the three groups was Peptostreptococcus micros, Prevotella intermedia, and Peptostreptococcus anaerobius. Patients with T1DM-DNI and T2DM-DNI had higher white blood cell (WBC) counts and C-reactive protein (CRP) levels, more cases of surgery, more cases of tracheostomy, longer hospital stays, more mediastinal complications, and higher mortality rates than those without DM-DNI. Patients in the death subgroup in T1DM-DNI had higher WBC counts, band forms, and CRP levels than those in the survival subgroup. Patients with DM-DNI had more severe disease and higher mortality rate than those without DM-DNI. KP and Peptostreptococcus micros are the leading pathogens for both patients with T1DM-DNI and those with T2DM-DNI. Clinicians should beware of high serum levels of infection markers, which indicate potential mortality.

High Risk of Peritonsillar Abscess in End-Stage Renal Disease Patients: A Nationwide Real-World Cohort Study

Background: Peritonsillar abscess (PTA) is an infectious emergency in the head and neck, and patients with end-stage renal disease (ESRD) have an immunocompromised status. However, no relevant research has focused on the ESRD–PTA relationship. This study explored PTA in ESRD patients and their prognosis. Methods: We identified 157,026 patients diagnosed as having ESRD over January 1997 to December 2013 from Taiwan’s National Health Insurance Research Database (NHIRD). Each patient with ESRD (hereafter, patients) was matched with one control without chronic kidney disease (CKD; hereafter, controls) by sex, age, urbanization level, and income. Next, PTA incidence until death or the end of 2013 was compared between the two groups, and the relative risk of PTA was analyzed using a multiple logistic regression model. Results: The patients had a significantly higher PTA incidence than did the controls (incidence rate ratio: 2.02, 95% confidence interval [CI]: 1.40–2.91, p < 0.001). The Kaplan–Meier analysis revealed that the patients had a higher cumulative incidence of PTA than did the controls (p < 0.001). In Cox regression analysis, the patients had nearly twofold higher PTA risk (adjusted hazard ratio [HR]: 1.98, 95% CI: 1.37–2.86, p < 0.001). The between-group differences in the PTA-related hospital stay length (8.1 ± 10.3 days in patients and 5.7 ± 4.6 days in controls, p = 0.09), consequent deep-neck infection complication (4.2% in patients and 6.3% in controls, p = 0.682), and mortality (0.0% in both groups) were nonsignificant. Conclusions: Although ESRD does not predict a poor prognosis of PTA, it is an independent PTA risk factor.

Changing trends of deep neck infections in southern China: A review of 127 cases

This study aimed to review our experience with the clinical characteristics and management of deep neck infections (DNIs) and determine the changing trends of their characteristics over time in southern China. Patients diagnosed with a DNI between January 2009 and December 2018 were screened retrospectively for their demographic characteristics, etiology of infection, site of infection, microbiology, treatment, and complications. In total, 127 patients were included: 41 (32.3%) were treated between 2009 and 2013 (group A), and 86 (67.7%) were treated between 2014 and 2018 (group B). The most common site of infection in group A was the parapharyngeal space (15 patients, 36.6%), while that in group B involved multiple spaces (36 patients, 41.9%). The leucocyte count (×109 cells/L) was 13.23 ± 4.19 in group A and 16.04 ± 4.33 in group B (p < 0.001). Streptococcus viridans was the most common bacteria in both groups. The mean hospital stay was 21.46 ± 33.09 days in group A and 10.44 ± 6.19 days in group B. The rate of diabetes mellitus (DM) in group A was lower than that in group B (8/41 and 33/86, respectively; p = 0.034). Airway obstruction was the most common complication in both groups. DNIs are more likely to show multi-space involvement, affect more DM patients, and be associated with higher leucocyte counts over time. We infer that the duration from morbidity to admission and that from admission to operation play roles in the successful management of DNIs, possibly causing fewer complications, lower mortality rates, and shorter hospital stays. DM patients require increased attention.

Type 2 Diabetes Mellitus Increases Peritonsillar Abscess Susceptibility: Real-World Evidence

Objectives

Type 2 diabetes mellitus (T2DM) is a risk factor for deep neck infection (DNI) and leads to complications and poor outcomes. Our study aimed to investigate the risk, prognosis, and complications of peritonsillar abscess (PTA) in patients with T2DM.

Methods

We extracted data of patients newly diagnosed as having T2DM between January 2000 and December 2011 from Taiwan’s National Health Insurance Research Database. These patients were matched with patients without T2DM, and PTA incidence was compared between both cohorts.

Results

In total, 67,852 patients with and 135,704 patients without T2DM were enrolled. PTA incidence was significantly higher in patients with T2DM (incidence rate ratio, 1.91; P<0.001); moreover, PTA incidence was higher at 1 to 5 years after T2DM diagnosis than at <1 and >5 years after T2DM diagnosis. Cox regression analysis showed that patients with T2DM had an approximately 2-fold higher PTA risk (adjusted hazard ratio [aHR]: 1.89, P<0.001). Patients with a higher adapted Diabetes Complications Severity Index (aDCSI) had higher PTA risk than those with a lower aDCSI (aHRs: 2.17 for aDCSI ≥1, P=0.006 and 1.81 for aDCSI=0, P=0.002). T2DM patients with a high aDCSI (≥1) had a nonsignificantly longer hospitalization duration and a higher rate of DNI complications than did those with a low aDCSI (=0).

Conclusion

In patients with T2DM, PTA incidence was relatively high, and it increased with T2DM severity. Moreover, T2DM patients should be particularly careful about PTA within 1 to 5 years after the diagnosis, and physicians should keep in mind that the prognosis of PTA was correlated with T2DM severity.

Real-world evidence and optimization of vocal dysfunction in end-stage renal disease patients with secondary hyperparathyroidism

Patients with end-stage renal disease (ESRD) may demonstrate secondary hyperparathyroidism (SHPT), characterized by parathyroid hormone oversecretion in response to electrolyte imbalance (e.g., hypocalcemia and hyperphosphatemia). Moreover, this electrolyte imbalance may affect vocal cord muscle contraction and lead to voice change. Here, we explored the effects of SHPT on the voices of patients with ESRD. We used data of 147,026 patients with ESRD from the registry for catastrophic illness patients, a sub-database of Taiwan National Health Insurance Research Database. We divided these patients into 2 groups based on whether they had hyperparathyroidism (HPT) and compared vocal dysfunction (VD) incidence among them. We also prospectively included 60 ESRD patients with SHPT; 45 of them underwent parathyroidectomy. Preoperatively and postoperatively, voice analysis was used to investigate changes in vocal parameters. In the real-world database analysis, the presence of HPT significantly increased VD incidence in patients with ESRD (p = 0.003): Cox regression analysis results indicated that patients with ESRD had an approximately 1.6-fold increased VD risk (p = 0.003). In the clinical analysis, the “jitter” and “shimmer” factors improved significantly after operation, whereas the aerodynamic factors remained unchanged. In conclusion, SHPT was an independent risk factor for VD in patients with ESRD, mainly affecting their acoustic factors.

Allergic Rhinitis and Laryngeal Pathology: Real-World Evidence

Allergic rhinitis (AR) is correlated with diseases including allergic laryngitis, chronic obstructive pulmonary disease (COPD), asthma, and chronic rhinosinusitis (CRS). The unified airway model suggests that inflammation can spread in both lower and upper respiratory tracts. Moreover, some voice problems-laryngeal edema, dysphonia, and vocal nodules-have been associated with AR. We examined the association between AR and laryngeal pathology. We investigated 51,618 patients with AR between 1 January 1997 and 31 December 2013, along with 206,472 patients without AR matched based on age, gender, urbanization level, and socioeconomic status at a 1:4 ratio. We followed patients up to the end of 2013 or their death. The occurrence of laryngeal pathology was the primary outcome. Individuals with AR had a 2.43 times higher risk of laryngeal pathology than the comparison cohort group (adjusted HR: 2.43, 95% CI: 2.36-2.50, p < 0.001). Patients diagnosed as having AR exhibited higher comorbidity rates, including of asthma, COPD, CRS, gastroesophageal reflux disease, and nasal septum deviation, than those of the comparison cohort. Our results strongly indicate that AR is an independent risk factor for laryngeal pathology. Therefore, when treating AR and voice problems, physicians should be attuned to possible laryngeal pathology.

Increased Risk of Nasal Septal Abscess After Septoplasty in Patients with Type 2 Diabetes Mellitus

OBJECTIVE/HYPOTHESIS

To investigate the risk of nasal septal abscess (NSA) in patients with type 2 diabetes mellitus (T2DM) after septoplasty.

STUDY DESIGN

Retrospective cohort study through Taiwan National Health Insurance database.

METHODS

The Taiwan National Health Insurance Research Database was used to conduct this retrospective cohort study. A total of 382 patients with T2DM (DM group) diagnosed between 2000 and 2010 and 382 matched patients without a DM diagnosis (non-DM group) were enrolled. Patients were followed up until death or December 31, 2013. NSA incidence was the main outcome.

RESULTS

After septoplasty, the cumulative incidence of NSA in the DM group was significantly higher than that in the non-DM group (P < .001). Cox proportional hazards regression indicated a significant association between T2DM and higher NSA incidence (adjusted hazard ratio, 2.62; 95% CI, 1.44-3.61; P < .001). However, subgroup analysis and sensitivity testing demonstrated that the effect of T2DM on NSA risk was stable. In addition, the subgroup with a Diabetes Complications Severity Index (DCSI) of ≥1 had higher NSA risk than that with DCSI = 0 (adjusted hazard ratio, 3.58; 95% CI, 2.10-6.09; P < .001). The treatment type for NSA did not differ between the groups.

CONCLUSIONS

T2DM is an independent risk factor for NSA in patients undergoing nasal septoplasty, and the NSA risk is greater among patients with high DM severity.

LEVEL OF EVIDENCE

IV Laryngoscope, 131:E2420-E2425, 2021.

Complicated Posterior Cervical Skin and Soft Tissue Infections at a Single Referral Center

Background

Although the incidence and mortality of complicated skin and soft tissue infections have decreased, this infection is still relatively frequent and can be associated with lethal complications. In this study, the authors present our clinical experience of patients with complicated posterior cervical skin and soft tissue infections (CPCSSTIs) diagnosed and treated in a reconstructive unit in northeastern China.

Methods

A retrospective chart review of patients diagnosed with CPCSSTIs from January 2009 to December 2018 was performed. To make the results objective and convincing, a data analysis was performed relating to demographic characteristics, clinical presentation, predisposing factor, bacterial culture, laboratory and radiographic evaluations, diagnostic clues, management, and complications as well as the clinical course and outcome.

Results

During the ten-year period, there were 174 consecutive patients admitted to our reconstructive center with final diagnosis of CPCSSTIs included. All the patients were adults, and the majority were male (67.2%). The patient's mean age was 51.3 years (range, 15-88 years). There were 114 patients (65.5%) that had associated systemic diseases, with diabetes mellitus (40.2%) as the most common predisposing factor. Common presented clinical symptoms were pain (90.8%), swelling (85.1%), and erythema (77%) of the neck. Surgical treatment was performed in all the patients, and most of them (83.9%) received the first surgery within 24 h. The most commonly isolated pathogen was Staphylococcus aureus (30%). Vancomycin (21.3%) was the most commonly used antibiotics, followed by cefepime (18.4%). All the patients survived and were discharged with a mean duration of hospitalization of 28.7 days. Those patients with predisposing factors (31.4 ± 12.35 days) or complications (41.0 ± 12.5 days) tended to have a longer hospital stay. The mean total costs of admission per patient were 47 644 RMB.

Conclusion

This study highlights the high cost burden of CPCSSTI patients. Those patients with predisposing factors or complications tended to have a longer hospital stay.

Deep Neck Infection in Systemic Lupus Erythematosus Patients: Real-World Evidence

Systemic lupus erythematosus (SLE) might increase deep neck infection (DNI) risk, but evidence supporting this hypothesis is limited. In this retrospective follow-up study, the SLE-DNI association was investigated using data from the Registry for Catastrophic Illness Patients, which is a subset of the Taiwan National Health Insurance Research Database. All patients newly diagnosed as having SLE in 1997-2011 were identified, and every SLE patient was individually matched to four patients without SLE according to sex, age, and socioeconomic status. The study outcome was DNI occurrence. DNI treatment modalities and prognoses in SLE and non-SLE patients, along with the association of steroid dose with DNI risk, were also studied. In total, 17,426 SLE and 69,704 non-SLE patients were enrolled. Cumulative DNI incidence was significantly higher in the SLE cohort than in the non-SLE cohort (p < 0.001). The Cox regression model demonstrated that SLE significantly increased DNI risk (hazard ratio: 4.70; 95% confidence interval: 3.50-6.32, p < 0.001). Moreover, in the sensitivity and subgroup analyses, the effect of SLE on DNI was stable. Relatively few SLE-DNI patients received surgical interventions (15.6% vs. 28.6%, p = 0.033). The between-group differences in tracheostomy use and hospitalisation duration were nonsignificant. In SLE patients, high steroid doses significantly increased DNI incidence (≥3 vs. <3 mg/day = 2.21% vs. 0.52%, p < 0.001). This is the first study demonstrating that SLE increases DNI risk by approximately five times and that high steroid dose increases DNI incidence in SLE patients.

Risk of Alzheimer's Disease in Obstructive Sleep Apnea Patients With or Without Treatment: Real-World Evidence

OBJECTIVE

To assess the risk of Alzheimer's disease (AD) in patients with obstructive sleep apnea (OSA) with or without treatment based on real-world evidence.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients newly diagnosed with OSA during 1997-2012 were identified using the National Health Insurance Research Database of Taiwan. Patients without OSA were randomly selected and matched in a 1:4 ratio by age, sex, urbanization level, and income. All patients were followed up until death or the end of 2013. The primary outcome was AD occurrence.

RESULTS

This study included 3,978 OSA patients and 15,912 non-OSA patients. OSA was independently and significantly associated with a higher incidence of AD in an adjusted Cox proportional hazard model (adjusted hazard ratio: 2.12; 95% confidence interval [CI], 1.27-3.56). The average period of AD detection from the time of OSA occurrence was 5.44 years (standard deviation: 2.96). Subgroup analyses revealed that the effect of OSA remained significant in patients aged ≥60 years, male subgroups, patients without CPAP or surgical treatment, and patients without pharmacological therapies. Patients with OSA who received treatment (continuous positive airway pressure or surgery) exhibited a significantly reduced risk of AD compared with those without treatment (incidence rate ratio 0.23, 95% CI, 0.06-0.98).

CONCLUSION

OSA is independently associated with an increased risk of AD. Treatment for OSA reduces the AD risk in OSA patients. AD irreversibility renders OSA as a potential modifiable target for slowing or preventing the process of AD development.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:2292-2298, 2020.

Epidemiology, Treatment, and Prevention of Nosocomial Bacterial Pneumonia

Septicaemia likely results in high case-fatality rates in the present multidrug-resistant (MDR) era. Amongst them are hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), two frequent fatal septicaemic entities amongst hospitalised patients. We reviewed the PubMed database to identify the common organisms implicated in HAP/VAP, to explore the respective risk factors, and to find the appropriate antibiotic choice. Apart from methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Enterobacteriaceae spp., MDR or extensively drug-resistant (XDR)-Acinetobacter baumannii complex spp., followed by Stenotrophomonas maltophilia, Chryseobacterium indologenes, and Elizabethkingia meningoseptica are ranked as the top Gram-negative bacteria (GNB) implicated in HAP/VAP. Carbapenem-resistant Enterobacteriaceae notably emerged as an important concern in HAP/VAP. The above-mentioned pathogens have respective risk factors involved in their acquisition. In the present XDR era, tigecycline, colistin, and ceftazidime-avibactam are antibiotics effective against the Klebsiella pneumoniae carbapenemase and oxacillinase producers amongst the Enterobacteriaceae isolates implicated in HAP/VAP. Antibiotic combination regimens are recommended in the treatment of MDR/XDR-P. aeruginosa or A. baumannii complex isolates. Some special patient populations need prolonged courses (>7-day) and/or a combination regimen of antibiotic therapy. Implementation of an antibiotic stewardship policy and the measures recommended by the United States (US) Institute for Healthcare were shown to decrease the incidence rates of HAP/VAP substantially.

The Association Between Decompensated Liver Cirrhosis and Deep Neck Infection: Real-World Evidence

BACKGROUND

Deep neck infection (DNI) can progress to become a life-threatening complication. Liver cirrhosis, which is related to poor immune conditions, is a likely risk factor for DNI. This study investigated the risk and mortality of DNI in patients with decompensated liver cirrhosis (DLC).

METHODS

We performed a nationwide cohort study using the National Health Insurance Research Database (NHIRD) in Taiwan. We included a total of 33,175 patients with DLC between 2000 and 2013, from the Catastrophic Illness Patient Database, a subsection of the NHIRD, along with 33,175 patients without cirrhosis who were matched in a 1:1 proportion for age, sex, and socioeconomic status. The occurrence of DNI was the primary study outcome. The risk, treatment, and mortalities of DNI were evaluated in the study and comparison cohorts.

RESULTS

DLC Patients had a significantly higher incidence of DNI than noncirrhotic patients (p < 0.001). The adjusted Cox proportional hazard regression showed that DLC was associated with a significantly higher risk of DNI (adjusted hazard ratio, 4.11; 95% confidence interval, 3.16-5.35, p < 0.001). The mortality rate in cirrhotic patients with DNI was not significantly higher than that in noncirrhotic patients with DNI (11.6% vs. 9.8%; p = 0.651).

CONCLUSIONS

This study is the first to investigate the correlation between DLC and DNI. The study findings strongly indicate that DLC is an independent risk factor for DNI. Cirrhotic patients with DNI do not have a significantly poorer survival rate than noncirrhotic patients with DNI. Therefore, physicians should be alert to potential DNI occurrence in DLC patients. Besides this, intensive care and appropriate surgical drainage can yield similar survival outcomes in DLC-DNI and noncirrhosis-DNI patients.

Real-world evidence for increased deep neck infection risk in patients with rheumatoid arthritis

OBJECTIVE

To investigate the association between rheumatoid arthritis (RA) and deep neck infection (DNI).

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients newly diagnosed with RA between 2000 and 2011 were identified from the National Health Insurance Research Database in Taiwan. Moreover, patients without RA were randomly selected and matched at a 1:4 ratio by age, sex, urbanization level, income, and diabetes mellitus. The patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of DNI.

RESULTS

In total, 30,207 patients with RA and 120,828 matched patients without RA were enrolled. Patients with RA had a significantly higher cumulative incidence of DNI than those without RA (P < 0.001). The adjusted Cox proportional hazard model demonstrated that RA was significantly associated with a higher incidence of DNI (hazard ratio: 2.80, 95% confidence interval: 2.26-3.46, P < 0.001). Therapeutic methods (surgical or nonsurgical) did not differ significantly between the patients with RA-DNI and with non-RA-DNI. Patients with RA-DNI had higher rates of tracheostomy, mediastinitis, mediastinitis-related mortality, and mortality than patients with non-RA-DNI, although these differences were without statistical significance. RA patients receiving no therapy experienced higher rates of DNI compared with those receiving methotrexate alone, disease-modifying antirheumatic drugs, or biologic therapies.

CONCLUSION

This study is the first to investigate the association between RA and DNI. We conclude RA is an independent predisposing factor for DNI.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1402-1407, 2020.