Severe odontogenic infections with septic progress - a constant and increasing challenge

doi:10.21203/rs.2.9842/v1

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Severe odontogenic infections with septic progress - a constant and increasing challenge

https://doi.org/10.21203/rs.2.9842/v1

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published 02 Aug, 2019

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Objective

More than 90% of all infections of the head and neck region can be traced back to an odontogenic origin. In rare cases they can lead to sepsis, which may pose a vital threat to the patient. The purpose of this study was to analyse characteristics concerning etiology and progress of severe odontogenic infections with a fulminant development.

Patients and Methods

In a retrospective analysis from 02/2012 to 09/2017 all patients with odontogenic infections requiring hospital admission were included. Among 483 patients 16 patients (13 male, 3 female) showed severe exacerbation with septic progress. The average age was 52.8 years. All patients underwent at least one surgical procedure that involved an extraoral incision and drainage as well as high volume irrigation intraoperatively. At least one revision was required for 4 of the patients. 3 patients showed an exceedingly severe disease progression with multiorgan dysfunction syndrome (MODS) and circulatory arrest. Antibiotic treatment was adjusted according to the results of an antibiogram and resistogram. Irrigation with saline was done multiple times daily.

Results

16 patients showed odontogenic infections that spread over multiple maxillo-facial and cervical regions accompanied by septic laboratory signs. All these patients needed intensive care and a tracheostomy. The hospitalization period on the average was 27.8 days. In 16 cases risk factors e.g. for the development of odontogenic abscesses were present. Intraoperative swabs showed a typical polymicrobial aerobic and anaerobic spectrum of oral bacterias, especially anaerobes and streptococci, mainly Streptocococcus viridans.

Conclusion

Odontogenic infections with fulminant progression should be treated according to clinical and imaging data with immediate surgical incision and drainage including elimination of odontogenic focus and intensified intra- and postoperative irrigation. If needed, repeated imaging followed by further incisions must be performed. Immediate antibiotic treatment adapted to the antibiogram is of most importance.

Clinical relevance

For abscesses that spread over multiple levels with initial signs of severe infections a combination of tazobactam and piperacillin has proven to be a good first choice and can be recommended as such.

Head & Neck Surgery

Dentistry

odontogenic infection

sepsis

antibiotic therapy

septicaemia

hospital care

Odontogenic infections make up the majority of infections of the head and neck area (Zheng L et al., 2013). Odontogenic infections can spread and cause severe complications, e.g. compromised airways, sepsis, tissue necrosis, endocarditis, mediastinitis and deep neck infections. (Igoumenakis D et al., 2014) These severe odontogenic infections can be potentially life-threatening (Wang LF et al., 2003; Zheng L et al., 2013). There are several predisposing factors which may exacerbate odontogenic infections, such as immunodeficiency (HIV), long-term diabetes mellitus, obesity, chronic alcohol abuse, hepatitis, liver cirrhosis, immunosuppression after organ transplantation, chemotherapy, radiotherapy and systemic lupus erythematosus (Juncar M et al., 2014; Peters ES et al., 1996; Sandner A, 2011; Seppänen L et al., 2008; Whitesides L et al., 2000) Usually odontogenic infections respond well to a combination of surgical sanitation, incision and drainage and antibiotic therapy. (Jundt JS, 2012; Wang LF et al., 2003) Odontogenic infections exhibit a variety of different pathogens. Streptococci, especially Streptococcus viridans, a representative of gram-positiv aerobic bacteria and Prevotella species, an gram-negative anaerobic bacteria are common pathogen in odontogenic infections (Nair PN, 2004; Warnke PH et al., 2008). The purpose of this study was to discover initial and follow up characteristics in terms of etiology and sequence of especially severe manifestations of odontogenic abscesses.

This retrospective study included all 483 patients with odontogenic infections, who were hospitalized from February 2012 to September 2017 at the Department of Oral and Maxillofacial surgery, University Hospital Tubingen. The treatment for all patients included incision, drainage and surgical sanitation of the odontogenic focus plus antibiotic treatment. Intraoperative swabs were taken to adjust the antibiotic treatment following performance of an antibiogram and a resistogram. From this population 16 patients (13 male, 3 female) with an average age of 52.75 (SD 9.5) exhibited critical courses and required postoperative intensive medical care. 9 patients had a preoperative CT-scan to get an exact overview over the extension of the infection. We confirm that I have read the Helsinki Declaration adn have followed the guidelines in this investigation. This study has been approved by the local ethical committee.

All 16 patients suffered from preexisting conditions, some of which may have contributed as predisposing factors for odontogenic abscesses and a systemic inflammatory reaction, for example, diabetes mellitus, obesity, chronic alcohol and nicotine abuse, rheumatism, cardiological and neuro-psychiatric disorders and poor oral hygiene. A decayed mandibular molar or premolar was the infectious focus in all 16 patients (Table 1). All patients showed swelling of the affected areas, trismus, dysphagia, dyspnea, affection of several fascial spaces, phlegmonous spread and laboratory parameters of septicemia and a CRP above 200 mg/l with white blood cell counts greater than 19*1000/ µl at admittance. Preoperatively the white blood cell count averaged 22.0±10.6*1000 cells/µl, the CRP 251±1.0 mg/ml. The preoperative CT scan of the head and neck region in 9 patients provided an exact overview of the extension of the infection and the affected fascial spaces. An antibiotic therapy with Clindamycin 600 mg 1-0-1 was administered in 3 patients already before hospital admission and surgical sanitation of the odontogenous focus. All Patients underwent extraoral incision, drainage of the affected areas and elimination of the odontogenic focus under general anaesthesia. On average the maximum number of drainage tubes inserted was 9.1± standard deviation. A second look surgery was required in 4 patients, in 2 cases up to 4 surgical operations and in 2 cases up to 6 operations.

9 patients received an initial intravenous antibiotic therapy in calculated manner with cefuroxim 1.5 g 3x /d and 7 patients with ampicillin/sulbactam 3g 3x/d after hospital admission. Intraoperative swabs were taken by inserting the swab into the abscess space. These swabs showed a typical polymicrobial aerobic and anaerobic spectrum of oral bacterias. Streptococcus viridans was the most predominating bacterium (75 %) , followed by Staphylococcus epidermidis (38 %), Enterococcus faecalis (31 %) and Prevotella oris (31 %) (table 2). All antibiograms and resistograms included following antibiotics: ampicillin, ceferoxime, clindamycin, erythromycin, penicillin, piperacillin and tazobactam. Clindamycin had an increased resistence to all groups of microrganisms whereas tazobactam and piperacillin showed suspectibility to all isolated bacteria (table 3).

In all 16 patients postoperative intensive medical care was required. The average length of postoperative medical care was 20.3 days (ranging from 8 to 33 days). All patients needed a temporary tracheostomy to secure airway management. The mean postoperative artificial respiration time was 15.6 days (ranging from 6 to 27 days). The average length of the inpatient stay was 27.8days (ranging from 11 to 40 days). 5 patients had multi organ dysfunction syndrome (MODS) and circulatory arrest. The abscess cavity was irrigated multiple times a day (mean 2.3/die) with 100 ml or more saline 0.9%. According to the swab results antibiotic treatment was adjusted to the antibiogram in all cases. After 2.3 days on average antibiotic treatment with tazobactam and piperacillin was started for all patients showing signs of a septic course. The mean time for the CRP parameter to decrease was during the third inpatient day (Figure 2). Generally, the white blood cell count dropped on the first postoperative day (Figure 3).

Odontogenic abscesses with fulminant progression that lead to severe, sometimes life-threatening complications like sepsis, airway obstruction, fasciitis, tissue necrosis, acute respiratory distress syndrome (ARDS), thrombosis, mediastinitis, and multiorgan dysfunction syndrome (MODS) are rare, but require extensive interdisciplinary collaboration especially with specialists for anesthesiology and intensive care medicine. Some predisposing factors or co-morbidities, e.g. diabetes mellitus, obesity, poor oral hygiene, and long-term nicotine or alcohol abuse may aggravate such septic progressions. These cases show greatly increased inpatient times combined with a worse prognosis compared to patients who do not exhibit the named factors (Lorenzini G et al, 2011; Seppänen L et al., 2008; Tung-Yiu W et al., 2000).

During the observation period of 5.5 years 16 of 483 patients (3.3%) with odontogenic infections showed a septic course. All 16 patients displayed at least one risk factor or co-morbidity, which may have promoted the critical course of their infection with extended hospitalisation and intensive care. We observed in all 16 cases of severe odontogenic abscesses a premolar or molar mandibular focus and demand for postoperative respiratory assistance or tracheostomy. This is in accordance with recent literature (Sanchez R et al., 2011; Zheng L et al., 2013). We recommend a preoperative CT-scan with contrast agent in cases with septic laboratory signs to get an exact overview of the extension of the abcess space. If the expected alleviation after initial surgical treatment with incision, drainage and perioperative antibiotic therapy is delayed, an immediate re-CT examination and targeted re-incision should be initiated without hesitation (Kinzer S et al., 2009). In our findings clindamycin demonstrated a reduced susceptibility in all groups of isolated pathogens. Tazobactam and piperacillin showed no resistence to any bacteria isolated.

Surgical intervention included incision, drainage, sanitation of the odontogenic focus and antibiotic treatment as the first-line therapy (Jundt JS, 2012). Current literature is controversial on whether irrigative or non-irrigative drainage tubes are superior (Bouloux GF et al., 2012). From our experience, we prefer high-volume irrigation of the abscess cavity with isotonic saline solution (0.9%) in cases with septic progression. This hypothesis corresponds with our findings. The isolated pathogens of the intraoperative swabs showed a typical polymicrobial aerobic and anaerobic spectrum of oral bacteria. Streptococcus viridans and Staphylococcus epidermidis, Enterococcus faecalis were the most predominating pathogens. The initial calculated antibiotic therapy should have a focus on these pathogens to inhibit the risk of infection spreading and lower the risk of possible serious complications. Initiating a pathogen adapted antibiotic treatment as soon as possible and with tazobactam and piperacillin in combination as first line medication is preferred. Patients that show CRP values above 200 mg/l and white blood cell counts greater than 19*1000/µl on admission require special attention. Our patients showed a noticeable decrease in their inflammation parameters during the second day after use of tazobactam and piperacillin.

Conclusion

1. Bouloux GF et al., 2012. Irrigating drains for severe odontogenic infections do not improve outcome. J Oral Maxillofac Surg. (71(1)), 42–46.

2. Igoumenakis D et al., 2014. Severe odontogenic infections: causes of spread and their management. Surg Infect (15), 64–68.

3. Juncar M et al., 2014. Evolution assessment of head and neck infections in diabetic patients- a case control study. J Cranimaxillofac Surg (42), 498–502.

4. Jundt JS, G.R., 2012. Characteristics and cost impact of severe odontogenic infections. Oral Surg Oral Med Oral Path Oral Radiol (114), 558–566.

5. Kinzer S et al., 2009. Severe deep neck space infections and mediastinitis of odontogenic origin: clinical relevance and implications for diagnosis and treatment. Ata Otolaryngeal (129), 62–70.

6. Lorenzini G et al, 2011. Cervical necrotizing fasciitis of odontogenic origin involving the temporal region - a case report. J Cranimaxillofac Surg (39), 570–573.

7. Nair PN, 2004. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med (15), 348–381.

8. Peters ES et al., 1996. Risk factors affecting hospital length of stay in patients with odontogenic maxillofacial infections (54(12)), 1386–1391.

9. Sanchez R et al., 2011. Severe odontogenic infections: epidemiological, microbiological and therapeutic factors. Med Oral Pat Oral Cir Bucal (16), 670–676.

10. Sandner A, B.J., 2011. Update on necrotizing mediastinitis: causes, approaches to management and outcomes. Curr Infect Dis Rep (13(3)), 278–286.

11. Seppänen L et al., 2008. Analysis of systemic and local odontogenic infection complications requiring hospital care. J Infect (57(2)), 116–122.

12. Tung-Yiu W et al., 2000. Cervical necrotizing fasciitis of odontogenic origin: a case report of 11 cases. J Oral Maxillofac Surg (58), 1347–1352.

13. Wang LF et al., 2003. Characterizationsof life-threatining deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol (24(2)), 111–117.

14. Warnke PH et al., 2008. Penicillin compared with other advanced broad spectrum antibiotics regarding antibacterial activity against oral pathogens isolated from odontogenic abscesses. J Craniomaxillofac Surg (36(8)), 462–467.

15. Whitesides L et al., 2000. Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases. J Oral Maxillofac Surg (58(2)), 144–151.

16. Zheng L et al., 2013. Comparison of multi-space infections of the head and neck in the eldery and non-eldery: part I the descriptive data. J Cranimaxillofac Surg (41), 208–212.

Ethics approval and consent to participate

The study was appoved by the local independent Ethics Committee of the University Hospital Tuebingen.

Consent for publication

Any Patient signed our institutional consent form to publish individual person’s data.

Availability of data and materials

All Data and Materials are available at a local server of the Department of Oral and Maillofacial Surgery of the University Hospital Germany.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors

Competing interests

The authors declare that they have no competing interests

Authors' contributions

HW and drafted the manuscript and developed the design. AN an Cw participates in its design and performed statistical analysis. SR participated in its design. SH participated in its design and coordination. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

No.	Gender	Age (years)	Etiology (tooth)	Risk factors/ comorbidities	Therapy	Complications
1	♂	53	35	obesity, nicotine abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, revision (6x), tracheostomy	sepsis, acute respiratory insufficiency
2	♂	62	47	obesity, diabetes mellitus, nicotine abuse, alcohol abuse, depression, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, MODS, acute respiratory insufficiency
3	♂	44	36	nicotine abuse, depression, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
4	♀	39	46	obesity, diabetes mellitus, COPD, nicotine abuse, poor oral hygiene	tooth removal, extra-/intraoral incision and drainage, revision (4x), tracheostomy	sepsis, MODS, circulatory arrest, acute respiratory insufficiency
5	♂	77	46	diabetes mellitus, COPD, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
6	♂	65	36	rheumatism, chronic heart failure	tooth removal, extra-/intraoral incision and drainage, revision (4x), tracheostomy	sepsis, MODS, circulatory arrest, acute respiratory insufficiency
7	♂	45	35	Nicotine abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
8	♀	49	37	obesity, diabetes mellitus, alcohol abuse, nicotine abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
9	♂	57	36	depression, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
10	♀	37	46	obesity, diabetes mellitus, poor oral hygiene	tooth removal, extra-/ intraoral incision and drainage, tracheostomy	sepsis, acute renal failure,acute respiratory insufficiency
11	♂	63	34	obesity, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
12	♂	52	47	depression, nicotine abuse, NSAR abuse, poor oral hygiene	tooth removal, extra-/ intraoral incision and drainage, revision (6x), tracheostomy	sepsis, MODS, circulatory arrest, acute respiratory insufficiency
13	♂	47	46	nicotine abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
14	♂	54	46	depression, nicotine abuse, NSAR abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, MODS, acute respiratory insufficiency
15	♂	51	36	nicotine abuse, poor oral hygiene	tooth removal, extra-/ intraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency
16	♂	49	35	COPD, nicotine abuse, poor oral hygiene	tooth removal, extraoral incision and drainage, tracheostomy	sepsis, acute respiratory insufficiency

Table 1 Overview of patients with severe odontogenic infections with septic progression

Bacteria

No of patients (%)

Gram-positiv aerobic bacteria

Streptococcus viridans

Staphylococcus epidermidis

Streptococcus constellatus

Streptococcus salvarius

Streptococcus oralis

Enterococcus faecalis

12 (75 %)

6 (38 %)

3 (19%)

2 (13 %)

1 (6 %)

5 (31 %)

Gram-negative aerobic bacteria

Neisseria subflavia

Escheria coli

2 (13 %)

1 (6 %)

Gram-negative anaerobic bacteria

Prevotella oris

Haemophilus haemolyticus

Porphyromonas gingivalis

5 (31 %)

3 (19 %)

2 (13 %)

Gram-positive anaerobic bacteria

Actinomyces meyeri

Peptostreptococcus micros

3 (19 %)

1 (6%)

Table 2 Bacteria cultured from odontogenic infections with septic progress

Antibiotics	Number of isolates susceptible for	Number of isolates resistant to
Ampicillin	14 (87 %)	2 (13 %)
Ceferoxime	13 (81 %)	3 (19 %)
Clindamycin	10 (62 %)	6 (38 %)
Erythromycin	11 (69 %)	5 (31 %)
Penicillin	12 (75 %)	4 (25%)
Piperacillin/tazobactam	16 (100 %)	0 (0 %)

Table 3 Susceptibility and resistence of isolated pathogens from odontogenic infections

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Journal Publication

published 02 Aug, 2019

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Review #2 received at journal
07 Jul, 2019
Editorial decision: Minor revision
07 Jul, 2019
Reviewer #2 agreed at journal
05 Jul, 2019
Review #1 received at journal
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Reviewer #1 agreed at journal
28 May, 2019
Reviewers invited by journal
23 May, 2019
Submission checks completed at journal
22 May, 2019
Editor invited by journal
22 May, 2019
Editor assigned by journal
22 May, 2019
First submitted to journal
08 May, 2019

You are reading this older preprint version

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Severe odontogenic infections with septic progress - a constant and increasing challenge

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Abstract

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Introduction

Materials and Methods

Results

Discussion

References

Declerations

Table

Status:

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