Parotid glands only have serous secretions. A decrease secretion or interruption of it can be caused by several factors that could be infectious (fungal, viral and bacterial) or noninfectious (sialolith, tumor, constriction, drugs, anesthesia, autoimmunity, radiotherapy, allergy, diabetes, etc.). This, in turn, could result in a decrease in ductal swish that leads to bacterial accumulation and growth around the Stenson’s duct orifice in a retrograde manner and causes sialadenitis. Staphylococcus aureus is the most commonly identified bacterial species, and the parotid gland has shown to be the most common involvement among other major salivary glands. Such an infection may extend in an acute and aggressive manner. Emergency care must be taken because of pain, swelling, and functional disabilities. Unless, the treatment has been done, Bell’s palsy may happen which would extend to the external auditory meatus and result in fistula formation and mediastinitis (11).
Nearly all of the authors have consensus on the antibiotic prescription in addition to supportive treatment (1–9, 11–17), but in Bradley et al. study (10), the incision and drainage has been suggested as a primary treatment.
As a treatment of choice, it has been focused on the empiric antibiotic prescription of Penicillin resistant to beta-lactamase or first generation cephalosporin. In some studies (12), Vancomycin, Teicoplanin and Linezolid have been suggested if there was any resistant species and for non-responsive cases. According to Harbison et al. study (13), anaerobes and aerobes are possibly covered by clindamycin, Cefoxitin, Imipenem, Metronidazole plus one macrolide or the Penicillin plus Clavulanate (Co- Amoxiclav). These results are the same as in Brook’s study (12). According to Enoch et al. (14), in two cases of bacterial sialadenitis with mixed bacterial involvement, after treatment with Flucloxacillin and Metronidazole, Vancomycin could cover the infection in resistant cases. As a conclusion, there is a consensus on the empiric antibiotic therapy on Penicillin resistant to beta-lactamase and first generation Cephalosporins. Brook believes in MRSAs (Methicillin-resistant Staphylococcus aureus) and gram negative species as a main cause in non-responding cases (12). There was a consensus in intravenous form as the way of prescription (2, 12–14). Although diabetics, patients on anti-hypertensive and anti-depressant drugs have also dry mouth, in the current study we decided to sample from patients with Sjogren’s syndrome, since the dry mouth can be proved by serum changes and biopsy as the diagnostic criteria of this syndrome according to AECG criteria (1) but in mentioned conditions collecting non-stimulating saliva is necessary for diagnosis which may not be accurate enough for definite diagnosis. Patients with secondary Sjogren’s syndrome are more frequent than primary ones, and we preferred to take the samples from them.
According to one study (18), SA has been isolated from 55% of infections and remnant 45% of the cases are specified to: gram positive bacteria (Streptococcus Viridans, Pyogenic
Streptococci, Peptostreptococci, Hemophilus influenza) and in 22% cases, gram negative
bacillus (Pseudomona aeroginosa, Klebsiella pneumonia, Neisseria catharalis, E-coli) in 16% of
cases and anaerobes (Salmonella, Fusobacterium, Bacteroides, Prevotella and Porphiromunas)
in 4% of cases (10, 12). In some other studies, parotiditis has been rarely reported from
Mycobacterium Tuberculosis, Mycobacterium Keluna and Mycobacterium Fortuitum (8–10).
E-Test method is the most sensitive and accurate method to evaluate microbial sensitivity in microbiology. It is also able to evaluate MIC. This method has more utility in resistant infections, parotiditis extended to anatomic spaces, and in hospitalized patients. Therefore, we used E-Test to compare two first line antibiotics to combat SA isolated from patients with Sjogren’s
syndrome. In this study the patients should have not consumed any antibiotics at the time of sampling or within 21 days before it. In some studies this time has been considered to be four to six weeks, while in other studies the authors didn’t persist on it. These are while Chardin (21) excluded patients who had consumed antibiotics at the time of sampling or within 45 days before it.
The subjects’ age range varied from 29 to 78 years old, and we divided them into two groups of 29–54 and 55–78 years-old. We found a significant difference between the bacterial sensitivity to Oxacillin and Cephalothin (p = 0.001). The correlation coefficient between variables was 0.821, which was also significant (p = 0.0001) which shows a linear relationship between the two groups and this means that every increase in Oxacillin MIC measure can be observed for Cephalothin, too. There was a significant relationship between age and average MIC measurement for both antibiotics (p = 0.004 and p = 0.47 for age groups 29–54 and 55–78, respectively). There was also a significant relationship between gender and average MIC measurement of both antibiotics. (p = 0.01 and p = 0.008 for men and women, respectively).
Comparing MIC measures of the two antibiotics between two age groups, we found it higher in patients older than 55 years old; in other words, higher dosages are required to cover infection in elderly patients. It can be described such a difference from different aspects. First of all, a young patient may have experienced fewer infections, less drug and side effects of them like nonresponsiveness as a result of MRSA existence. But elderly patients have been suffered from dry mouth for many years, which leads to more DMFT values in two jaws. According to Mc Farlane study (22), these patients have shown greater isolation of SA, Candida Albicans and Coliform Bacillus. Secondly, poly-pharmacy is the main cause of dry mouth in elderly patients which can complicate xerostomia in Sjogren’s syndrome patients. The third reason, it has been proved that xerostomia is more extensive and persistent among the elderly patients (1).
Observing greater average MIC values in women compared to men could be related to the factors affecting the local and systemic immunity. Recently, British scientists in Cambridge University have found micro-RNAs on the X-chromosomes being silent in the healthy situations and active during infection and neoplasia. This fact has also been supported by Belgian and Canadian scientists (23–25). In autoimmune disorders like Sjogren’s syndrome, these micro-RNAs can't
be as useful as they must be and weakens the systemic defense which may describe the risen
average MIC. In a study in China, researchers found greater values of DMFT, trauma from occlusion and wearing in women than men which reveals the weaker local immunity in women compared to men (26).
In the current study, SA was isolated from 30 patients (48%) which was more similar to the Jackson study (with 56%) than to Smith’s (with 60%). It may be because of similarity in the manner of sampling (applying paper point instead of the swap). Sampling by swab on mucosa can involve to the orifice and remove bacteria more effectively than sampling by paper point. According to Smith et al. (27) SA can be isolated from 20% of healthy adults which is similar to Jackson et al. study (28) with the rate of isolation about 24% in adults, 36% in elderly patients and 56% in RA patients. This isolation would be greater in infants, elderly patients, RA and Sjogren’s patients and blood dyscrasias. Again in Smith study, SA isolation was about 23–48% in denture patients and 63% in denture patients with angular cheilitis. SA is classified to MSSA (Methicillin Sensitive Staph Aureus) and MRSA (Methicillin Resistant Staph Aureus). According to Smith (27) the MSSA varies between the regions being sampled from. For example, sampling with the swap from parotid duct in comparison with other regions of the mouth (tongue, buccal mucosa, floor of the mouth, and saliva) showed less isolated MRSA. Resistance was reported in only 3% of the patients, and about 97% of the patients were MSSA. The MRSA prevalence was mostly related to age, hospitalization and missing teeth. The result of this study was similar to ours.
In a review study of Turnige et al. (20), from the studies of Fong et al.(29) and Regamey et al.(30), it has been concluded that the Cephalosporins have a variable stability in front of Beta-lactamase which relates to its chemical constructions.
According to the Steckleberg et al. (31) and Carrizosa et al. (32), Cephalothin and Cephazolin were less effective in rabbit models with endocarditis. Glinka et al. (33), Vouillamoz et al. (34) and Chambers et al. (35), have concluded that the first-generation Cephalosporins are more effective than second and third-generations. None of the Cephalosporins except Cefamandole, Cefuroxime and cefaclor, are effective against SA, but it is obvious that all Cephalosporins can make primary coverage against it. Beta-lactamase Resistant Penicillins (Dicloxacillin, Nafcillin, Oxacillin and Flucloxacillin) are different from each other but this difference is not significant, and their average MIC has been calculated between 0.125 and 0.5.