The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin

The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin

YBJOM-4255; No. of Pages 3 ARTICLE IN PRESS Available online at www.sciencedirect.com British Journal of Oral and Maxillofacial Surgery xxx (2014) x...

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YBJOM-4255; No. of Pages 3

ARTICLE IN PRESS Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx

Leading article

The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin Samir Farmahan ∗ , Dery Tuopar, Phillip J. Ameerally Northampton General Hospital, Oral and Maxillofacial Department, Cliftonville, Northampton, NN1 5BD, Oral and Maxillofacial Department, Northampton General Hospital (England) Accepted 4 February 2014

Abstract It is common surgical practice to take a specimen for microbial culture and sensitivity when incising and draining infections of odontogenic origin in the head and neck. We aimed to find out if routine testing has any therapeutic value. We retrospectively studied 90 patients (57 male and 33 female) admitted to Northampton General Hospital for treatment of odontogenic infections, and reviewed admission details, antimicrobial treatment, microbiological findings and their sensitivity or resistance, and complications. Specimens were sent from 72 (80%) patients of which 61 (85%) were infected. The most commonly isolated organism was Streptococcus viridans. Interim reports were published after a mean of 3 days (range 1-4), and 94% of patients were discharged within a mean of 2 days (range 0-9) postoperatively. Almost 95% of patients were discharged before results were available, and there were no reported complications. We therefore suggest that microbial culture has little therapeutic value in the management of these patients. With culture and sensitivity tests costing £25 - £30, omission of this practice in the case of uncomplicated (single tissue space) odontogenic infections could save resources in the National Health Service without affecting the care of patients. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Relevance; Microbiology; Specimens; Odontogenic; Dental; Infections

Introduction Culture and sensitivity testing is considered essential for the treatment of many infections. For infections of odontogenic origin in the head and neck, treatment usually involves removal of the causative tooth, incision and drainage, and antibiotics. Many patients recover quickly and are discharged from hospital promptly. Organisms that cause odontogenic infections have been described at length,1–3 but there is little evidence of the therapeutic benefit of culture in these cases. We therefore aimed

∗ Corresponding author at: 14 Myrtle Avenue, Bedfont, Middlesex, TW14 9QU. Tel.: +07824811360. E-mail address: Farmahan [email protected] (S. Farmahan).

to find out whether routine culture and sensitivity tests have any therapeutic value in the treatment of patients with odontogenic infections.

Methods We retrospectively studied data from the clinical records of 90 patients admitted for inpatient treatment of odontogenic space infections in the head and neck at Northampton General Hospital between April 2011 and March 2013. Patients were identified from the Trust’s database. Details included age, sex, smoking status, associated medical conditions, antibiotics given, previous antibiotic treatment, duration of hospital stay, dates of interim and final

http://dx.doi.org/10.1016/j.bjoms.2014.02.027 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Farmahan S, et al. The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.02.027

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Table 1 Antibiotics prescribed intravenously.

Table 2 Microbiological results.

Antibiotic

No. (%) of cases (n = 90)

Isolated organism

No. (%) of cases (n = 61)

Amoxicillin + metronidazole Co-amoxiclav Co-amoxiclav + metronidazole Clindamycin + metronidazole Clarithromycin + metronidazole Metronidazole Cefuroxime + metronidazole

33 (37) 31 (34) 10 (11) 8 (9) 5 (6) 2 (2) 1 (1)

Streptococcus viridans Anaerobes Group C streptococci Group B streptococci Staphylococcus aureus Streptococcus milleri Candida albicans

35 (57) 15 (25) 3 (5) 2 (3) 2 (3) 1 (2) 3 (5)

bacteriological results, results of culture and sensitivity, and complications.

Results A total of 57 male and 33 female patients with a mean age of 37 years (range 1 – 95) were included. Of them, 49 (54%) were smokers, and 16 (18%) were allergic to penicillin. From onset the mean delay in presentation to accident and emergency (A&E) was 5 days (range 0-22), and 3 days (range 0-17) to a general dental practitioner or general medical practitioner. There were 61 (68%) referrals from A&E, 15 (17%) from dentists, and 14 (16%) from general practitioners. A total of 44 patients (49%) had previously had antimicrobial treatment orally before presenting to the hospital, either from their dentist or general practitioner. The mean length of the course of antibiotics taken before presentation to A&E was 4 days (range 1-10). All 90 patients were given antibiotics intravenously as inpatients and had a mean of 6 doses (range 2-22). Most were prescribed amoxicillin and metronidazole or co-amoxiclav on admission (Table 1). Ten (11%) were given antibiotics only, 14 (16%) had incision and drainage under local anaesthesia, 3 (3%) has incision and drainage under general anaesthesia, 5 (6%) had a tooth extracted and incision and drainage under local anaesthesia, 7 (8%) had a tooth extracted under general anaesthesia, and 51 (57%) had a tooth extracted and incision and drainage under general anaesthesia. The mean time from presentation to treatment was one day (range 0-3) and from treatment to discharge was 2 days (range 0-9). The mean duration of hospital stay was 3 days (range 1-10). A total of 72 (80%) patients had swabs taken, and microorganisms were isolated in 61 (85%). Of these, bacteria were isolated in 58 (95%) cultures: 43 (74%) were aerobic infections and 15 (26%) were anaerobic. All infected samples were tested for anaerobic sensitivity. Candida albicans was identified in 3 samples. The most commonly isolated organism from all cases was Streptococcus viridans (Table 2). Interim microbiological results were published in 48 (79%) cases and were available in a mean of 3 days (range 1–4) after collection. Final results were available in all cases

after a mean of 5 days (range 3 – 9). Antibiotic regimens were not changed for any patients after the results became available. A total of 74 (82%) patients were discharged with antibiotics orally. Nine (10%) were prescribed antibiotics that would not have been effective in treating the isolated bacteria and they were all discharged before the results were available. Usually, patients were given postoperative antibiotics intravenously for about 2 days. Around 80% 74 patients were discharged with a 5-7 day course (mean 6) of antibiotics to take orally. The mean duration of antibiotic treatment was 10 days (range 1-18) (Fig. 1). This included antibiotics taken before admission, and those given while an inpatient and at discharge. According to clinical records, no patients required further intervention or alteration of prescribed antimicrobial treatment after discharge.

Discussion Microbial culture and sensitivity is regarded as essential for the treatment of many infections. Treatment of odontogenic infections in the head and neck usually includes removal of the causative tooth, incision and drainage, and antibiotics. However, in clinical practice, antimicrobial treatment is commenced before results are available. Our study shows no short-term complications after treatment with antibiotics or operation, or both. Although swabs were taken in 80% of patients, most were discharged before any microbiological results were available. Cultures showed documented and common organisms known to cause odontogenic infections,1–4 and the antimicrobial sensitivities of these organisms were also predictable.3–6 This shows that these investigations lack therapeutic value. Clinicians are aware of the technical difficulties with taking a swab from the depth of a wound. Contamination from contact with the skin or oral mucosa can provide misleading of incorrect information,7 and the resulting culture may reflect only surface contamination and not correlate with the pathogenic bacteria.8,9 The culture and reporting of a microbiological specimen has been reported to cost £25–£30, not including the

Please cite this article in press as: Farmahan S, et al. The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.02.027

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Fig. 1. Duration of overall antibiotic treatment.

associated staff costs.10 The 72 samples taken for this group cost approximately £2000. Our study is limited by its retrospective nature. We are currently collecting prospective data on patients with infections in the head and neck. Although no patients were readmitted or required further intervention after discharge, they could have presented again to their dentist, general practitioner, or another A&E department. The results would have been stronger if the patients had been followed up and checked for postoperative complications.

Conclusions We propose that sampling in patients who present with uncomplicated (single tissue space) odontogenic infections in the head and neck is not done routinely. However, this would not be appropriate in patients with immunodeficiency, complicating coexisting conditions, or postoperative complications.

Conflict of Interest Statement There have been no financial and personal relationships with other people or organisations that could inappropriately influence (bias) our work.

Ethics Statement No work on patients or volunteers was performed and so ethical approval was not required.

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Please cite this article in press as: Farmahan S, et al. The clinical relevance of microbiology specimens in head and neck space infections of odontogenic origin. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.02.027