Risk Factors Affecting Length of Stay in Patients with Deep Neck Space Infection.

OBJECTIVES: Analyze risk factors affecting length of stay (LOS) for patients presenting with deep neck space infections including care by medical versus surgical team. METHODS: This is a retrospective chart review from January 2005 through May 2018 at the University of Kentucky analyzing factors related to deep neck space abscesses. Patients included adults >18 years old admitted for deep neck space infections undergoing surgical intervention. This study compared effects of treatment on a medical versus surgical service on LOS while accounting for patient confounders. Independent variables included age, gender, tobacco use, medical comorbidities, Charlson comorbidity index, American Society of Anesthesiology (ASA) classification, presence of drain, readmissions, and repeat surgical interventions. Univariate and multivariate analysis were performed. RESULTS: One hundred sixty-three patients were included in the analysis. LOS was significantly longer for those on medicine services (P < .001). Patients on medicine services had a higher incidence of diabetes (P = .011), higher Charlson comorbidity score (P = .001), and higher incidence of repeat interventions (P = .005). Postoperative LOS remained lower for patients on a surgical service (P = .009) after adjusting for Charlson comorbidity scores. Presence of a drain or tobacco use was not significant between service management (P = .89; P = .63) or LOS (P = .366; P = .225). CONCLUSION: Increased postoperative LOS was associated with age, diabetes, ASA class, Charlson comorbidity index, and repeat procedures. Patients on a medicine service had longer LOS and higher comorbidity indices. Patients had shorter hospital stays on surgical services after adjusting for comorbidity indices. Use of a drain or presence of tobacco use did not affect LOS. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:2133-2137, 2020.

The pathogenic microbial flora and its antibiotic susceptibility pattern in odontogenic infections.

Suppurative head and neck infections of odontogenic origin are the most frequent type of head and neck infections. According to the literature, 7-10% of all antibiotics are currently prescribed for their treatment. Since penicillin was invented, the overall antibiotic sensitivity and resistance pattern of the isolated pathogenic microflora has continuously changed. The response of microorganisms to antibiotics and the development of resistance to their action is a purely evolutive process characterized by genetic mutations, acquisition of genetic material or alteration of gene expression and metabolic adaptations. All this makes challenging and difficult the correct choice of empirical antibiotic treatment for head and neck space infections even today. The aim of this paper was to evaluate the literature and to evidence the most frequent locations of odontogenic head and neck infections, the dominant pathogenic microbial flora, the genetic mutations and metabolic changes necessary for bacteria in order to aquire antibiotic resistance and as well its susceptibility and resistance to common antibiotics. We also aimed to highlight the possible changes in bacterial resistance to antibiotics over time, and to assess whether or not there is a need for fundamental changes in the empirical antibiotic treatment of these infections and show which these would be.

Group A Streptococcal DNase Sda1 Impairs Plasmacytoid Dendritic Cells' Type 1 Interferon Response.

Group A Streptococcus causes severe invasive infections, including necrotizing fasciitis. The expression of an array of virulence factors targeting specific host immune functions impedes successful bacterial clearance. The virulence factor streptococcal DNase Sda1 was previously shown to interfere with the entrapment of bacteria through neutrophil extracellular traps and TLR9 signaling. In this study, we showed that plasmacytoid dendritic cells are recruited to the infected tissue during group A streptococcal necrotizing fasciitis. We found that the streptococcal DNase Sda1 impairs plasmacytoid dendritic cell recruitment by reducing IFN-1 levels at the site of infection. We found that streptococcal DNase Sda1 interferes with stabilization of the DNA by the host molecule HMGB1 protein, which may account for decreased IFN-1 levels at the site of infection.

Triple diagnostics for early detection of ambivalent necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is an uncommon, rapidly progressive and potential lethal condition. Over the last decade time to surgery decreased and outcome improved, most likely due to increased awareness and more timely referral. Early recognition is key to improve mortality and morbidity. However, early referral frequently makes it a challenge to recognize this heterogeneous disease in its initial stages. Signs and symptoms might be misleading or absent, while the most prominent skin marks might be in discrepancy with the position of the fascial necrosis. Gram staining and especially fresh frozen section histology might be a useful adjunct. METHODS: Retrospective analysis of 3 year period. Non-transferred patients who presented with suspected necrotizing fasciitis are included. ASA classification was determined. Mortality was documented. RESULTS: In total, 21 patients are included. Most patients suffered from severe comorbidities. In 11 patients, diagnoses was confirmed based on intra-operative macroscopic findings. Histology and/or microbiotic findings resulted in 6/10 remaining patients in a change in treatment strategy. In total, 17 patients proved to suffer necrotizing fasciitis. In the cohort series 2 patients died due to necrotizing fasciitis. CONCLUSION: In the early phases of necrotizing fasciitis, clinical presentation can be ambivalent. In the present cohort, triple diagnostics consisting of an incisional biopsy with macroscopic, histologic and microbiotic findings was helpful in timely identification of necrotizing fasciitis.

Pseudomonas aeruginosa wound infection involves activation of its iron acquisition system in response to fascial contact.

BACKGROUND: Wound infections are traditionally thought to occur when microbial burden exceeds the innate clearance capacity of host immune system. Here, we introduce the idea that the wound environment itself plays a significant contributory role to wound infection. METHODS: We developed a clinically relevant murine model of soft tissue infection to explore the role of activation of microbial virulence in response to tissue factors as a mechanism by which pathogenic bacteria cause wound infections. Mice underwent abdominal skin incision and light muscle injury with a crushing forceps versus skin incision alone followed by topical inoculation of Pseudomonas aeruginosa. Mice were sacrificed on postoperative Day 6, and abdominal tissues were analyzed for clinical signs of wound infection. To determine if specific wound tissue components induce bacterial virulence, P. aeruginosa was exposed to the skin, fascia, and muscle. RESULTS: Gross wound infection caused by P. aeruginosa was observed to be significantly increased in injured tissues versus noninjured (80% vs.10%) tissues (n = 20 per group, p < 0.0001). Exposure of P. aeruginosa to individual tissue components demonstrated that fascia significantly induced bacterial virulence as judged by the production of pyocyanin, a redox-active phenazine compound known to kill immune cells. Whole-genome transcriptional profiling of P. aeruginosa exposed to the fascia demonstrated activation of multiple genes responsible for the synthesis of the iron scavenging molecule pyochelin. CONCLUSION: We conclude that wound elements, in particular fascia, may play a significant role in enhancing the virulence of P. aeruginosa and may contribute to the pathogenesis of clinical wound infection.

Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis.

BACKGROUND: Propionibacterium organisms are commonly recovered from deep cultures obtained at the time of revision arthroplasty. This study sought to determine whether deep cultures obtained at the time of primary arthroplasty can be substantially positive for Propionibacterium despite thorough skin preparation and preoperative intravenous antibiotic prophylaxis. METHODS: After timely administration of preoperative antibiotics chosen specifically for their activity against Propionibacterium and after double skin preparation, specimens from the dermis, fascia, capsule, synovium, and glenoid tissue were sterilely harvested from 10 male patients undergoing primary shoulder arthroplasty and were submitted for culture for Propionibacterium. RESULTS: Of the 50 specimens, 7 were positive for Propionibacterium: 3 in each of 2 patients and 1 in 1 patient. The specimen sources having positive anaerobic cultures were the dermis (1 of 10), fascia (2 of 10), synovium (1 of 10), and glenoid tissue (3 of 10). None of these patients had evidence of infection at the time of the arthroplasty. DISCUSSION AND CONCLUSION: Preoperative antibiotics and skin preparation do not always eliminate Propionibacterium from the surgical field of primary shoulder arthroplasty. The presence of these bacteria in the arthroplasty wound may pose a risk of delayed shoulder arthroplasty failure from the subtle type of periprosthetic infection typically associated with Propionibacterium.

Head and neck infection and inflammation.

This article discusses the imaging manifestations of infectious and inflammatory conditions of the head and neck. Special attention is paid to the sites, routes of spread, and complications of neck infections. Because the clinical signs and symptoms and the complications of these conditions are often determined by the precise anatomic site involved, anatomic considerations are stressed. Familiarity with the fascial layers, spaces of the neck, and the contents of each space is helpful for this discussion. The fascial layers of the neck are important barriers to infection, and once infection is established, the fascial layers play a part in directing its spread.

Bezold's abscess in the setting of untreated HIV infection.

INTRODUCTION: Reports of Bezold's abscess are rare. Classically, Bezold's abscess is described as a complication of mastoiditis in which infection spreads deep to the sternocleidomastoid muscle and throughout the fascial planes of the neck. Antibiotic treatment of suppurative otitis media has considerably decreased the incidence of complications resulting from this disease. We present a unique case report of Bezold's abscess in the setting ofa patient with untreated HIV. To our knowledge, this is the first reported case of Bezold's abscess and HIV. Despite its rarity, clinicians must have a high suspicion for Bezold's abscess in the setting of complicated otitis media and HIV; it must be recognized early in immunocompromised patients and treated aggressively due to its potentially fatal outcome. STUDY DESIGN: Case report and review of the literature. METHODS: We review the clinical course of a thirty five year old male HIV patient with a chronically draining ear and progressive neck stiffness, found to have a Bezold's abscess on CT. The incidence, pathogenesis and treatment of Bezold's abscess are discussed with special reference to the clinical presentation in the setting of an immunocompromised host. RESULTS: After broad-spectrum intravenous antibiotic therapy, mastoidectomy and surgical incision and drainage of the neck abscess, the patient recovered and had begun antiretroviral therapy at six-month follow-up. CONCLUSIONS: Bezold's abscess should be considered in the setting of complicated otitis media with neck stiffness and immunocompromised, specifically untreated HIV. The diagnosis and prompt, aggressive treatment of Bezold's abscess is necessary for an optimal clinical outcome

A case of brain abscess extended from deep fascial space infection.

A case of brain abscess in the temporal lobe caused by direct intracranial extension of deep neck abscess is described. The abscess also spread to the orbital cavity through infraorbital fissure. The possible etiology of this case might be dental surgery. The diagnostic imaging clearly showed the routes of intracranial and -orbital extension of parapharyngeal and masticator space abscesses. From the abscess specimens, oral streptococci, anaerobic streptococci, and anaerobic gram-negative bacilli were isolated. Antimicrobial susceptibility testing of isolates showed that some Prevotella and Fusobacterium strains had decreased susceptibility to penicillin, and these bacteria produced beta-lactamase. The bacteria from the deep neck abscess were consistent with those detected from the brain abscess. Proper diagnosis, aggressive surgical intervention, and antibiotics chemotherapy saved the patient from this life-threatening condition.

Severe necrotizing soft-tissue infections and nonsteroidal anti-inflammatory drugs.

BACKGROUND: Severe necrotizing soft-tissue infection (NSTI) is a rare but potentially life-threatening condition if not recognized and treated early. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been implicated as a contributing factor, but their role remains debated. AIMS: The aim of our study was to investigate the potential relationship between cases of NSTI recorded in the French Pharmacovigilance system and exposure to NSAIDs. METHODS: Cases of NSTI and randomly selected matched noncase controls (without skin disease) were identified in the database of the Spontaneous Reporting System in France for the period 2000-2004. Exposure to NSAIDs and other factors were investigated using conditional logistic regression. RESULTS: We found 38 cases of NSTI in 2000-04: 12 infants (0-23 months), 16 children (2-15 years) and 10 adults (>15 years), and we selected 228 controls. The median age of the sample was 4 years. Of the 38 cases, 25 were exposed to ibuprofen and 24 presented with varicella. The adjusted odds ratio for exposure to NSAIDs was 31.38 (95% CI 6.40-153.84), and 17.55 (95% CI 3.47-88.65) for viral infection. Other predisposing factors (diabetes, immunosuppression, injecting drugs) were not found to be associated, although this may have been due to the very small number of cases of NSTI/necrotizing fasciitis in adults reported in the database. CONCLUSION: Despite the limitations related to a spontaneous reporting system, this study indicates a strong association between NSAID use and NSTI. Although it was not possible to conclude if NSAIDs increase the risk of necrotizing complications in all patients, their use may mask the symptoms and delay diagnosis.

Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck.

This article reviews life-threatening infections of the head and neck. It discusses the anatomic boundaries, pathophysiologic processes, clinical manifestations, potential complications, and suggested therapies of infections of the submandibular, lateral pharyngeal, retropharyngeal, prevertebral, and danger spaces.

Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery.

The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.

Tuberculosis of the endothoracic fascia.

A 13-year-old boy presented with a history of respiratory infection that had progressed for 3 months. A chest X-ray showed pathological findings that suggested endothoracic fascia compromise (Skarby sign). The thorax computerized axial tomography scan revealed multiple opacities in the fascia. A biopsy was performed, and a pathological lymph node with caseous material was obtained. Thirty days later, Mycobacterium tuberculosis var. hominis was obtained from the culture. The diagnosis of tuberculosis of the endothoracic fascia was confirmed. Treatment included 9 months with isoniacide and rifampin, and 2 months with pirazynamide and streptomycin, with excellent response. Vitamin B6 was added.

Comparison of bacterial inoculation and transcutaneous oxygen tension in the rabbit S1 perforator and latissimus dorsi musculocutaneous flaps.

Muscle and musculocutaneous flaps have been used reliably in reconstruction of soft-tissue defects for many years. Previous experimental studies have shown musculocutaneous flaps to be superior to the random pattern and fasciocutaneous flaps in the management of infected wounds. Over the past decade, perforator flaps have gained acceptance as alternative methods of reconstruction in the clinical setting that can decrease donor-site morbidity and hospital stay, and increase patient satisfaction. The authors theorized that perforator flaps may be able to handle infected wounds better than random pattern and fasciocutaneous flaps because their blood supply is essentially the same as many of their musculocutaneous counterparts. The goal of this study was to compare the S1 perforator-based skin flap and latissimus dorsi musculocutaneous flap in the dorsal flank of the rabbit with the introduction of bacteria to simulate both superficial and deep wound infection. Measurements of oxygen tension and regional perfusion index were performed on both types of flaps to ascertain their viability and capacity to heal. The authors found no statistical significance between latissimus dorsi musculocutaneous and S1 perforator flaps in the rabbit with respect to superficial and deep wound infections. The regional perfusion index was calculated for postoperative days 1, 2, and 4. No statistically significant difference between the two flaps using the regional perfusion index could be identified. Additionally, regional perfusion for both types of flaps was greater than 0.6, indicating that their capacity to heal wounds is similar.

Deep fascial space infection of the neck: a continuing challenge.

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Evidence for superantigen involvement in severe group a streptococcal tissue infections.

Host-pathogen interactions were studied in tissue biopsy samples from patients with severe invasive group A streptococcus (GAS) infections. Skin, subcutaneous tissue, and fascia biopsy samples were divided into clinical grade 1 (no evidence of inflammation [n=7]) or clinical grade 2 (inflamed tissue--erythema and edema including cellulitis, fasciitis, and necrotizing fasciitis [n=24]). In situ imaging demonstrated significantly higher bacterial load in biopsy samples of higher clinical grade (P<.05), and the bacterial load correlated with the in vivo expression of the superantigen streptococcal pyrogenic exotoxin F (P<.02). Increased expression of the interleukin-1 cytokines and significantly higher expression of tumor necrosis factor-beta, interferon-gamma, and the homing receptors CC chemokine receptor 5, CD44, and cutaneous lymphocyte-associated antigen (P<.002-.05) were observed in biopsy samples of higher clinical grade. Thus, the cytokine profile at the local site of infection mimics that of a typical superantigen cytokine response. The findings of this study demonstrate a critical role for superantigens and Th1 cytokines in GAS tissue infections.

Incidence of deep fascial space infection after surgical removal of the mandibular third molars.

Nine hundred and ninety-three patients who underwent surgical removal of the mandibular third molars with oral antibiotic prophylaxis were examined to determine the incidence of postoperative deep fascial space infection and its background factors. Postoperative deep fascial space infection was observed in 8 of the patients (0.8%; 4 males and 4 females), and submandibular spaces were involved in all infected patients. Only 1 of these 8 patients was an immune compromised host. Patients aged 30 years or more had a significantly higher incidence of deep fascial space infection than those aged under 30. Five patients had partial bony impactions and 3 had complete bony impactions. However, the incidence of infection according to the molar positions was not significantly different between partial bony impaction and complete bony impaction. The 8 patients had not had pericoronitis preoperatively. The clinical courses of all were favorable after antibiotics were administered intravenously. In conclusion, the incidence of deep fascial space infection after removal of the mandibular third molars was low, at 0.8%. However, it may be desirable to remove the molars, if applicable, at a younger age because of the higher incidence of infection in patients aged over 30. The results of this study also offer information that will be useful as a basis for obtaining informed consent from patients whose mandibular third molars are to be removed.