Odontogenic Infections: Early Incision and Drainage Decreases Length of Hospitalization

Maxillofacial infections from an odontogenic source are a cause of significant morbidity and rarely mortality.  The infection may spread from the surrounding dento-alveolar segment to the underlying bone, soft tissues, and ultimately fascial planes of the head and neck. These infections often require an incision and drainage procedure. Severe odontogenic infections may lead to airway compromise requiring mechanical ventilatory support.  Furthermore, various antibiotic regimens exist to guide therapy towards the most common organisms involved. The goal of this study is to identify developing and updated trends in the management of severe odontogenic infections.

We performed a retrospective review of adult patients who underwent surgical incision and drainage in the operating room as treatment for an odontogenic infection.  We reviewed 10 years of University of Pennsylvania Health System records (1/1/2004-1/1/2014).  Using CPT codes, surgical logs, and electronic health records, we gathered data regarding patient age, length of time to I and D (in hours), initial antibiotic regimen, culture data, fascial spaces involved, and length of hospitalization (days).  We subdivided infections based on the severity score (Flynn et al.).  The severity scores (SS) range from 1-4 with categorization based on the involved fascial spaces.  A total of 132 patients underwent surgical incision and drainage for treatment of odontogenic infections and were including in the study.

Of the 132 patients who underwent surgical incision and drainage, the majority (101) had a severity score of 2 (moderate risk to airway structures).  This was defined by involvement of one or more of the following spaces; submandibular, sublingual, pterygomandibular, submasseteric, superficial temporal, or deep temporal spaces. Patients were separated based on time to incision and drainage.  The shortest average hospital stay occurred in those SS 2 patients who had surgical I and D within 10 hours of admission (average hospital stay 3.8 days).  The longest hospitalizations occurred in patients who were drained >40 hours after admission.  We found that patients with SS 2 infections that were drained within 10 hours of admission had a significantly shorter length of hospitalization compared to patients that were drained between 10-20 hours and greater than 40 hours after admission (unpaired T-Test: p = 0.0004, 95% CI: -3.29 to -1.02 and p = 0.0029 with 95% CI -3.97 to -0.89 respectively).  Over 10 years, multiple antibiotic regimens were used in treatment of these infections.  Most commonly clindamycin or ampicillin/sublactam were chosen as initial antibiotic regimens.  Cultures were sent in 117 of 132 I and D procedures.  33% of all cultures grew gram negative flora.  30% grew alpha hemolytic streptococcus.  Other common organisms included coagulase negative staphylococcus (19%), peptostreptococcus (13.6%), E. corrodens (10.2%), and streptococcus constellatus (7.7%). 

Conclusions:  Although the average time to incision and drainage is affected by multiple factors it appears that an earlier surgical treatment results in a decreased overall hospitalization time.  Specifically, for moderate risk infections, an incision and drainage within 10 hours results in a significantly shorter length of hospitalization.  Given the propensity for gram negative organisms, we support the use of ampicillin/sublactam as a first line antimicrobial over clindamycin for the treatment of odontogenic infections. For patients with penicillin allergies, clindamycin is an acceptable agent, as early surgical treatment appears to be of greater importance than antibiotic choice.

References:

Flynn TR, et al. Severe odontogenic infections, part 1; prospective report. Journal of Oral and Maxillofacial Surgery. 2006 Jul;64(7): 1093-1103.

Flynn, TR, et al. Severe odontogenic infections, part 2; prospective outcomes study. Journal of Oral and Maxillofacial Surgery 2006 Jul;64(7): 1104-1113

Igoumenakis Dimosthenis, et al. Severe Odontogenic Infections: Causes of Spread and Their Management. Surgical Infections. February 2014, 15(1): 64-68.