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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 5-9

Current trends in pathogenesis, management, bacteriology, and antibiotic resistance in deep neck space infections: An institutional review


1 Department of Otolaryngology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission05-Sep-2019
Date of Acceptance20-Oct-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Dr. Harsimran Tiwana
Department of Otolaryngology, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_19_19

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  Abstract 


Context: Deep neck space infection is a potentially morbid condition characterized by pus collection in various potential and true spaces of the neck. With this study, we attempt to highlight, the changes in etiological factors in the current scenario, and management protocols for deep neck space infections. Furthermore, we studied the prevalence of antibiotic resistance in isolated microorganisms. Aims: To study the etiology, antibiotic sensitivity pattern, and management of deep neck space infections in adults and pediatric patients. Settings and Design: A retrospective analysis of patients undergoing surgical management of deep neck space infections at a tertiary care institute in India. Subjects and Methods: Analysis of records of 222 patients who underwent surgical management for deep neck space infections was done. All the patients received empirical antibiotic therapy within 30 min of hospital admission. The patients treated with conservative management were excluded from the study. Cultures and antibiotic sensitivities were obtained for patients undergoing surgical management. Results: Dental infection (52%) was the most common predisposing factor for deep neck space infections in adults followed by diabetes mellitus (28.2%). Multispace involvement was the most common presentation followed by parapharyngeal space involvement. The majority of the cultures were sterile (42.6%). The most common pathogen on cultures was Staphylococcus aureus (13.1% in adults and 47.4% in pediatric age group). The incidence of methicillin-resistant S. aureus (MRSA) was 22.7%, which was lower than what has been observed in the previous studies. Klebsiella pneumoniae isolates were found to have high incidence of resistance to cefotaxime (50%), cefepime (38.5%), and ceftazidime (75%). Complications were seen in 4.5% (n = 10) of patients with an overall mortality of 0.9% (n = 2). Conclusions: In view of comparatively lower incidence of MRSA, combination of amoxicillin-clavulanic acid along with clindamycin is a reasonable first-line antibiotic therapy for deep neck space infections. In patients with diabetes, amikacin or piperacillin-tazobactam can be added to the regime, as there is a higher incidence of infection by K. pneumoniae. Surgical management remains the mainstay of treatment and is associated with improved outcome.

Keywords: Antibiotics, deep neck space infections, sensitivity pattern, surgical drainage


How to cite this article:
Tiwana H, Gupta S, Prakash DN, Panda N, Chetan B, Angrup A, Ray P, Bakshi J, Mohindra S, Gupta R, Virk R, Verma R, Bansal S, Ramavat AS, Nayak GR. Current trends in pathogenesis, management, bacteriology, and antibiotic resistance in deep neck space infections: An institutional review. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:5-9

How to cite this URL:
Tiwana H, Gupta S, Prakash DN, Panda N, Chetan B, Angrup A, Ray P, Bakshi J, Mohindra S, Gupta R, Virk R, Verma R, Bansal S, Ramavat AS, Nayak GR. Current trends in pathogenesis, management, bacteriology, and antibiotic resistance in deep neck space infections: An institutional review. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2020 Jul 9];4:5-9. Available from: http://www.aiaohns.in/text.asp?2020/4/1/5/288171




  Introduction Top


The investing layer of deep cervical fascia divides the neck into true and potential spaces, which are freely communicating.[1] In the event of infection in these spaces, the close proximity to airway structures and preformed pathways can give rise to complications such as empyema, mediastinitis, pericarditis, jugular-vein thrombosis, and septic shock.[2] Early diagnosis and management are the key to avoiding potentially life-threatening complications of deep neck space infections. The incidence and mortality due to deep neck space infections have reduced due to the use of antibiotics.[3] However, due to rampant misuse of antibiotics, antibiotic-resistant strains of microorganisms are developing.[4] Antibiotic resistance is an upcoming problem owing to the lack of proper antibiotic usage protocols and over the counter availability of antibiotics, particularly in India.

The anatomic knowledge of deep neck spaces and their communication pathways is a must for surgical management of deep neck space infections.

This study aims to highlight the course and management of deep neck space infections. The patient characteristics have been correlated with the immunological status along with the microorganisms involved and finally, the course of the disease. The patterns of antibiotic resistance of the commonly involved microorganisms were also studied.


  Subjects and Methods Top


The medical records of all patients undergoing surgical management for deep neck space infections at a tertiary healthcare center in North India, from January 2012 to January 2018, were retrospectively analyzed. The Departments of Otolaryngology and Medical Microbiology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India, conducted the study jointly.

The patients presenting with deep neck space infections were admitted, and empirical antibiotic therapy was started within 30 min of hospital admission. All patients underwent routine blood investigations including hemoglobin, total and differential leukocyte counts, blood sugar analysis, HIV ELISA, serum electrolytes, and renal functions. Contrast-enhanced computed tomography of the neck was obtained in most of the patients. However, noncontrast study was done in patients having deranged renal functions. Immediate surgical management by incision and drainage was the mainstay of treatment in most of the patients. Only the patients having superficial cellulitis were subjected to a course of intravenous antibiotics and surgical management was planned if there was no improvement within 24 h. Patients undergoing conservative management were excluded from the study.

Aerobic cultures and antibiotic sensitivities were obtained for all the patients undergoing surgical management.

In the postoperative period, patients were managed with twice daily aseptic dressings and culture directed antibiotics.


  Results Top


Demographics

Of 222 patients, 62.7% were males and 37.27% were females. The age ranged from 4 weeks to 90 years, with median and interquartile range (IQR) for age being 35.00 and 11.75–52.00 years, respectively. Of 222 patients, 25.7% patients belonged to the pediatric age group (age <12 years). The median and IQR for hospital stay was 8 and 5–11 days, respectively.

The incidence of tobacco consumption in the study population was 27.6%. Tobacco consumption and subsequent poor oro-dental hygiene could have predisposed individuals to dental infections and deep neck space infections. The other predisposing factors are listed in [Table 1].
Table 1: Predisposing factors

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Site distribution for deep neck space infections

The data of site distribution were collected from the radiology reports and operative findings [Table 2].
Table 2: Site distribution for deep neck space infections in different subgroups

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Bacteriology

Of 222 patients, culture reports were available for 202 patients [Table 3]. The culture results were analyzed separately for adults and pediatric age group. Majority of the cultures were sterile i.e., 42.6% patients. About 11.4% of the cultures showed microbiological growth of no significance.
Table 3: Bacteriology of deep neck space infections

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The distribution of microorganisms infecting different deep neck spaces was studied. Among the organisms isolated, Staphylococcus aureus was the most commonly isolated organism from patients with multi-space infections (24.6%), submandibular abscess (32.1%), parapharyngeal abscess (21.7%), Ludwig's angina (15.4%), parotid abscess (38.9%), retropharyngeal abscess (25%), and masseteric abscess (12.5%).

The bacteriological growth patterns in patients with necrotizing fasciitis were different from deep neck space infections. The most common organism encountered in Necrotising fasciitis was Escherichiacoli (16.7%), followed by an equal incidence of Klebsiellapneumoniae (5.5%), Streptococcusanginosus (5.5%), and Acinetobacterbaumannii (5.5%) [Table 3].

Microorganisms and patterns of antibiotic resistance

The antibiotic resistance patterns of commonly isolated bacterial pathogens, namely S. aureus, K. pneumoniae, and alpha-hemolytic streptococci were studied. The antibiotic sensitivity was checked for commonly used antibiotics for that particular pathogen.

For S. aureus, antibiotic sensitivity was checked for commonly used antibiotics such as methicillin, ciprofloxacin, erythromycin, clindamycin, and vancomycin [Figure 1]. Sensitivities for higher antibiotics such as teicoplanin, linezolid, and netilmicin were also checked. Of all the S. aureus positive cultures, antibiotic resistance was noted in 22.7% (methicillin), 77.8% (ciprofloxacin), 55.56% (erythromycin) and 9% (clindamycin). All isolates were sensitive to vancomycin, teicoplanin, netlimicin, and linezolid.
Figure 1: Antibiotic sensitivity pattern of Staphylococcus aureus

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Cultures showing growth of K. pneumoniae underwent sensitivity testing for amikacin, cefotaxime, cefepime, ceftazidime, piperacillin-tazobactam, and imipenem [Figure 2]. Of all the Klebsiella isolates, 75% were resistant to ceftazidime, 50 % were resistant to cefotaxime, 38.5% were resistant to cefepime, and 10% were resistant to imipenem. None of the cultures showed resistance to amikacin and piperacillin-tazobactam.
Figure 2: Antibiotic sensitivity pattern of Klebsiella pneumoniae

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Antibiotic sensitivities were checked for erythromycin, clindamycin, vancomycin, teicoplanin, linezolid, ampicillin, gentamicin, and methicillin in cultures showing growth of alpha-hemolytic streptococci [Figure 3]. About 16.67% cultures showed resistance to ampicillin. There was 100% sensitivity to all the other antibiotics tested.
Figure 3: Antibiotic sensitivity pattern of alpha hemolytic Streptococci

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Complications

Overall, 4.5% (n = 10) patients developed complications. Complications included septic shock (2.7%), mediastinitis (0.9%), empyema (0.9%), internal jugular vein thrombosis (1.3%), and death (0.9%).


  Discussion Top


Deep neck space infection is a potentially life-threatening condition characterized by the collection of pus in spaces of neck, namely submandibular space, sublingual, parotid, parapharyngeal, retropharyngeal, peritonsillar, and masseteric space.[5]

The estimated incidence of deep neck space infections is 10/100,000 in adults and 2/100,000 in children.[5] Although there is no age or gender predilection for deep neck space infections, we observed a higher preponderance in adults (65.3%) with a median age of 35 years. The incidence of deep neck space infections in adults is on the rise due to an increase in systemic illnesses and decrease in the effectiveness of defense mechanisms.[2] We observed a higher incidence in male gender (62.7%); Eftekharian et al. and Ridder et al. have made similar observations in previous studies.[6],[7]

As with previous studies, the odontogenic infection was the most common predisposing factor identified in adults (52%).[8],[9] Immunocompromised status due to diabetes mellitus, HIV positivity, exogenous steroid use, and failure to thrive was another significant risk factor. Any condition, which impairs host cell immunity, predisposes the individual to develop deep neck space infections.[10]

In contrast to previous studies, those report a high incidence of tonsillitis (31.68%),[2] and upper airway infection (13%),[9] history of tonsillitis or upper respiratory tract infection was not identified as a significant etiological factor. Accordingly, the incidence of the tonsillar abscess (0.46%) and retropharyngeal abscess (7%) was quite low in the study. Earlier diagnosis and treatment of tonsillitis and upper respiratory tract infections may explain this changing trend. Similarly, timely management of dental conditions may further reduce the incidence of deep neck space infections and complications. This can be achieved by sensitizing general population to the importance of dental hygiene.

A high incidence of tobacco use was noted in our study (27.6%). Previous studies have speculated tobacco use and smoking as one of the risk factors for deep neck space infections.[11] The formation of subgingival biofilms and associated poor oro-dental hygiene lead to a higher incidence of deep neck space infections in tobacco users.[12]

Multispace involvement was the most common presentation across all the age groups, similar to the study by Brito et al., which had multi-space involvement in 41.8% of the adult population.[2] The anatomy of deep neck spaces is such that the spaces are freely communicating with each other, leading to the rapid spread of infection from one space to other spaces. However, previous studies have shown that retropharyngeal abscess is the most common presentation in pediatric age group.[13],[14] A higher incidence of multi-space involvement among the pediatric age group was seen in our study. Malnutrition, illiteracy, lack of access to primary health care in our country resulted in delayed presentation and hence, more extensive disease as compared to Western population.

About 42.6% of the specimens that were cultured for sensitivity were found to be sterile. This could be due to the empirical administration of antibiotics before surgical drainage.[4],[15] The most common microorganism isolated was S. aureus irrespective of the age group (13.1% in adults, 47.4% in the pediatric group). Although many previous studies have reported Streptococcus species as the commonest isolated organism in deep neck space infections,[4],[9] higher incidence of S. aureus in our study, may be related to geographical factors. It could reflect a changing trend in the microbiology of deep neck space infections, secondary to antibiotic overuse and emerging antibiotic resistance. The second-most common organism isolated in adults was K. pneumoniae. A higher proportion of diabetics among adults may explain this. Previous studies have shown higher rates of K. pneumoniae isolation among diabetic patients.[9],[16]

It has been observed that the incidence of methicillin resistance in Staphylococcus is on a rise.[17] In different neck abscess case series, the reported incidence of methicillin resistant S. aureus varies from 27% to 64.7%, with more recent series showing a higher incidence of resistance.[18],[19] Of, all the staphylococcus isolates, methicillin resistance was seen in 22.7% of our cases, which is lower than the reported incidence in literature. This comparatively lower incidence of methicillin resistance justifies the use of penicillin group of drugs as the first-line empirical antimicrobial therapy in patients with deep neck space abscesses. A combination of penicillin with β-lactamase inhibitor (clavulanic acid) is ideal for optimal coverage.[2]

Clindamycin is another empirically used antibiotic in the management of deep neck space abscesses. Previously conducted studies show a clindamycin sensitivity as high as 86%–100%, among S. aureus isolates.[19] A similar pattern was seen in our study; with only 9% S. aureus isolates showing resistance to clindamycin. Comparatively, there was a higher incidence of resistance to erythromycin (55.5%) and ciprofloxacin (77.8%). The observed incidence of erythromycin resistance is higher than what has been seen in the previous study by Guss etal. (25%–45%).[19]

None of the isolates demonstrated resistance to vancomycin, teicoplanin, netilmicin, and linezolid. Although there are reports ofin vitro resistance to these antibiotics, no reports of resistance to these antibiotics in isolates from deep neck abscesses were found in literature.

Clinicians need to be aware about the resistance patterns of S. aureus to various commonly used antibiotics. There was a high incidence of resistance to commonly used antibiotics such as erythromycin and ciprofloxacin. However, from the observations in the current study, it can be safely concluded that the penicillin group and clindamycin either alone or in combination can be safely used for empirical management of deep neck space abscesses. In addition, clindamycin is a safe alternative in patients having allergy to the penicillin group. Higher antibiotics should be reserved for patients showing antibiotic resistance to penicillin and clindamycin group on culture sensitivity. There is no role of antibiotics such as vancomycin, teicoplanin, netilmicin, and linezolid in empirical management of deep neck space abscesses.

Among alpha streptococci culture-positive specimens, 16.67% of the isolates showed resistance to ampicillin. Kuriyama et al. made a similar observation in pus specimens from odontogenic infections.[20] However, there was 100% sensitivity to other tested antibiotics (erythromycin, clindamycin, methicillin, gentamicin, vancomycin, teicoplanin, and linezolid).

Isolates strains of K. pneumoniae showed a high incidence of resistance to cefotaxime (50% resistance) and ceftazidime (75% resistance). There was 100% sensitivity to amikacin and piperacillin-tazobactam. In view of the higher incidence of Klebsiella isolates in diabetic patients, it is important to be aware of its antibiotic sensitivity pattern. There is a justification to add amikacin or piperacillin-tazobactam empirically, in diabetic patients with deep neck space abscess, if there is no clinical improvement with clindamycin and penicillin group of drugs.

All patients underwent early surgical intervention. Earlier surgical intervention is associated with lower risk complications and lesser duration of hospital stay, as reported by Parhiscar and Har-El.[21] The role of conservative management is limited only to patients with superficial cellulitis.

One of the limitations of our study is the nonavailability of anaerobic culture sensitivity reports.


  Conclusions Top


Early diagnosis and management of dental infections may reduce the incidence of deep neck space infections and associated morbidity.

Although there are significant concerns related to antibiotic resistance, a much lower antibiotic resistance was observed in the bacterial isolates in our study. Thus, a combination of amoxicillin-clavulanic acid along with clindamycin is a reasonable first-line therapy for deep neck space infections. In patients with amoxicillin sensitivity, clindamycin is a good alternative. However, given the high incidence of K. pneumoniae in diabetics, it is rational to include amikacin or piperacillin-tazobactam in the empirical antibiotic regimen.

Surgical management remains the mainstay of treatment for deep neck space abscesses, with earlier surgical management being associated with improved outcomes and decreased risk of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Brito TP, Hazboun IM, Fernandes FL, Bento LR, Zappelini CEM, Chone CT, et al. Deep neck abscesses: Study of 101 cases. Braz J Otorhinolaryngol 2017;83:341-8.  Back to cited text no. 2
    
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Lee JK, Kim HD, Lim SC. Predisposing factors of complicated deep neck infection: An analysis of 158 cases. Yonsei Med J 2007;48:55-62.  Back to cited text no. 3
    
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Yang W, Hu L, Wang Z, Nie G, Li X, Lin D, et al. Deep neck infection: A Review of 130 cases in southern china. Medicine (Baltimore) 2015;94:e994.  Back to cited text no. 4
    
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Santos Gorjón P, Blanco Pérez P, Morales Martín AC, Del Pozo de Dios JC, Estévez Alonso S, Calle de la Cabanillas MI, et al. Deep neck infection. Review of 286 cases. Acta Otorrinolaringol Esp 2012;63:31-41.  Back to cited text no. 5
    
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Eftekharian A, Roozbahany NA, Vaezeafshar R, Narimani N. Deep neck infections: A retrospective review of 112 cases. Eur Arch Otorhinolaryngol 2009;266:273-7.  Back to cited text no. 6
    
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Ridder GJ, Technau-Ihling K, Sander A, Boedeker CC. Spectrum and management of deep neck space infections: An 8-year experience of 234 cases. Otolaryngol Head Neck Surg 2005;133:709-14.  Back to cited text no. 7
    
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Coelho MS, Ramos G, Prestes LC, Soccol A, Oliveira MSB, LoboP et al. Deep neck infections – Classification in levels of severity. Int Arch Otorhinolaryngol 2009;13:184-8.  Back to cited text no. 8
    
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Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS, et al. Deep neck infection: Analysis of 185 cases. Head Neck 2004;26:854-60.  Back to cited text no. 9
    
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Opitz D, Camerer C, Camerer DM, Raguse JD, Menneking H, Hoffmeister B, et al. Incidence and management of severe odontogenic infections-a retrospective analysis from 2004 to 2011. J Craniomaxillofac Surg 2015;43:285-9.  Back to cited text no. 10
    
11.
Kataria G, Saxena A, Bhagat S, Singh B, Kaur M, Kaur G, et al. Deep neck space infections: A Study of 76 cases. Iran J Otorhinolaryngol 2015;27:293-9.  Back to cited text no. 11
    
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Anil S, Al-Ghamdi HS. The impact of periodontal infections on systemic diseases. An update for medical practitioners. Saudi Med J 2006;27:767-76.  Back to cited text no. 12
    
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Dawes LC, Bova R, Carter P. Retropharyngeal abscess in children. ANZ J Surg 2002;72:417-20.  Back to cited text no. 13
    
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Abdel-Haq NM, Harahsheh A, Asmar BL. Retropharyngeal abscess in children: The emerging role of group A beta hemolytic streptococcus. South Med J 2006;99:927-31.  Back to cited text no. 14
    
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Sethi DS, Stanley RE. Parapharyngeal abscesses. J Laryngol Otol 1991;105:1025-30.  Back to cited text no. 15
    
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Roscoe DL, Hoang L. Microbiologic investigations for head and neck infections. Infect Dis Clin North Am 2007;21:283-304.  Back to cited text no. 16
    
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Barker KF. Antibiotic resistance: A current perspective. Br J Clin Pharmacol 1999;48:109-24.  Back to cited text no. 17
    
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Ossowski K, Chun RH, Suskind D, Baroody FM. Increased isolation of methicillin-resistant Staphylococcus aureus in pediatric head and neck abscesses. Arch Otolaryngol Head Neck Surg 2006;132:1176-81.  Back to cited text no. 18
    
19.
Guss J, Kazahaya K. Antibiotic-resistant Staphylococcus aureus in community-acquired pediatric neck abscesses. Int J Pediatr Otorhinolaryngol 2007;71:943-8.  Back to cited text no. 19
    
20.
Kuriyama T, Karasawa T, Nakagawa K, Yamamoto E, Nakamura S. Bacteriology and antimicrobial susceptibility of gram-positive cocci isolated from pus specimens of orofacial odontogenic infections. Oral Microbiol Immunol 2002;17:132-5.  Back to cited text no. 20
    
21.
Parhiscar A, Har-El G. Deep neck abscess: A retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001;110:1051-4.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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