Available online at www.sciencedirect.

com

British Journal of Oral and Maxillofacial Surgery 52 (2014) 629–631

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

Available online 3 June 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 odonto-
genic 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 ther-
apeutic 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 1@msn.com (S. Farmahan).
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.
to find out whether routine culture and sensitivity tests have
any therapeutic value in the treatment of patients with odon-
togenic 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
630 S. Farmahan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 629–631
Table 1
Antibiotics prescribed intravenously.
Antibiotic No. (%) of cases
(n = 90)
Amoxicillin + metronidazole 33 (37)
Co-amoxiclav 31 (34)
Co-amoxiclav + metronidazole 10 (11)
Clindamycin + metronidazole 8 (9)
Clarithromycin + metronidazole 5 (6)
Metronidazole 2 (2)
Cefuroxime + metronidazole 1 (1)
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 emer-
gency (A&E) was 5 days (range 0-22), and 3 days (range
0-17) to a general dental practitioner or general medical prac-
titioner. 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 antimicro-
bial 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 aero-
bic infections and 15 (26%) were anaerobic. All infected
samples were tested for anaerobic sensitivity. Candida albi-
cans 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
Table 2
Microbiological results.
Isolated organism No. (%) of cases
(n = 61)
Streptococcus viridans 35 (57)
Anaerobes 15 (25)
Group C streptococci 3 (5)
Group B streptococci 2 (3)
Staphylococcus aureus 2 (3)
Streptococcus milleri 1 (2)
Candida albicans 3 (5)
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 antibi-
otics 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 dis-
charge.
According to clinical records, no patients required further
intervention or alteration of prescribed antimicrobial treat-
ment 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 com-
menced before results are available.
Our study shows no short-term complications after treat-
ment 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 odon-
togenic 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 tak-
ing a swab from the depth of a wound. Contamination from
contact with the skin or oral mucosa can provide mislead-
ing 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 speci-
men has been reported to cost £25–£30, not including the
 S. Farmahan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 629–631
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 cur-
rently 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 compli-
cations.
Conflict of Interest Statement
There have been no financial and personal relationships with
other people or organisations that could inappropriately influ-
ence (bias) our work.
631
Ethics Statement
No work on patients or volunteers was performed and so
ethical approval was not required.
References
1. Rega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic sensitiv-
ities of head and neck space infections of odontogenic origin. J Oral
Maxillofac Surg 2006;64:1377–80.
2. Lewis MA, MacFarlane TW, McGowan DA. A microbiological and clin-
ical review of the acute dentoalveolor abscess. Br J Oral Maxillofac Surg
1990;28:359–66.
3. Turner JE, Moore DW, Shaw BS. Prevalence and antibiotic susceptibility
of organisms isolated from acute soft-tissue abscesses secondary to dental
caries. Oral Surg Oral Med Oral Pathol 1975;39:848–57.
4. Woods R. The changing nature of pyogenic dental infections. Aust Dent
J 1981;26:209–13.
5. Woods R. An assessment of antibiotics for the treatment of pyogenic
dental infections. Aust Dent J 1975;20:10–3.
6. Gabrielson ML, Stroh E. Antibiotic efficacy in odontogenic infections. J
Oral Surg 1975;33:607–10.
7. Fowler E. Wound infection: a nurse’s perspective. Ostomy Wound Manage
1998;44:44–52.
8. Rudensky B, Lipschits M, Isaacsohn M, Sonnenblick M. Infected pres-
sure sores: comparison of methods for bacterial identification. South Med
J 1992;85:901–3.
9. Brown DL, Smith DJ. Bacterial colonization/infection and the surgi-
cal management of pressure ulcers. Ostomy Wound Manage 1999;45,
119S–20S.
10. Gilchrist B. Taking a wound swab. Nurs Times 2000;96:2.