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British Journal of Oral and Maxillofacial Surgery 48 (2010) 37–39

Microbiology of odontogenic infections in deep neck spaces:

A retrospective study
Laith Hussein Al-Qamachi a,∗ , Hiba Aga b,1 , Jeremy McMahon c,2 , Alistair Leanord c,2 ,
Nicholas Hammersley d
a Department of Vascular Surgery, Ninewells Hospital, Dundee, DD1 9SY, United Kingdom
b Department of Orthopaedics, Ninewells Hospital, Dundee, DD1 9SY, United Kingdom
c Southern General Hospital, 1345 Govan Road, Glasgow, G51 4TF, United Kingdom
d Monklands Hospital, Monkscourt Avenue, Airdrie, ML6 0JS, United Kingdom

Accepted 11 December 2008

Abstract

The primary treatment of deep neck spaces odontogenic infection (DNSOI) with suppuration is surgery. Systemic antimicrobial therapy
is an important adjunct. The initial prescription of antimicrobial therapy is empirical. Over the last decade we have observed a change in
practice with the use of second-generation cephalosporins, in conjunction with metronidazole, replacing benzylpencillin and metronidazole.
More recently evidence has emerged suggesting that antimicrobial resistance in nosocomial infections could be related to the widespread
use of second and third-generation cephalosporins. This study was therefore initiated to determine whether this change in prescribing was
justified. A total of 75 cases were retrospectively identified by scrutiny of the operating theatre data. These patients presented with significant
DNSOI that required surgical drainage. Streptococcus milleri and mixed anaerobes were predominant. Only in three cases (4%) there were
penicillin-resistant microorganisms. The substitution of benzylpenicillin for cefuroxime as an initial empiric therapy for DNSOI seems likely
to have been equally efficacious in the large majority of cases. On the other hand, studies in preference of cephalosporins are based on in vitro
trials. A multi-centre randomized controlled clinical trial directly comparing initial empiric second-generation cephalosporin therapy with
benzylpenicillin in non-allergic patients is justified.
© 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Deep neck spaces odontogenic infections; Benzylpenicillin

Introduction removal of the source of infection. Systemic antimicrobial

Most odontogenic infections are readily resolved by removal
of the source of the infection with or without antimicro-
bial drugs. However, a few involve the deep cervical spaces.
These may be life threatening, because they may spread to
the airway, assessment and protection of which is therefore
necessary, together with prompt drainage of any pus, and
∗
Corresponding author. Tel.: +44 7834812478.
E-mail address: hibatlaith@yahoo.co.uk (L.H. Al-Qamachi).
1 Tel: +44 779 3372771.
2 Tel: +44 141 2011100.
agents are an important adjunct.
These antimicrobial agents are selected empirically, but
the main factors behind the choice are: susceptibility of the
likely microorganisms; the pharmacological properties of the
drugs; the best way to give them; and their potential toxicity
and side effects.1,2
␤-Lactam antibiotics, particularly benzyl penicillin, has
been recommended as first line antibiotic, because it is effec-
tive against most bacteria, has a low incidence of side effects
and a narrow spectrum of bacterial activity. It is also rela-
tively inexpensive. However, the suggestion that it may not
be active against streptococci and anaerobes has led to the
additional use of metronidazole. We have also noticed a shift

0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.12.007
38 L.H. Al-Qamachi et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 37–39

away from penicillin with metronidazole, to the use of a Table 1

second-generation cephalosporin with metronidazole. This Organisms identified.
seems logical as cephalosporins are bactericidal, have few Organisms identified Number (%) of
side effects, and some have stronger in vitro bactericidal cases (n = 75)
activity against pathogens specific to odontogenic deep space Streptococcus milleri 14 (19)
infections, particularly the ␤-lactamase-producing bacteria, Mixed anaerobes 7 (9)
Both Streptococcus milleri and mixed anaerobes 5 (7)
where the stability of the second-generation cephalosporins Actinomyces spp. 1 (1)
has been confirmed.3 S. aureus 2 (3)
However, the wide use of cephalosporins has potentially Escherichia coli 1 (1)
serious adverse consequences, and it is the recognition of Normal oral flora 18 (24)
these that has prompted this investigation. Our aim was to No significant growth 27 (36)
find out whether the use of second-generation cephalosporins
in preference to benzyl penicillin as first line treatment for Table 2
deep odontogenic infections is justified. Sensitivity and resistance of organisms to various antimicrobial agents.
Organisms Susceptible Resistant
Streptococcus milleri (n = 19)
Methods Penicillin All 0
Cefuroxine All 0
A surgically relevant infection of odontogenic origin was Mixed anaerobes (n = 12)
defined by the presence of deep collections of pus in one Metronidazole All 0
or more neck spaces that required incision and drainage in
S. aureus (n = 2)
the operating theatre. A total of 75 patients were identified, Penicillin 0 All
and their microbiological reports obtained. Cefuroxime All 0
Intravenous antimicrobial treatment was started empiri- Flucloxacillin All 0
cally on admission with cefuroxime and metronidazole. Actinomyces species (n = 1)
Specimens of pus were obtained routinely in the operat- Penicillin All 0
ing theatre at the time of incision and drainage. Swabs were Escherichia coli (n = 1)
obtained from involved neck spaces; they were processed and Amoxicillin 0 All
organisms identified in the Department of Clinical Microbi- Co-amoxiclav All 0
ology at Monklands Hospital using standard microbiological Cefotaxime All 0
Gentamicin All 0
methods.4
Patients were maintained on intravenous treatment until
they had clearly improved and drains were removed. Patients Kuriyama et al. investigated the in vitro antibiotic sus-
were discharged home after a period of 24 h had elapsed with- ceptibility rate of the major groups of organisms isolated
out fever. At discharge they were given a 5-day course of and found that that of aerobic isolates to benzyl peni-
antibiotics, usually cefuroxime and metronidazole. If there cillin varied from 72% to 100%. Inhibition of 90% of
was no satisfactory clinical response, further swabs were Strep viridans had a susceptibility rate of 77%, indicat-
taken; imaging was used to identify residual collections of ing that penicillin remains reasonably effective.1 However,
pus, and further intervention made as indicated. cephalosporins had greater antimicrobial activity against
the major group of organisms with a susceptibility rate of
98%. Second-generation cephalosporins were resistant to ␤-
Results
lactamase-producing organisms isolated from odontogenic
From the 75 patients, pathogenic bacteria were cultured in infections.7 This report provides a rational basis for the
30 (40%) (Table 1). substitution of second-generation cephalosporins for ben-
We found that in all the 19 patients from whom Strep- zyl penicillin in the empirical management of such deep
tococcus milleri was grown, the bacteria were sensitive to infections. However, it is the broad spectrum cover of the
penicillin. Metronidazole was effective in all cases with cephalosporins that is most likely to encourage overgrowth
mixed anaerobes (Table 2). of Candida albicans.8
Coagulase-negative staphylococci are an important source
of nosocomial infection. There have been studies that
Discussion seem to show that methicillin resistance in coagulase-
negative staphylococci is associated with the therapeutic
The findings of this study are consistent with those of previous and prophylactic use of cephalosporins. It is even possi-
reports. When the pathogenic microorganisms of odonto- ble that the cephalosporins have a role in the molecular
genic deep space cervical infections were identified, Strep initiation of resistance.8 Methicillin-resistant Staph aureus
viridans and anaerobic organisms predominated.5,6 (MRSA) has also been associated with the widespread use
 L.H. Al-Qamachi et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 37–39
of second-generation cephalosporins. We intend to under-
take a multi-centre randomized controlled clinical trial to
compare initial empirical treatment with a second-generation
cephalosporin, with that by benzyl penicillin in patients who
are not allergic to penicillin.
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