Use of Peripherally Inserted Central Catheters in the Management of Recalcitrant Maxillofacial Infection

doi:10.1016/j.joms.2007.06.681

Journal of Oral and Maxillofacial Surgery

Volume 66, Issue 2, February 2008, Pages 330-335

https://doi.org/10.1016/j.joms.2007.06.681 Get rights and content

Purpose

The most common short-term method for the delivery of parenteral antimicrobial therapy in an acute hospitalized patient has traditionally been via a short peripherally inserted intravenous cannula. This approach, however, has significant limitations, particularly in patients who require prolonged, uninterrupted intravenous access. In this article, we report on our experience with an alternative method used to establish and maintain medium- to long-term intravenous access utilizing a peripherally inserted central catheter (PICC) to treat patients presenting with aggressive or recalcitrant maxillofacial head and neck infections.

Materials and Methods

We undertook a retrospective review of the medical records of 100 consecutive patients admitted to a tertiary referral teaching hospital, during the period February 2006 to February 2007, with a primary diagnosis of infection in the oral and maxillofacial region. We identified 6 patients in whom a PICC was used in the treatment of the condition. We also analyzed data obtained from an audit conducted by our infectious diseases unit. This audit recorded the outcome of 849 nurse-placed PICCs in the department’s ambulatory intravenous therapy service. Using this data, we also performed a PICC line survival analysis and in so doing, calculated the complication rates.

Results

In our series, the delivery of PICC-based therapy accounted for 6% of the treatment provided for all cases of maxillofacial sepsis. This included 3 cases of actinomycosis, 2 cases of odontogenic osteomyelitis, and 1 case of a zoonotic facial abscess/cellulitis. In this series of patients, catheters remained in situ for an average of 33 days (range 12-42 days). The audit data demonstrated that more than 75% of nurse-placed PICCs are functional without complication at 60 days. The most common complication was phlebitis (1 per 1,000 catheter days). Infection was rare (0.2 per 1,000 catheter days).

Conclusions

PICC is a safe and most reliable means of administering medium- to long-term intravenous antibiotics. We feel PICC-based therapy should be considered in the management of select patients with aggressive or recalcitrant maxillofacial head and neck sepsis.

Section snippets

Materials and Methods

Medical records were retrospectively retrieved from 100 consecutive patients with a primary diagnosis of dental abscess, submandibular abscess, or cellulitis face/neck, who were admitted to the John Hunter Hospital, Newcastle, Australia, under the care of the Department of Maxillofacial Surgery.

All patients included in the study required initial admission to hospital and were inpatients between February 2006 and February 2007.

We also reviewed data obtained from our infectious diseases

Results

In this study, PICC-based therapy accounted for 6% of treatment provided for in all cases of maxillofacial sepsis. This included 3 cases of actinomycosis, 2 cases of odontogenic osteomyelitis, and 1 case of zoonotic abscess/cellulitis.

The patient cohort was comprised of 5 male and 1 female patient with an age range of 23 to 72 years. All patients were symptomatic prior to their diagnosis. The 3 cases of actinomycosis presented with jaw swelling and cutaneous sinus tracts. In most cases the

Discussion

Although PICC placement is a relatively new approach to provide access for delivery of intravenous therapy in the surgical setting, it has been widely used in both a medical and intensive care setting since the mid 1970s. PICC allows reliable and painless entry to the venous system and therefore can be used to administer fluids, parenteral nutrition, irritant medications or toxic chemotherapeutic agents, and also facilitate hemodialysis or repeat blood sampling.⁶ In common with other central

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Cited by (16)

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?
2021, Journal of Oral and Maxillofacial Surgery
To review treatment of osteomyelitis of the jaw (OMJ) and determine whether antibiotic route and/or length of administration impacts resolution of infection postsurgically.
The investigators designed a retrospective cohort study enrolling a sample of patients treated at Harborview Medical Center from January 1, 2009 to December 31, 2019. The primary predictor variable was antibiotic administration route: oral (PO) only, intravenous (IV) only, IV transitioned to PO (IV + PO), or none. The secondary predictor was duration of antibiotic therapy (≤6 weeks or >6 weeks). The primary outcome variable was resolution of infection at 2 months follow-up posttreatment completion. The secondary outcome variable was number of surgeries to resolution of infection. Descriptive, bivariate, and multiple linear regression statistics were computed, with statistical significance set at P < .05.
Sixty-seven individuals met inclusion criteria (38 male), mean age 51 years (18 to 88). Forty-nine (73%) received PO antibiotics, 12 (18%) IV + PO, 3 (4%) IV, and 3 (4%) none. Both PO and IV antibiotics were associated with clinical resolution (P = .022, .005, respectively) compared with debridement alone. Antibiotic duration of ≤6 weeks compared with >6 weeks was not significant. Seventy-six percent (51 of 67) required only 1 surgery. In the multivariate logistic regression, PO was associated with clinical resolution (P = .025, OR = 5.05). Penicillin allergy (P = 0.049, OR = 0.223) and diabetes (P = .008, OR = 0.104) were adversely associated with outcome.
OMJ was successfully treated with oral antibiotics and surgery. Prescribing 6 weeks of IV antibiotics may be antiquated. Clinicians should consider oral penicillins as first line whenever possible. Further studies are recommended.
A mathematical approach improves the predictability of length of hospitalization due to acute odontogenic infection: A retrospective investigation of 303 patients
2019, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Surgical intervention comprising incision and drainage is indisputably inevitable for a sufficient treatment of abscess (Walia et al., 2014). Intravenous antibiotics are often selected as a sustaining therapy option (Islam et al., 2008). Unfortunately, subsiding susceptibility rates of bacteria against commonly administered antibiotics are undoubtedly an increasing issue in odontogenic infection treatment (Heim et al., 2016).
Increasing rates of hospitalization of patients diagnosed with acute odontogenic infection have become a burden for public health care, with significant economic concerns. The aim of this study was to investigate factors that tend to prolong hospital length of stay (LOS) in the treatment of severe infections. We present a statistical model that enables the prediction of LOS by exposing the feasibility of the essential statistical determinants.
A 5-year retrospective study investigated records of 303 in-hospital patients with abscess of odontogenic origin. Time-to-event models were used to analyse data where the outcome variable is the time to the occurrence of a specific event. Here, the focus is on a statistical model for the prediction of LOS of patients.
The group of all patients (n = 303) was analysed by considering seven characteristics of the patients (age, gender, spreading of infection, localization of infection focus, type of administered antibiotics, diagnosed diabetes mellitus, and existence of a remaining infection focus). Age (p = 0.049; rc = −0.007) and spreading of infection (p < 0.001; rc = −0.965) showed a significant impact on the LOS. Subjects were divided into two groups. Group A (n = 185) consisted of patients who presented with a severe odontogenic infection and not yet removed infection focus; group B were patients having undergone outpatient operative tooth removal (n = 118). To group A patients’ data, two new risk factors (“days between abscess incision and removal of infection focus” = dbir and “removal of infection focus during the same stay as abscess incision” = riss) replaced the risk factors “remaining infection focus.” A significant impact on the LOS was detected for dbir (p < 0.001; rc = −0.15) and riss (p < 0.001; rc = −1.76). Our statistical model explicitly describes how the probability for discharge depends on the time and how specific characteristics affect the LOS. We observed a significantly higher LOS in older patients and subjects with infection spreading. In group A patients, dbir and riss had a highly significant impact on the LOS.
Predicting the LOS may promote transparency to costs and management of patients under inpatient treatment. Our statistical model describes the probability of a discharge at time t compared to a discharge later than t (a LOS longer than t). Furthermore, the model enables a prediction of the LOS of each patient for practitioners in an easy way.
The role of C-reactive protein and white blood cell count in the prediction of length of stay in hospital and severity of odontogenic abscess
2018, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Furthermore, high costs in the treatment of patients with odontogenic infections are an increasing burden for public health care systems (Jundt and Gutta, 2012). The therapy of choice and the best treatment is extended surgical incision and drainage, combined with intravenously administered antibiotics (Islam et al., 2008; Walia et al., 2014; Heim et al., 2017). Additionally, removal of the infection focus is mandatory (Jundt and Gutta, 2012).
Odontogenic infections and subsequent developing abscess remain to be a potentially life-threatening event, due to septicemia, airway compression and spreading into sensitive anatomic tissues. C-reactive proten (CRP) and white blood cell (WBC) count are routinely blood-measured indicators for inflammation. Are CRP-levels and WBC-count predictive factors of the developement of odontogenic abscess?
A 4-year retrospective study evaluated hospital records of 218 patients, diagnosed and inpatiently treated for acute odontogenic abscess. They received surgical incision, drainage and intravenous antibiotics. CRP-levels and WBC-counts were measured preoperativly.
218 subjects were enrolled in this study. Patients hospitalized 10 days or more showed significantly higher CRP-levels (p = < 0.001) and WBC-counts (p = 0.006) on admission day than patients with lower LOS. CRP-levels of patients with LOS from 7–9 days were significantly lower (p = 0.47) than in people hospitalized 10 days or more. Abscess focus in the mandible shows significantly higher WBC-counts (p = 0.014). Multiple space infections present a significantly higher CRP (p = 0.003) and WBC (p < 0.001) on admission day.
According to the presented data, CRP-levels and WBC-count can be regarded as predictive factors for LOS (length of stay in hospital) in patients with long term hospitalization (CRP:7–9 days and > 10 days; WBC: > 10 days). Further WBC and CRP are suitable to predict multiple space infections and localisation of the abscess (WBC) in certain limits.
In predicting the developement of odontogenic abscess, CRP is more capable in providing exact statements regarding the LOS. However, WBC-counts are more suitable in predicting multiple space infections and localization of infection.
Microbiology and antibiotic sensitivity of head and neck space infections of odontogenic origin. Differences in inpatient and outpatient management
2017, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Suppuration is often localized to the affected tooth, but can also spread into other spaces, and can be potentially life threatening as a result of airway compromise, septicemia, cavernous sinus thrombosis, brain abscess, and shock, if not treated at an early stage (Boscolo-Rizzo and Da Mosto, 2009; Tavakoli et al., 2013; DeAngelis et al., 2014). The majority of dental abscesses can be treated sufficiently by surgical intervention, such as incision and drainage of pus (Islam et al., 2008). Bacteria are undoubtedly the main pathogens of odontogenic abscesses.
The microbial flora of infections of the orofacial region of odontogenic origin is typically polymicrobial. Shortly after mass production of the first antibiotics, antibiotic resistant microorganisms were observed.
A 28-months retrospective study evaluated hospital records of 107 patients that were treated for head and neck infections of odontogenic origin. All patients underwent surgical incision and drainage.
There were 65 male (61%) and 42 female (39%) patients ranging in age from 5 to 91 years, with a mean age of 48 years (SD = 21). 52 patients underwent outpatient management and 55 patients inpatient management. A total of 92 bacterial strains were isolated from 107 patients, accounting for 0.86 isolates per patient. Overall 46 bacterial strains were isolated from patients that underwent outpatient and 34 bacterial strains that underwent inpatient treatment. 32.6% of the strains, isolated from outpatient treated individuals showed resistances against one or more of the tested antibiotics. Isolated strains of inpatient treated individuals showed resistances in 52.9%.
According to this study's data, penicillin continues to be a highly effective antibiotic to be used against viridans streptococci, group C Streptococci and prevotella, whereas clindamycin was not shown to be effective as an empirical drug of choice for most odontogenic infections.
Microorganisms that show low susceptibility to one or more of the standard antibiotic therapy regimes have a significantly higher chance of causing serious health problems, a tendency of spreading and are more likely to require an inpatient management with admission of IV antibiotics. Penicillin continues to be a highly effective antibiotic to be used against viridans streptococci, group C Streptococci and prevotella, whereas clindamycin could not be shown to be effective as an empirical drug of choice for a high number of odontogenic infections.
Empiric systemic antibiotics for hospitalized patients with severe odontogenic infections
2016, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Predisposing factors for severe progression of an odontogenic infection are deficiencies of immunological competence, such as human immunodeficiency virus positivity, long-term diabetes mellitus, chronic alcohol abuse, hepatitis and liver cirrhosis, systemic lupus erythematosus, and history of immunosuppression after transplant surgery (Peters et al., 1996; Whitesides et al., 2000; Seppanen et al., 2008; Sandner and Börgermann, 2011). Patients with severe odontogenic abscesses benefit most from a biphasic treatment, incision, and drainage combined with intravenous antibiotic therapy (Wang et al., 2003; Islam et al., 2008; Walia et al., 2014). Additionally, immediate or secondary removal of the odontogenic focus is inevitable for sufficient therapy (Jundt and Gutta, 2012).
Odontogenic infections may lead to severe head and neck infections with potentially great health risk. Age, location of purulent affected sites and beta-lactam allergy are some mentionable factors regarding patients' in-hospital stay and course of disease. Are there new challenges regarding bacteria' antibiotic resistance for empiric treatment and what influences do they have on patients' clinical course?
We analyzed in a 4-year retrospective study the medical records of 294 in-hospital patients with severe odontogenic infections. On a routine base bacteria were identified and susceptibility testing was performed. Length of stay in-hospital was evaluated regarding patients' age, beta-lactam allergy profile, affected sites and bacteria susceptibility to empiric antibiotics.
Length of stay in-hospital was detected to be associated with affected space and penicillin allergy as well (p < 0.05). Isolates presented large amounts of aerobic gram-positive bacteria (64.2%), followed by facultative anaerobic bacteria (gram+/15.8%, gram−/12.7%). Tested ampicillin in combination with sulbactam (or without) and cephalosporins displayed high susceptibility rates, revealing distinguished results regarding clindamycin (p < 0.05). Co-trimoxazol and moxifloxacin showed high overall susceptibility rates (MOX: 94.7%, COTRIM: 92.6%).
This study demonstrates ampicillin/sulbactam in addition to surgical intervention is a good standard in treatment of severe odontogenic neck infections. Cephalosporins seem to be a considerable option as well. If beta-lactam allergy is diagnosed co-trimoxazol and moxifloxacin represent relevant alternatives.
Age, allergic profile and bacteria' resistance patterns for empiric antibiotics have an influence on patients in-hospital stay. Ampicillin/sulbactam proves itself to be good for empiric antibiosis in severe odontogenic infections. Furthermore cephalosporins could be considered as another option in treatment. However moxifloxacin and co-trimoxazol deserves further investigation as empiric antibiosis in odontogenic infections if beta-lactam allergy is diagnosed.
Prospective randomized comparative evaluation of proximal valve polyurethane and distal valve silicone peripherally inserted central catheters
2010, Journal of Vascular and Interventional Radiology
The objective of this study was to evaluate and compare the relative durability and complications between the proximal valve polyurethane and distal valve silicone peripherally inserted central catheters (PICCs).
Institutional review board approval was obtained. A total of 326 patients (mean age, 50.4 years) was assigned randomly to receive either a proximal valve polyurethane PICC (n = 198) or a distal valve silicone Groshong PICC (n = 194). All PICCs were inserted under radiologic guidance by interventional radiologists. Follow-up data were collected until catheter removal because of complications or treatment completion.
The mean catheter dwell time was 25.6 days (range, 1–245 days). Complications were encountered in 26.8% and 47.9% of the proximal valve polyurethane PICCs and distal valve silicone PICCs, respectively (P < .001). Significantly higher incidences of phlebitis (23.2% versus 11.6%, P = .003) and catheter-related infection (6.2% versus 2%, P = 0.043) were noted in the distal valve silicone PICCs. No significant differences in the incidence of catheter occlusion, fracture, or dislodgement were found. Multivariate logistic regression analysis showed a higher complication rate in the distal valve silicone PICCs corrected for patients' age, sex, underlying morbidity, indication, peripheral vein accessed, arm used, catheter tip placement, and the number of venepunctures attempted.
Proximal valve polyurethane PICCs were more durable than distal valve silicone PICCs, which were associated with a higher incidence of phlebitis and infection, probably related to the materials of the catheters and the designs and placements of the catheter valves.

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Basic and patient-oriented researchUse of Peripherally Inserted Central Catheters in the Management of Recalcitrant Maxillofacial Infection

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Otolaryngol Head Neck Surg

Surgery

Mayo Clin Proc

Otolaryngol Head Neck Surg

Deep neck infections: Analysis of 185 cases

Head Neck

Severe odontogenic infections

Aust Dent J

Major maxillofacial infections: An evaluation of 107 cases

Aust Dent J

Basic and patient-oriented research
Use of Peripherally Inserted Central Catheters in the Management of Recalcitrant Maxillofacial Infection