Anaerobic bacteremia following tooth extraction and removal of osteosynthesis plates

J Oral Maxillofac Surg 45:477-480,1987

Anaerobic Bacteremia Following Tooth Extraction and Removal of Osteosynthesis Plates J.-E. OTTEN MD, DMD,* K. PELZ, MD,t AND G. CHRISTMANN* The occurrence of bacteremia was investigated in 39 patients undergoing tooth extraction (Group 1), surgical removal of impacted third molars (Group 2), or removal of osteosynthesis plates (Group 3). None of the 39 patients had bacteremia before anesthesia or after nasal intubation for general anesthesia. In two of 23 patients bacteria could be isolated after local anesthesia. Microorganisms were isolated in 14 of 19 patients (74%) with tooth extraction. In nine, a mixture of facultative anaerobic ("aerobic") and strict anaerobic bacteria were identified; in five, anaerobes were isolated exclusively. Two to 130 bacteria were cultured per 10 ml venous blood. Endocarditis causing alpha-hemolytic streptococci were found in seven cases (50%). At least one of the predominating anaerobes (Bacteroides, Fusobacteria, or Peptostreptococcii were found in all positive cases. Bacteremia was found in 40% of the Group 2 patients. There was no bacteremia in the Group 3 patients. The pathogenic relevance of anaerobic bacteremia is discussed and as a consequence it is suggested that the risk of developing organ abscesses as well as the problem of endocarditis following dental bacteremia has to be taken into consideration. On the basis of sensitivity testing, erythromycin does not appear to be the drug of choice in penicillin-allergic patients.

scess using two case examples. Numerous characteristics of pathogenicity have now been established for these difficult to detect microorganisms." This study was carried out to determine the incidence of anaerobic bacteremia caused by tooth extraction and osteosynthesis plate removal. Based on the facultative anaerobic ("aerobic") and anaerobic bacterial spectrum detected, the authors hoped to assess the pathogenic relevance, particularly of the abscess-producing anaerobes, by establishing the types of species and the number of bacteria. The results were compared with those of other pertinent studies to determine whether there were any regional differences. A further objective was to determine whether there was any connection between the characteristics of bacteremia and the type of surgical procedure in the oral cavity namely, routine tooth extraction, surgical tooth removal, and the removal of ostosynthetic plates. The sensitivity of the bacterial species to various antibiotics was also studied.

It has been known for several years that tooth extraction can cause bacterial dissemination into the bloodstream.' Microbiologic investigations carried out in the last few years have produced more detailed information on the species of the bacteria involved.t-' Besides the alpha-hemolytic streptococci, which are considered endocarditis-producing pathogens, anaerobes have begun to draw special attention. They can cause abscesses in the various parenchymatous organs such as the liver,4.5 lung," and brain'? Ingham et al." have described the relationship between tooth extraction and cerebral ab-

* Department of Oral and Maxillofacial Surgery. University of Freiburg, Freiburg, West Germany. t Department of Medical Microbiology, University of Freiburg, Freiburg, West Germany. Address correspondence and reprint requests to Dr. Otten: Klinikum-der-Albert-Ludwigs-Universitat, Hugstetter Str. 55, 0-7800 Freiburg i Dr, West Germany. 0278-2391/87 $0.00 + .25

477

478

BACTEREMIA FOLLOWING TOOTH EXTRACTION

Table 2. Anaerobic Species Identified in Bacteremia After Tooth Extraction (14 out of 19 cases)

Patients and Methods PATIENTS

The 39 patients included in the study (19 females, 20 males ; age, 4-64 years) were divided into three groups. Nineteen patients (Group I) underwent tooth extraction because of caries and, in some cases, periodontal disease. In most cases, radiographs revealed signs of periapical granulomas. Parti ally impacted third molars were surgically removed in 10 patients (Group 2). These teeth all communicated with the oral cavity. In 10 other cases (Group 3), osteosynthesis plates that had been inserted for treatment of fractures or dysgnathias were surgically removed. The plates had been implanted at least six months before and showed no clinical signs of inflammation. An intraoral incision away from the periodontium was used in each of the latter cases. None of the patients showed any signs of local or general infection. Sixteen of them were treated under general anesthesia and 23 under local anesthesia. No preoperative antibiotics were prescribed and no special disinfection of the mouth was done. The patients generally had fair oral hygiene.

Species

Strains

Per cent

Black-pigmented Bacteroides Ba cteroides sp. Fusobacterium nucleatum Peptostreptococcus sp . Selenomonas sp. Eubact erium sp. Gram-negative rods Gram-positive rods Yeillonella parvula Arachnia propionica Actinolllyces israelii

9 7 7 6

64 50 50

3 3

21 21

2 2 2 2

14 14 14 14

1

7

43

lated and identified using modern microbiologic rnethods'v-!' including a colony count. Obvious contaminants such as propionibacterium acnes and coagulase negative Staphylococci were excluded. Growth of these species on only one or two of the six parallelly incubated plates was the criterion of exclusion. Antibiotic sensitivity tests were performed by agar diffusion for penicillin, ampicillin, erythromycin, c1indamycin, and metronidazole. Results

MICROBIOLOGY

Blood samples were taken for bacteriologic examination at three different times: at the time of venipuncture (to), three to five minutes after the local or general anesthesia had been started (t l ) , and three to five minutes after the surgical procedure (t 2) . Extreme caution was taken to ensure sterility. Ten ml of venous blood was placed in the lysis centrifugation blood culture device (Dupont Isolator to) and was processed within two hours. The sediment was then innoculated in equal parts on two chocolate agar plates and four anaerobic blood-agar plates. Following incubation for a minimum of six days , the cultured bacteria were isoTable 1. Facultative Anaerobic Species Identified in Bacteremia Following Tooth Extraction (14 out of 19 cases) Species

Strains

Per cent

Streptococcus sanguis I Streptococcus-M'G-intermedius Streptococcus sanguis II Streptococcus mutans Str eptococcus sp, A ctinolllyces odontolyticus Actinomyces sp. A ctinobac. actinomyc, comit, Haemophilus influenzae

3 3 2

21 21

14 7 7 7

7 7 7

At time to, bacteremia could not be detected in a ny of the 39 patients. Neither were there any positive blood samples found after nasal intubation (t l ) . However, after local anesthesia, anaerobic strains were isolated in two of 23 cases; one case of Bacteroides sp. with three bacteria per to ml of venous blood and one case in which two "aerobic" and two anaerobic strains were cultured in a concentration of 49 microorganisms per to ml venous blood (Streptococcus sanguis I, Streptococcus sanguis II , Selenomonas sp., Fusobacterium nucleatum). In 19 patients with routine tooth extraction (Group I), bacteremia wa s confirmed after the operation in 14 (74%). Nine of these cases had a mixture of "aerobic" and anaerobic bacteria with two to nine different species per patient. Five cases had exclusively anaerobic isolates, with one to eight species per case. The results of the facultative anaerobic identification are presented in Table 1. Endocarditiscausing , alpha-hemolytic streptococci iStreptococcus-M'G-intennedius, Streptococcus sanguis I and II, and Streptococcus mutans) were found in seven cases. The colony count revealed two to five bacteria per 10 ml venous blood. With the exception of a Haemophilus and an Actinobacillus strain, all of the bacteria proved to be sensitive to penicillin. All strains were also sensitive to ampicillin.

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OTIEN ET AL.

Table 3. Facultative and Pure Anaerobic Species Identified in Bacteremia After Removal of Partially Impacted Teeth (4 out of 10 cases) Species

Strains

Facultative anaerobes Streptococcus sanguis I Streptococcus salivarius Staphylococcus aureus Anaerobes Actinomyces israelii Gram-positive rods

The results of the identification of the pure anaerobes are shown in Table 2. Black-pigmented Bacteroides, non-pigmented Bacteroides, Fusobacteria, and Peptostreptococci were isolated in all cases at rates of 43-64%. Two unidentified gramnegative anaerobic rods were suspected to belong to either the Bacteroides or the Fusobacteria. Two to 130 bacteria were cultured per 10 ml blood. The isolates were all sensitive to metronidazole and penicillin with the exception of two Arachnia strains that proved resistant to metronidazole, and two black-pigmented Bacteroides that were resistant to penicillin. All of the Fusobacteria and the Veillonelles were resistant to erythromycin. Apart from one strain of Veillonella, all the anaerobes were sensitive to clindamycin. In contrast to the 14 of 19 cases of simple tooth extraction in whom there was bacteremia, in the 10 patients undergoing surgical removal of third molars (Group 2), bacteremia could be confirmed in only four cases (40%). The results of identification are presented in Table 3. Only four "aerobic" and two anaerobic strains in a low concentration (two to 20 bacteria per 10 ml blood) were detected. Bacteroides, Fusobacteria, and Peptostreptococci were not present. All of the isolates, with the exception of a one strain of Staphylococcus aureus, were sensitive to penicillin. In the 10 patients in Group 3 (removal of osteosynthesis plates), no bacteria could be isolated in the blood samples. Discussion

As expected, the highest incidence of bacteremia occurred in the patients who had undergone tooth extraction. The 74% incidence correlates with the results of other investigations from Canada.P the United States," and Great Britain'" published between 1982-1984 that reported an occurrence rate of 73-77%. In this study, the high rate of bacterial isolates per patient is remarkable: 73 isolates out of 18 positive cases. This might be due to the use of

the blood-culture device, the lysis centrifugation system, which is well suited for isolating anaerobes.Pi" Another aspect dealt with in the present investigation was the incidence of bacteremia in accordance with the type of intraoral intervention. A comparison of the results in Group 1 (simple tooth extraction) with those in Group 3 (removal of osteosynthesis plates) suggests that the periodontium of the teeth is the mainsource for dissemination of bacteria into the intravascular compartment. Most of the circulating "aerobic" and anaerobic bacteria that were isolated have been cultured before out of various periodontal and endodontal lesions."? The results show that pure anaerobic bacteremia following tooth extraction are more prevalent, both in quality and quantity, than facultative anaerobic bacteremia. The endocarditis-related facultative microorganisms were only found in 50% of the bacteremia cases. In contrast, anaerobic abscesscausing microorganisms were detected in 100% of the bacteremia cases. Colony counting gave an average of 19.3 anaerobes and 6.6 "aerobes" per 10 ml of venous blood. The results of species isolation and identification in this study correlate with those results obtained in a previous investigation 18 on odontogenic abscesses with Bacteroides, Fusobacteria, and Peptostreptococci being the most predominant microorganisms. Each of these anaerobe species occurred at about the same rate in both studies. Their local pathogenicity in the oral cavity has been conclusively confirmed and their role in the development of abscesses in the brain, liver, or lung, as previously mentioned, is well known. 4'-8 The authors believe that there may be a link between the oral anaerobic bacteria and organ abscesses and that this relationship has not been adequately investigated. In comparing the results of publications on dental bacteremia from Canada.P the United States, 13 and Great Britain':' since 1982, a significant difference in the types of pathogenic species involved was not found. Therefore, the authors believe that the need for antibiotic prophylaxis is not a regional problem. When considering the choice of antibiotics for prophylaxis or therapy, the problem of endocarditis following dental bacteremia as well as the risk of developing abscesses in the brain, liver or lung must be taken into account; the authors do not know which risk is higher. Gunteroth'? reported 3.6% of his endocarditis cases as being related to tooth extraction. To their knowledge, there is no concrete information on the risk of anaerobic bacteremia; they feel that both risks should be taken into equal account. For high risk patients who have to be protected from the consequences of oral bac-

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BACTEREMIA FOLLOWING TOOTH EXTRACTION

teremia, the authors prefer to admini ster penicillin and metronidazole iv for antibiotic prophylaxis. The study results show that erythromycin should not be the drug-of-choice for antibiotic prophylaxis in penicillin-allergic patients. In accordance with the latest recommendation of the Swiss Study Group on Prophylaxis of Endocarditis.P-" clindarnycin is preferred for prevention of consequences from dental bacteremia in penillin-allergic patients.

II.

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