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Eikenella corrodens: A pathogen in head and neck infections
Eikenella corrodens: A pathogen in head
and neck infections Jerry L. Jones, D.D.S., Santa Fe, N. M.
M.S.D.,
and DonaldA.
Romig, M.D.,
F.A.C.P.,
E. corrodens as a co-existent or primary causal agent in six cases of osteomyelitis or orofacial infections following trauma or elective dental extraction is presented. The importance of this facultative gram-negative bacillus as a head and neck pathogen is discussed.
T
he presence of anaerobic bacteria, and more specifically Eikenella corrodens, as a causative agent in head and neck infections has been appreciated recently.5* I4 Many of the cases of E. corrodens infections have been reported in medical-surgical patients with mixed infections;2 but the organism has been noted as the only infecting agent in patients with meningitis, subdural empyema,*, 5 osteomyelitis, l, “3 lg and endocarditis.6* l5 The increasing reports of E. corrodens infections in,volving the head and neck, and specifically the oral cavity, ‘3 ‘** l7 demonstrate the importance of understanding this pathogen and being aware of its possible presence in infections of this area for treatment purposes. REVIEW OF THE LITERATURE E. corrodens is a facultative anaerobic gramnegative bacillus and was originally called the HB-1 strain of King. *OHenriksen” described three strains of an anaerobic gram-negative bacilli that showed similar properties of colonial growth on solid media. Holm*l also noted that the colonies pitted the agar and named the bacillus the “corroding bacillus.” Twenty-one different strains were obtained by Eiken3 from abscesses, soft-tissue infections, and sputum. Because of the characteristic colonial morphology, he suggested the name Bacteroides corrodens. Three of the strains described by Eiken were microaerophilic and the others were obligate anaerobes; all grew slowly, and most were isolated from mixed infections. Jackson and colleagues’ then studied B. corrodens and found that it could be separated into two groups-a facultative anaerobic “corroding bacillus” and an obligately anaerobic “corroding bacillus.” Biochemical differences between the two groups were noted, as 00304220/79/120501+05$00.50/0
0
1979 The C. V. Mosby Co.
were differences in immunologic specificity. Jackson and Goodman9 then reclassified the facultative organisms E. corrodens, while the obligate anaerobes continued to be called B. corrodens. Riley** found that the HB- 1 strains of King were identical to the E. corrodens of Jackson and associates. A review of reports of isolates and clinical infections reveals the importance of the pathogen to the orodigestive tract. Khairat’ recovered B. corrodens from the blood of sixteen to sixty-four patients with positive blood cultures following dental extraction. Brooks and isolations from associate? reported E. corrodens thirty-eight subcutaneous abscesses in twenty-five patients with a history of parenteral drug abuse (methylphenidate). Typically, these patients put their mouths to the injection sites. Glassman and Simpson’ reported three cases of infections involving E. corrodens. In two cases dental manipulation was in the recent history, and the third had a laryngeal carcinoma. Goodman’* reported Eikenella organisms in oral infections in five patients who had undergone endodontic therapy for dentoalveolar infections of odontogenic origin. E. corrodens as a causative agent in mandibular osteomyelitis has been reported by Stern and co-authors” and Carruthers and Sommers.‘s A variety of human infections with E. corrodens have been reported, and many of these are associated with the head and neck, oral cavity, fractures of the facial bones, or human bites.‘, 5, 6, 17. Is, 23 In a clinical review of orofacial odontogenic infections, Chow and colleagues’4 stated that the largest reservoir of anaerobic bacteria was found in dental plaque and in the gingival crevice. Bacteroids species were among the anaerobic bacteria found in large numbers in these oral sites. This report of cases further 501
502
Jones and Romig
Oral Surg. December, 1979
Table 1. Case summary P&w
Age ISex
V.B.
.58/F
Right mandible (following dental extractions)
E. c0rr0den.c
t
F.M.
34/M
Left mandibular body fracture
I.M.
28/M
Fracture. angle
V.P.
G.B.
IS/F
28/M
Organism
SOWY
mid-
left mandibular
Fracture, right mandibular aymphysis
Fracture, angle
right mandibular
1~orr0drn.s. A .stwptocwcus
B. frcrgilh, E. c~orr0den.s
A .srrq~tocwcus, z. c~orr0den.s
Coagulase-positive staphylococcus, B. frugilis. E. corrodcws
Antirnic~rohitrl duration of Rx
Surgicul
Rx
Penicillin G. 2 months
I Odontectomy 2. Sequestrectomy tion catheter
Ccphalosporin. 14 days; penicillin G 6 weeks Cephalosporin. 20 days: clindamycin, 14 days Ccphalosporin. 14 days; clindamycin. I4 days Pencillin G. IO days: clindamycin, 14 days
I. Sequestrectomy and removal of foreign body (wires) 2. Autogenous bone graft, left mandible 3. Bilateral ramus osteotomies I. Open reduction of facial fractures 2. Sequestrectomy body (wires) I. Open reduction 2. Incision
insertion
and removal of mandibular
and drainage
I. Open reduction 2. Incision
with
of irriga-
of foreign fracture
of symphysis
of facial fractures
and drainage
of right mandibu-
lar angle
emphasizes the importance of E. corrodens in odontogenic infections or those secondary to trauma to the orofacial region.
there has been no evidence of recurrence of infection during 2% years of follow-up. The current radiographic appearance of the patient’s mandible is normal.
CASE REPORTS Case 1
CASE 2
(Table I)
A %-year-old woman was seen in the office complaining of pain and swelling of the right mandible. Examination revealed exquisite tenderness along the inferior border of the right mandible, with moderate edema and multiple cutaneous draining sinuses. The history revealed that two mandibular right teeth had been extracted 2 months previously by the patient’s general dentist. There had been recurrent bouts of pain and swelling which were treated intermittently with small doses of penicillin or erythromycin. Radiographs revealed recent extraction sites in the right mandible, with diffuse radiolucency from the symphysis to the mandibular angle and loss of normal trabeculation. The patient was admitted to the hospital and, under sedation and local anesthesia, five remaining periodontally involved teeth in the area were removed. The right mandible was debrided of multiple bony sequestra and specimens were sent for aerobic, anaerobic, and fungal cultures. The intraoral wound was closed, and an extraoral irrigation catheter was inserted. Intravenous penicillin (12,000,OOO units per day) was started, and the wound was irrigated with saline solution containing penicillin. The wound drainage and facial swelling decreased markedly. The catheter was removed on the fourth postoperative day. A pure culture of E. corrodens was obtained in 48 hours. The patient was discharged on the tenth day with instructions to take phenoxymethyl penicillin, 1 gm. every 6 hours for 1 month and then 500 mg. every 6 hours for 1 month. Subsequently, a complete mandibular dental prosthesis was constructed, and
A 34-year-old man had purulent drainage at the inferior border of the left mandible 6 weeks following an automobile accident in which he sustained multiple injuries, including (1) chest trauma with multiple fractured ribs and left pneumothorax. (2) an open fracture of the left femur, (3) facial lacerations, (4) an open comminuted fracture of the left mandibular midbody and a fracture dislocation of the right mandibular condyle. The initial repair of the facial injuries was performed elsewhere. Left submandibular cutaneous draining sinuses with nonunion of the left mandible and a malocclusion were apparent. Radiographs revealed numerous (six) interosseous wires in the left mandible with a large sequestrum of one of the fracture fragments. Results of previous cultures were undetermined. The patient was hospitalized for surgical debridement and sequestrectomy. E. corrodens and alpha-streptococcus were isolated from the sequestrum and wound. The patient was given high doses of penicillin for 1 month and placed in intermaxillary fixation with the occlusion that was obtained at the time of the original repair. The infection was controlled but because of the traumatic malocclusion, a fibrous union resulted in the left mandible. In December, 1977, the patient was readmitted, and the Class III malocclusion was corrected with bilateral vertical subcondylar osteotomies. An autogenous iliac crest bone graft was placed at the site of the fibrous union. The patient was immobilized for 6 weeks. The patient has been followed for 1 year and has a stable mandible with a functional occlusion and no evidence of infection.
Eikenella corrodens
Volume 48 Number 6 CASE 3
A 2%year-old Indian man was the victim of a hit-and-run automobile accident in which he sustained multiple system injuries, including open fracture of the left humerus, chest contusion with evidence of a myocardial injury, cerebral concussion, and multiple facial fractures and lacerations. The facial lacerations were closed in the emergency room, and the surgical repair of the facial fractures was delayed 10 days because of the myocardial contusion. The facial fractures included (1) an open comminuted displaced fracture of the left mandibular angle and right symphysis, (2) a LeFort I fracture of the maxilla, and (3) a comminuted fracture of the left infraorbital rim with a displaced zygomatic complex. Open reductions with internal fixation were performed through existing lacerations, and the patient was placed in intermaxillary fixation. A mandibular left third molar was removed at the time of surgery. The patient was given intravenous cephalosporin during the hospital course. Three weeks after fixation, the left mandibular incision dehisced with copious drainage. Aerobic and anaerobic culture isolated B. fragilis, and the patient was given clindamycin by mouth. In 2 weeks the infection was controlled, there was no drainage, and the edema was subsiding, but there was mobility at the left angle fracture. Mobility at the fracture site did not improve with fixation for 10 weeks. Radiographically, there was a sequestrum of one of the comminuted fracture segments. The patient was admitted to the hospital,.and interosseous wire and bony sequestrum were removed. Fibrous tissue in the fracture site at the left angle was removed, and it was thought that a bone graft was not indicated. The patient continued to receive intravenous or oral clindamycin during the hospitalization. Cultures of the wound and sequestrum grew only E. corrodens. Fixation was maintained an additional 5 weeks, after which time clinical stability of the fractures with normal occlusion and no evidence of infection was observed. The patient has been followed for 9 months, with no recurrence of infection and radiographic union of the fracture. CASE 4
A 15year-old girl sustained a closed head injury and a fracture of the left mandibular angle and right mandibular symphysis when she was struck by an automobile. The patient was admitted by a neurosurgeon, and consultation was requested concerning the facial injury. The symphysis fracture was displaced. Because a definitive reduction was postponed until the patient was stable from the neurologic injury, the fracture was reduced and stabilized with a circumdental wire. The patient was given cephalosporin intravenously. One week after the injury the patient was taken to the operating room where open reduction and internal fixation of the mandibular fractures were performed. Five days following the procedure the skin incision at the symphysis dehisced and drained copious amounts of purulent, foul-smelling exudate. Aerobic and anaerobic specimens were obtained by aspiration, and a drain was placed in the wound. Antibiotic therapy was changed to oral clindamycin. The cultures showed alpha streptococcus and E. corrodens. The drainage rapidly decreased, and the infection was easily controlled.
503
Clindamycin was continued for 14 days. At 6 weeks the fixation appliances were removed, with clinical stability at the fracture sites and no evidence of infection. CASE 5
A 2%year-old man was admitted to the hospital with multiple facial fractures sustained in an automobile accident. The facial injuries consisted of (1) a displaced fracture of the right mandibular angle and left mandibular symphysis, (2) a LeFort II fracture of the maxilla, and (3) a displaced fracture of the right zygomatic complex. The patient was started on intravenous penicillin. The day following admission the patient was taken to the operating room, where open reductions with internal fixation of the mandibular fractures and right zygomatic complex were performed. A right orbital floor fracture was reconstructed with a silicone rubber insert. The maxillary fracture was treated by internal suspension and intermaxillary fixation. An impacted third molar was removed from the fracture site at the right mandibular angle. Eight days following the procedure the patient was seen on an outpatient basis and sanguinopurulent drainage was observed from a dehiscence in the incision at the right angle. The patient was taking oral penicillin at this time. Specimens for aerobic, anaerobic, and fungal cultures were obtained, and a drain was placed in the wound. A coagulase-positive staphylococcus, B. fragilis, and E. corrodens were cultured. Penicillin was discontinued, and the patient was given clindamycin, 300 mg. every 8 hours, orally. Control of the infection progressed rapidly, and in 14 days the wound was dry. At I weeks the fixation appliances and suspension were removed, and the fractures were stable with no evidence of infection. The patient has been followed for 6 months. DISCUSSION Previous reports in the literature have dealt mainly with the characteristics of E. corrodens.2, 3* 6* g Marsden and Hyde5 were the first to publish detailed clinical cases infected with the organism. Since then other clinical accounts have shown this microorganism to be responsible for many serious infections involving numerous organ systems. E. corrodens isolated in pure culture has proved its pathogenicity, but primarily the organism has been isolated in conjunction with other organisms.*, 6 This association with other organisms (aerobes and anaerobes) is a well-recognized phenomenon. It is difficult to know whether or not the association in mixed infections is crucial with reference to pathogenesis, particularly in the oral cavity, the natural habitat of E. corrodens. Many authors have shown the ubiquitous nature of E. corrodens, and others have discussed specifically its presence in the upper respiratory tract and the oral cavity.5* lo, I*, I43 I7 Cases of human bites infected with E. corrodens have been observed. *, 4* 23Meningitis and subacute bacterial endocarditis infected with Eikenella have been observed in patients who have undergone
504
Jones and Romig
predisposing dental manipulation.5, I5 While E. corrodens has been seen in periapical dental infections and orofacial infections,“, l4 Eikenella causing osteomyelitis of the facial bones has been described in few instances. 17,” Four of the infections presented in this report were seen after facial trauma, while Case 1 had a history of recent dental extractions. The infections associated with the facial fractures occurred in areas of a compounded fracture through a periodontal membrane space. Also, in each case definitive surgical reduction of these fractures was delayed 7 to 10 days because of the patient’s medical status. Two of the infections occurred at the mandibular angle, and the third molar teeth in the fracture site were removed at the time of reduction of the fracture. Teeth were not removed in Case 4 in which a soft-tissue infection occurred at the site of the symphysis fracture. Similar to previous accounts, E. corrodens was cultured in four cases in association with other organisms, primarily B. fragilis and alpha streptococcus. A pure culture of the organism was isolated from the osteomyelitis in Case 1. In vitro antibiotic sensitivity testing by a disc agar method shows that the strains of E. corrodens are sensitive to many antibiotics, including penicillin G, ampicillin, cephalosporin, chloramphenicol, erythromytin, tetracycline, and vancomycin.‘6 The organism shows relative resistance to the aminoglycosides and, typically, resistance to clindamycin.’ Control of the infections in these reported cases was not a clinical problem when antimicrobial drugs were coupled with surgical management. As seen in Table I, two of the cases were treated with high doses of penicillin G and three were treated successfully with clindamycin after initial administration of cephalosporin. Two of the cases in which clindamycin was used involved softtissue orofacial infections in which multiple isolates were obtained. The patients were changed to clindamycin therapy because of the clinical appearance of the wounds and because early culture reports suggested anaerobic organisms. As a result of the works of Brooks and associates,’ the drugs of choice to treat Eikenella infections would be ampicillin, penicillin G, and, alternatively, tetracycline. Clindamycin and methicillin should have little clinical therapeutic usefulness.* However, in three of the cases reported here, clindamycin did not seem to lengthen the course of antimicrobial therapy or hinder the eradication of the infections. Osteomyelitis and orofacial infections are relatively uncommon complications in the treatment of facial fractures or exodontia, and when they occur staphylo-
Oral Surg. December, 1979
coccus and streptococcus are most commonly associated as causal agents. However, it is important that the clinician not overlook the possible presence of gramnegative anaerobes in infections of the orofacial region and that appropriate culture methods be used to identify these organisms. The relative difficulty of and the length of time involved in culturing this facultative gram-negative organism, as well as its proved abundance in the upper respiratory tract, point out the importance of suspecting E. corrodens as a co-existent or primary causal agent. Special thanks are due Dr. R. L. Farquhar for his assistance in the treatment of these patients and in compiling the data used in this article. REFERENCES I. Glassman, A. B., and Simpson, J. S.: Eikenella
2.
3. 4.
5. 6.
I. 8.
9
10 11 12 13 14 15 16
17
corrodes: A Clinical Problem, J. Am. Dent. Assoc. 91: 1237, 1975. Brooks, G. F., and others: Eikenella corrodens, a Recently Recognized Pathogen: Infections in Medical-Surgical Patients and in Association With Methylphenidate Abuse, Medicine 53: 325, 1974. Eiken, M.: Studies on an Anaerobic Rod-Spaced, GramNegative Microorganism: Bacteroides corrodens N. Sp., Acta Path. Microbial. Stand. 43: 404, 1958. Kaplan, J. M., McCracken, G. .I., and Nelson, J.D.: Infections in Children Caused by the HB Group of Bacteria, J. Pediatr. 82: 398.1973. Marsden, H. B., and Hyde, W. A.: Isolation of Bacteroides corrodens From Infections in Children, J. Clin. Pathol. 24: 117, 1970. Dorff, G. J., Jackson, L. J., and Rytel, N. W.: Infections With Eikenella corrodens, a Newly Recognized Human Pathogen, Ann. Intern. Med. SO: 305, 1974. Khairat, 0.: Bacteroides corrodens Isolated From Bacteremias, J. Pathol. Bacterial. 94: 29, 1967. Jackson, F. L., and others: Taxonomic Status of Facuitative and Bacilli” That Have Been Strictly Anaerobic “Corroding Classified as Bacteroides corrodens, J. Med. Microbial. 4: 17 1. 1971. Jackson, F. L., and Goodman, Y. E.: Transfer of the Facultative Anaerobic Organism Bacreroides corrodens Eiken to a New Genus, Eikenella, Int. J. Systemic Bacterial. 22: 73, 1972. Brooks, G. F., O’Denoghue, J. M., Ressing. J. P.. et al.: Eikenella corrodens: A Recently Recognized New Pathogen, Medicine 53: 32.5-342, 1974. Hetuiksen, S. D.: Studies in Gram-Negative Anaerobes; Gramnegative Rods With Spreading Colonies, Acta Pathol. Microbiol. Stand. 25: 368, 1948. Goodman, A. D.: Eikenella corrodens isolated in Oral Infections of Dental Origin, ORAL SURG. 44: 128-133. 1977. Robinson, J. V. A., and James A. L.: Some Serological Studies on Bacteroides corrodens, J. Gen. Microbial. 78: 193- 197, 1973. Chow, A. W., et al.: Orofacial Odontogenic Infections, Ann. Intern. Med. 88: 392-402, 1978. Geraci, J. E., Hermans, P. E., and Washington, J. A.: Eikenella corroders Endocarditis-Report of Cure in Two Cases, Mayo Clin. Proc. 49: 950-953, 1974. Robinson, J. V. A., and James, A. L.: In Vitro Susceptibility of Bacteroides corrodens and Eikeneila corrodens to Ten Chemotherapeutic Agents, Antimicrob. Agents Chemother. 6: 543. 546, 1974. Stem, K., and others: Eikenella Osteomyelitis of the Mandible
Eikenella corrodens
Volume 48 Number 6
18. 19. 20.
21.
Associated With Anemia of Chronic Disease, J. Oral Surg. 36: 285, 1978. Carruthers, N. M., and Sommers, H. M.: Letter: Eikenella corrodens Osteomyelitis, Ann. Intern. Med. 79: 900, 1973. Litwocks, L., and Carchardt, U.: Osteomyelitis Caused by A Bacteroides corrodem-like Organism (HB-I), Clin. Med. 80: 21, 1973. King, E. 0.: Round Table: Current Trends in Diagnostic Microbiology; the Identification of Unusual Pathogenic GramNegative Bacteria, Atlanta, Ga., 1%4, Department of Health, Education and Welfare, Public Health Service, Center for Disease Control. Holm. P.: Studies on the Etiology of Human Actinomycosis;
“Other Microbes” of Actinomycosis and Their Importance, Acta Pathol. Microbial. Stand. 27: 736, 1950. 22. Riley, P. A., Tatum, H. W., and Weaver, R. E.: Identity of HB-I of King and Eikenella corrodens (Eiken) Jackson and Goodman, Int. J. System. Bacterial. 23: 75-76, 1973. 23. Goldstein, E. J. C., and others: Bacteriology of Human and Animal Bite Wounds, J. Clin. Microbial. S: 667-672, 1978. Reprint requests to: Dr. Jerry L. Jones, D.D.S., M.S.D. 465 St. Michael’s Dr., Suite 110 Santa Fe, N. M. 87501
Erratum In the article entitled “Alterations in Osseous Crestal Height Following Interdental Osteotomies” by Dorfman and Turvey, which begins on page 120 of the August, 1979, issue of the JOURNAL, Fig. 7,B does not adequately show the tooth-bone relationship. Therefore, we are publishing a new Fig. 7 in which the crest of bone is more clearly visible in B.
Fig. 7. A, Presurgical bitewing of a representativecase where the osteotomy was performed in the preexisting extraction
space between
canine and premolar.
505
B, No significant
osseous crestal level changes postsurgically.
and neck infections Jerry L. Jones, D.D.S., Santa Fe, N. M.
M.S.D.,
and DonaldA.
Romig, M.D.,
F.A.C.P.,
E. corrodens as a co-existent or primary causal agent in six cases of osteomyelitis or orofacial infections following trauma or elective dental extraction is presented. The importance of this facultative gram-negative bacillus as a head and neck pathogen is discussed.
T
he presence of anaerobic bacteria, and more specifically Eikenella corrodens, as a causative agent in head and neck infections has been appreciated recently.5* I4 Many of the cases of E. corrodens infections have been reported in medical-surgical patients with mixed infections;2 but the organism has been noted as the only infecting agent in patients with meningitis, subdural empyema,*, 5 osteomyelitis, l, “3 lg and endocarditis.6* l5 The increasing reports of E. corrodens infections in,volving the head and neck, and specifically the oral cavity, ‘3 ‘** l7 demonstrate the importance of understanding this pathogen and being aware of its possible presence in infections of this area for treatment purposes. REVIEW OF THE LITERATURE E. corrodens is a facultative anaerobic gramnegative bacillus and was originally called the HB-1 strain of King. *OHenriksen” described three strains of an anaerobic gram-negative bacilli that showed similar properties of colonial growth on solid media. Holm*l also noted that the colonies pitted the agar and named the bacillus the “corroding bacillus.” Twenty-one different strains were obtained by Eiken3 from abscesses, soft-tissue infections, and sputum. Because of the characteristic colonial morphology, he suggested the name Bacteroides corrodens. Three of the strains described by Eiken were microaerophilic and the others were obligate anaerobes; all grew slowly, and most were isolated from mixed infections. Jackson and colleagues’ then studied B. corrodens and found that it could be separated into two groups-a facultative anaerobic “corroding bacillus” and an obligately anaerobic “corroding bacillus.” Biochemical differences between the two groups were noted, as 00304220/79/120501+05$00.50/0
0
1979 The C. V. Mosby Co.
were differences in immunologic specificity. Jackson and Goodman9 then reclassified the facultative organisms E. corrodens, while the obligate anaerobes continued to be called B. corrodens. Riley** found that the HB- 1 strains of King were identical to the E. corrodens of Jackson and associates. A review of reports of isolates and clinical infections reveals the importance of the pathogen to the orodigestive tract. Khairat’ recovered B. corrodens from the blood of sixteen to sixty-four patients with positive blood cultures following dental extraction. Brooks and isolations from associate? reported E. corrodens thirty-eight subcutaneous abscesses in twenty-five patients with a history of parenteral drug abuse (methylphenidate). Typically, these patients put their mouths to the injection sites. Glassman and Simpson’ reported three cases of infections involving E. corrodens. In two cases dental manipulation was in the recent history, and the third had a laryngeal carcinoma. Goodman’* reported Eikenella organisms in oral infections in five patients who had undergone endodontic therapy for dentoalveolar infections of odontogenic origin. E. corrodens as a causative agent in mandibular osteomyelitis has been reported by Stern and co-authors” and Carruthers and Sommers.‘s A variety of human infections with E. corrodens have been reported, and many of these are associated with the head and neck, oral cavity, fractures of the facial bones, or human bites.‘, 5, 6, 17. Is, 23 In a clinical review of orofacial odontogenic infections, Chow and colleagues’4 stated that the largest reservoir of anaerobic bacteria was found in dental plaque and in the gingival crevice. Bacteroids species were among the anaerobic bacteria found in large numbers in these oral sites. This report of cases further 501
502
Jones and Romig
Oral Surg. December, 1979
Table 1. Case summary P&w
Age ISex
V.B.
.58/F
Right mandible (following dental extractions)
E. c0rr0den.c
t
F.M.
34/M
Left mandibular body fracture
I.M.
28/M
Fracture. angle
V.P.
G.B.
IS/F
28/M
Organism
SOWY
mid-
left mandibular
Fracture, right mandibular aymphysis
Fracture, angle
right mandibular
1~orr0drn.s. A .stwptocwcus
B. frcrgilh, E. c~orr0den.s
A .srrq~tocwcus, z. c~orr0den.s
Coagulase-positive staphylococcus, B. frugilis. E. corrodcws
Antirnic~rohitrl duration of Rx
Surgicul
Rx
Penicillin G. 2 months
I Odontectomy 2. Sequestrectomy tion catheter
Ccphalosporin. 14 days; penicillin G 6 weeks Cephalosporin. 20 days: clindamycin, 14 days Ccphalosporin. 14 days; clindamycin. I4 days Pencillin G. IO days: clindamycin, 14 days
I. Sequestrectomy and removal of foreign body (wires) 2. Autogenous bone graft, left mandible 3. Bilateral ramus osteotomies I. Open reduction of facial fractures 2. Sequestrectomy body (wires) I. Open reduction 2. Incision
insertion
and removal of mandibular
and drainage
I. Open reduction 2. Incision
with
of irriga-
of foreign fracture
of symphysis
of facial fractures
and drainage
of right mandibu-
lar angle
emphasizes the importance of E. corrodens in odontogenic infections or those secondary to trauma to the orofacial region.
there has been no evidence of recurrence of infection during 2% years of follow-up. The current radiographic appearance of the patient’s mandible is normal.
CASE REPORTS Case 1
CASE 2
(Table I)
A %-year-old woman was seen in the office complaining of pain and swelling of the right mandible. Examination revealed exquisite tenderness along the inferior border of the right mandible, with moderate edema and multiple cutaneous draining sinuses. The history revealed that two mandibular right teeth had been extracted 2 months previously by the patient’s general dentist. There had been recurrent bouts of pain and swelling which were treated intermittently with small doses of penicillin or erythromycin. Radiographs revealed recent extraction sites in the right mandible, with diffuse radiolucency from the symphysis to the mandibular angle and loss of normal trabeculation. The patient was admitted to the hospital and, under sedation and local anesthesia, five remaining periodontally involved teeth in the area were removed. The right mandible was debrided of multiple bony sequestra and specimens were sent for aerobic, anaerobic, and fungal cultures. The intraoral wound was closed, and an extraoral irrigation catheter was inserted. Intravenous penicillin (12,000,OOO units per day) was started, and the wound was irrigated with saline solution containing penicillin. The wound drainage and facial swelling decreased markedly. The catheter was removed on the fourth postoperative day. A pure culture of E. corrodens was obtained in 48 hours. The patient was discharged on the tenth day with instructions to take phenoxymethyl penicillin, 1 gm. every 6 hours for 1 month and then 500 mg. every 6 hours for 1 month. Subsequently, a complete mandibular dental prosthesis was constructed, and
A 34-year-old man had purulent drainage at the inferior border of the left mandible 6 weeks following an automobile accident in which he sustained multiple injuries, including (1) chest trauma with multiple fractured ribs and left pneumothorax. (2) an open fracture of the left femur, (3) facial lacerations, (4) an open comminuted fracture of the left mandibular midbody and a fracture dislocation of the right mandibular condyle. The initial repair of the facial injuries was performed elsewhere. Left submandibular cutaneous draining sinuses with nonunion of the left mandible and a malocclusion were apparent. Radiographs revealed numerous (six) interosseous wires in the left mandible with a large sequestrum of one of the fracture fragments. Results of previous cultures were undetermined. The patient was hospitalized for surgical debridement and sequestrectomy. E. corrodens and alpha-streptococcus were isolated from the sequestrum and wound. The patient was given high doses of penicillin for 1 month and placed in intermaxillary fixation with the occlusion that was obtained at the time of the original repair. The infection was controlled but because of the traumatic malocclusion, a fibrous union resulted in the left mandible. In December, 1977, the patient was readmitted, and the Class III malocclusion was corrected with bilateral vertical subcondylar osteotomies. An autogenous iliac crest bone graft was placed at the site of the fibrous union. The patient was immobilized for 6 weeks. The patient has been followed for 1 year and has a stable mandible with a functional occlusion and no evidence of infection.
Eikenella corrodens
Volume 48 Number 6 CASE 3
A 2%year-old Indian man was the victim of a hit-and-run automobile accident in which he sustained multiple system injuries, including open fracture of the left humerus, chest contusion with evidence of a myocardial injury, cerebral concussion, and multiple facial fractures and lacerations. The facial lacerations were closed in the emergency room, and the surgical repair of the facial fractures was delayed 10 days because of the myocardial contusion. The facial fractures included (1) an open comminuted displaced fracture of the left mandibular angle and right symphysis, (2) a LeFort I fracture of the maxilla, and (3) a comminuted fracture of the left infraorbital rim with a displaced zygomatic complex. Open reductions with internal fixation were performed through existing lacerations, and the patient was placed in intermaxillary fixation. A mandibular left third molar was removed at the time of surgery. The patient was given intravenous cephalosporin during the hospital course. Three weeks after fixation, the left mandibular incision dehisced with copious drainage. Aerobic and anaerobic culture isolated B. fragilis, and the patient was given clindamycin by mouth. In 2 weeks the infection was controlled, there was no drainage, and the edema was subsiding, but there was mobility at the left angle fracture. Mobility at the fracture site did not improve with fixation for 10 weeks. Radiographically, there was a sequestrum of one of the comminuted fracture segments. The patient was admitted to the hospital,.and interosseous wire and bony sequestrum were removed. Fibrous tissue in the fracture site at the left angle was removed, and it was thought that a bone graft was not indicated. The patient continued to receive intravenous or oral clindamycin during the hospitalization. Cultures of the wound and sequestrum grew only E. corrodens. Fixation was maintained an additional 5 weeks, after which time clinical stability of the fractures with normal occlusion and no evidence of infection was observed. The patient has been followed for 9 months, with no recurrence of infection and radiographic union of the fracture. CASE 4
A 15year-old girl sustained a closed head injury and a fracture of the left mandibular angle and right mandibular symphysis when she was struck by an automobile. The patient was admitted by a neurosurgeon, and consultation was requested concerning the facial injury. The symphysis fracture was displaced. Because a definitive reduction was postponed until the patient was stable from the neurologic injury, the fracture was reduced and stabilized with a circumdental wire. The patient was given cephalosporin intravenously. One week after the injury the patient was taken to the operating room where open reduction and internal fixation of the mandibular fractures were performed. Five days following the procedure the skin incision at the symphysis dehisced and drained copious amounts of purulent, foul-smelling exudate. Aerobic and anaerobic specimens were obtained by aspiration, and a drain was placed in the wound. Antibiotic therapy was changed to oral clindamycin. The cultures showed alpha streptococcus and E. corrodens. The drainage rapidly decreased, and the infection was easily controlled.
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Clindamycin was continued for 14 days. At 6 weeks the fixation appliances were removed, with clinical stability at the fracture sites and no evidence of infection. CASE 5
A 2%year-old man was admitted to the hospital with multiple facial fractures sustained in an automobile accident. The facial injuries consisted of (1) a displaced fracture of the right mandibular angle and left mandibular symphysis, (2) a LeFort II fracture of the maxilla, and (3) a displaced fracture of the right zygomatic complex. The patient was started on intravenous penicillin. The day following admission the patient was taken to the operating room, where open reductions with internal fixation of the mandibular fractures and right zygomatic complex were performed. A right orbital floor fracture was reconstructed with a silicone rubber insert. The maxillary fracture was treated by internal suspension and intermaxillary fixation. An impacted third molar was removed from the fracture site at the right mandibular angle. Eight days following the procedure the patient was seen on an outpatient basis and sanguinopurulent drainage was observed from a dehiscence in the incision at the right angle. The patient was taking oral penicillin at this time. Specimens for aerobic, anaerobic, and fungal cultures were obtained, and a drain was placed in the wound. A coagulase-positive staphylococcus, B. fragilis, and E. corrodens were cultured. Penicillin was discontinued, and the patient was given clindamycin, 300 mg. every 8 hours, orally. Control of the infection progressed rapidly, and in 14 days the wound was dry. At I weeks the fixation appliances and suspension were removed, and the fractures were stable with no evidence of infection. The patient has been followed for 6 months. DISCUSSION Previous reports in the literature have dealt mainly with the characteristics of E. corrodens.2, 3* 6* g Marsden and Hyde5 were the first to publish detailed clinical cases infected with the organism. Since then other clinical accounts have shown this microorganism to be responsible for many serious infections involving numerous organ systems. E. corrodens isolated in pure culture has proved its pathogenicity, but primarily the organism has been isolated in conjunction with other organisms.*, 6 This association with other organisms (aerobes and anaerobes) is a well-recognized phenomenon. It is difficult to know whether or not the association in mixed infections is crucial with reference to pathogenesis, particularly in the oral cavity, the natural habitat of E. corrodens. Many authors have shown the ubiquitous nature of E. corrodens, and others have discussed specifically its presence in the upper respiratory tract and the oral cavity.5* lo, I*, I43 I7 Cases of human bites infected with E. corrodens have been observed. *, 4* 23Meningitis and subacute bacterial endocarditis infected with Eikenella have been observed in patients who have undergone
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Jones and Romig
predisposing dental manipulation.5, I5 While E. corrodens has been seen in periapical dental infections and orofacial infections,“, l4 Eikenella causing osteomyelitis of the facial bones has been described in few instances. 17,” Four of the infections presented in this report were seen after facial trauma, while Case 1 had a history of recent dental extractions. The infections associated with the facial fractures occurred in areas of a compounded fracture through a periodontal membrane space. Also, in each case definitive surgical reduction of these fractures was delayed 7 to 10 days because of the patient’s medical status. Two of the infections occurred at the mandibular angle, and the third molar teeth in the fracture site were removed at the time of reduction of the fracture. Teeth were not removed in Case 4 in which a soft-tissue infection occurred at the site of the symphysis fracture. Similar to previous accounts, E. corrodens was cultured in four cases in association with other organisms, primarily B. fragilis and alpha streptococcus. A pure culture of the organism was isolated from the osteomyelitis in Case 1. In vitro antibiotic sensitivity testing by a disc agar method shows that the strains of E. corrodens are sensitive to many antibiotics, including penicillin G, ampicillin, cephalosporin, chloramphenicol, erythromytin, tetracycline, and vancomycin.‘6 The organism shows relative resistance to the aminoglycosides and, typically, resistance to clindamycin.’ Control of the infections in these reported cases was not a clinical problem when antimicrobial drugs were coupled with surgical management. As seen in Table I, two of the cases were treated with high doses of penicillin G and three were treated successfully with clindamycin after initial administration of cephalosporin. Two of the cases in which clindamycin was used involved softtissue orofacial infections in which multiple isolates were obtained. The patients were changed to clindamycin therapy because of the clinical appearance of the wounds and because early culture reports suggested anaerobic organisms. As a result of the works of Brooks and associates,’ the drugs of choice to treat Eikenella infections would be ampicillin, penicillin G, and, alternatively, tetracycline. Clindamycin and methicillin should have little clinical therapeutic usefulness.* However, in three of the cases reported here, clindamycin did not seem to lengthen the course of antimicrobial therapy or hinder the eradication of the infections. Osteomyelitis and orofacial infections are relatively uncommon complications in the treatment of facial fractures or exodontia, and when they occur staphylo-
Oral Surg. December, 1979
coccus and streptococcus are most commonly associated as causal agents. However, it is important that the clinician not overlook the possible presence of gramnegative anaerobes in infections of the orofacial region and that appropriate culture methods be used to identify these organisms. The relative difficulty of and the length of time involved in culturing this facultative gram-negative organism, as well as its proved abundance in the upper respiratory tract, point out the importance of suspecting E. corrodens as a co-existent or primary causal agent. Special thanks are due Dr. R. L. Farquhar for his assistance in the treatment of these patients and in compiling the data used in this article. REFERENCES I. Glassman, A. B., and Simpson, J. S.: Eikenella
2.
3. 4.
5. 6.
I. 8.
9
10 11 12 13 14 15 16
17
corrodes: A Clinical Problem, J. Am. Dent. Assoc. 91: 1237, 1975. Brooks, G. F., and others: Eikenella corrodens, a Recently Recognized Pathogen: Infections in Medical-Surgical Patients and in Association With Methylphenidate Abuse, Medicine 53: 325, 1974. Eiken, M.: Studies on an Anaerobic Rod-Spaced, GramNegative Microorganism: Bacteroides corrodens N. Sp., Acta Path. Microbial. Stand. 43: 404, 1958. Kaplan, J. M., McCracken, G. .I., and Nelson, J.D.: Infections in Children Caused by the HB Group of Bacteria, J. Pediatr. 82: 398.1973. Marsden, H. B., and Hyde, W. A.: Isolation of Bacteroides corrodens From Infections in Children, J. Clin. Pathol. 24: 117, 1970. Dorff, G. J., Jackson, L. J., and Rytel, N. W.: Infections With Eikenella corrodens, a Newly Recognized Human Pathogen, Ann. Intern. Med. SO: 305, 1974. Khairat, 0.: Bacteroides corrodens Isolated From Bacteremias, J. Pathol. Bacterial. 94: 29, 1967. Jackson, F. L., and others: Taxonomic Status of Facuitative and Bacilli” That Have Been Strictly Anaerobic “Corroding Classified as Bacteroides corrodens, J. Med. Microbial. 4: 17 1. 1971. Jackson, F. L., and Goodman, Y. E.: Transfer of the Facultative Anaerobic Organism Bacreroides corrodens Eiken to a New Genus, Eikenella, Int. J. Systemic Bacterial. 22: 73, 1972. Brooks, G. F., O’Denoghue, J. M., Ressing. J. P.. et al.: Eikenella corrodens: A Recently Recognized New Pathogen, Medicine 53: 32.5-342, 1974. Hetuiksen, S. D.: Studies in Gram-Negative Anaerobes; Gramnegative Rods With Spreading Colonies, Acta Pathol. Microbiol. Stand. 25: 368, 1948. Goodman, A. D.: Eikenella corrodens isolated in Oral Infections of Dental Origin, ORAL SURG. 44: 128-133. 1977. Robinson, J. V. A., and James A. L.: Some Serological Studies on Bacteroides corrodens, J. Gen. Microbial. 78: 193- 197, 1973. Chow, A. W., et al.: Orofacial Odontogenic Infections, Ann. Intern. Med. 88: 392-402, 1978. Geraci, J. E., Hermans, P. E., and Washington, J. A.: Eikenella corroders Endocarditis-Report of Cure in Two Cases, Mayo Clin. Proc. 49: 950-953, 1974. Robinson, J. V. A., and James, A. L.: In Vitro Susceptibility of Bacteroides corrodens and Eikeneila corrodens to Ten Chemotherapeutic Agents, Antimicrob. Agents Chemother. 6: 543. 546, 1974. Stem, K., and others: Eikenella Osteomyelitis of the Mandible
Eikenella corrodens
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18. 19. 20.
21.
Associated With Anemia of Chronic Disease, J. Oral Surg. 36: 285, 1978. Carruthers, N. M., and Sommers, H. M.: Letter: Eikenella corrodens Osteomyelitis, Ann. Intern. Med. 79: 900, 1973. Litwocks, L., and Carchardt, U.: Osteomyelitis Caused by A Bacteroides corrodem-like Organism (HB-I), Clin. Med. 80: 21, 1973. King, E. 0.: Round Table: Current Trends in Diagnostic Microbiology; the Identification of Unusual Pathogenic GramNegative Bacteria, Atlanta, Ga., 1%4, Department of Health, Education and Welfare, Public Health Service, Center for Disease Control. Holm. P.: Studies on the Etiology of Human Actinomycosis;
“Other Microbes” of Actinomycosis and Their Importance, Acta Pathol. Microbial. Stand. 27: 736, 1950. 22. Riley, P. A., Tatum, H. W., and Weaver, R. E.: Identity of HB-I of King and Eikenella corrodens (Eiken) Jackson and Goodman, Int. J. System. Bacterial. 23: 75-76, 1973. 23. Goldstein, E. J. C., and others: Bacteriology of Human and Animal Bite Wounds, J. Clin. Microbial. S: 667-672, 1978. Reprint requests to: Dr. Jerry L. Jones, D.D.S., M.S.D. 465 St. Michael’s Dr., Suite 110 Santa Fe, N. M. 87501
Erratum In the article entitled “Alterations in Osseous Crestal Height Following Interdental Osteotomies” by Dorfman and Turvey, which begins on page 120 of the August, 1979, issue of the JOURNAL, Fig. 7,B does not adequately show the tooth-bone relationship. Therefore, we are publishing a new Fig. 7 in which the crest of bone is more clearly visible in B.
Fig. 7. A, Presurgical bitewing of a representativecase where the osteotomy was performed in the preexisting extraction
space between
canine and premolar.
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B, No significant
osseous crestal level changes postsurgically.