Ⅰ. INTRODUCTION

Odontogenic or oropharyngeal infection can cause fascial space infections of head and neck and the infections could extend to secondary fascial spaces infections(1). With multiple origins, facial space infections may communicate mutually with others and cause to be potent extension and complication(2). There are life-threatening complications such as airway obstruction, intracranial or pleuropulmonary extension, or haematogenous dissemination(1). The microbiological etiology of fascial space infections is usually polymicrobial and reflects the origin of infections(3).

Diabetes mellitus is one of the most common systemic diseases associated with head and neck infection (4). Huang et al reported that patients with deep neck infection who have diabetes usually display a clinical picture distinct from that in patients without diabetes, and thus should be treated in a different way(5). Glycated Hemoglobin (HbA1c) is a form of hemoglobin and The A1C test measures your average blood glucose for the past 2 to 3 months. Diabetes is diagnosed at an A1c of greater than or equal to 6.5%(6). However, There are only few reports about correlation between HbA1c level and fascial infection of head and neck. We conducted a study to delineate the microbiological and clinical characteristics, treatment, and outcome of fascial space infections of head and neck based on HbA1c level.

Ⅱ. MATERIALS and METHODS

1. PATIENTS

atients diagnosed with fascial space infection of head and necks from January 2010 to May 2019 at Samsung medical center were included in this retrospective study. Patients aged 12 or younger, superficial infections (limited at the level of platysma or dentoalveolar abscess), infections of surgical or traumatic wounds, and abscess related to bony fractures, osteomyelitis, or local malignant conditions were excluded. Total 62 patients were collected and classified into 2 groups according to the HbA1c level.

We reviewed their medical records about age, HbA1c level, underlying diseases, clinical presentations, laboratory findings, radiologic findings, types of antibiotics used, hospitalized period, complications, and pathogenic bacterium.

2. DATA COLLECTION

Clinical data on the initial presentations, demographic data, underlying diseases, laboratory findings on admission, treatment courses, and outcomes were collected. All pathogens were isolated from blood or fluid specimens obtained by surgical debridement or needle aspiration. The identification of microorganisms was on the basis of colonial morphology and traditional biochemistry reactions in test tubes. Duration of hospital stay was defined as the days between admission to and discharge from the hospital. A repetitive infection was defined as an infection by the same organism in any normally sterile body site before or after the study episode with a one-month disease-free interval. If infection recurred in the same site within one months, the case was regarded as an incomplete treatment.

3. STATISTICAL ANALYSIS

We compared 2 groups to identify factors associated with HbA1c. Data analysis was conducted using the SPSS version 21.0(SPSS Inc. IL, USA). Continuous data were expressed as means±standard deviation(SD) and were compared using t-test. Categorical variables, expressed as number and percentages, were compared using chi-squared test or Fisher’s exact test. A two-tailed P value of less than 0.05 was considered statistically significant.

Ⅲ. RESULTS

1. Demographics and HbA1c level

The baseline characteristics and initial HbA1c level in patients with diabetes mellitus and non-diabetes mellitus are shown in Table 1. The average age of each group was 59.8 (12 – 95) and 69.3 (32 - 96), respectively. There was no significant correlation between two groups. The average HbA1c level of each group was 5.9% (4.6 – 6.4%) and 8.8% (6.5 – 13.8%), respectively (Table 1).

2. Duration of hospitalization

There was a significant difference about the treatment period of each group. The average hospitalization period of each group was 9.6 days and 15.9 days, respectively (Table 2).

3. Laboratory examination

At the initial laboratory test, both two groups showed elevated level of WBC and CRP, but the difference value was noticeable (P<0.05). At the final examination, complete blood cell count (CBC) and CRP were within normal limits for both two groups. (Table 3).

4. Involved fascial space

Buccal, submandibular and parapharyngeal spaces showed the highest frequency of fascial infection on both groups. The average number of involved fascial space of each group was 1.1 and 1.4, respectively. (Table 4).

5. Main causative microorganisms

The most common causative microorganisms of Group 1 were Streptococcus spp. and Staphylococcus spp.. Otherwise, Klebsiella pneumonia and Streptococcus spp. were the most often detected pathogenic bacteria (Table 5).

Ⅳ. DISCCUSION

As common belief, infections are more common in diabetic patients, and some occur typically in them. Also infections occur with higher severity and are associated with an increased risk of complications in patients with diabetes mellitus. Several immunity systems are altered in patients with diabetes (7). Polymorphonuclear leukocyte function, chemotaxis, and phagocytosis may be affected (8-10). Antioxidant systems involved in bactericidal activity may also be impaired (11).

There are several studies about facial space infection of head and neck and comparison between diabetes mellitus group and non-diabetes mellitus group. The large majority of the papers concluded that diabetes mellitus group showed more severe infection, abnormal laboratory value, and frequent complications (12-14). In most of the papers, patients were divided into diabetes mellitus group and non-diabetes mellitus group with glucose level. However, physical and psychological stresses activate the adrenergic and glucocorticoid system, and stimulate synthesis of catecholamine which decreases insulin secretion and increase insulin resistance (15-17). Considering these factors, even well-modulated diabetes mellitus patients can show sudden increase of glucose level at the infection time.

Hemoglobin is a protein found in red blood cells. When glucose builds up in blood, it binds to hemoglobin in red blood cells. HbA1c test measures how much glucose in bound (6). Red blood cells live for about 3 months, so the test shows the average level of glucose in your blood for the past 3 months. The normal range for the hemoglobin A1c level is between 4% and 5.6%, but Levels of 6.5% or higher mean the patients have diabetes (18). In this study, we used HbA1c level as a diagnostic tool rather than glucose level considering its low variability.

According to most of studies, the hospitalization period and WBC, CRP level of diabetes patients were significantly higher (12, 14, 19). Our study showed similar result. We used Flomoxef as a 1st choice antibiotic and then chose other medications according to the bacterial and fungal susceptibility testing results. The bacteriologic patterns on fascial space infection of head and neck include aerobic, anaerobic, and facultative anaerobic bacteria. The dominant bacteria of diabetes group were Klebsiella pneumonia and Streptococcus spp. Otherwise, Staphylococcus spp. and Streptococcus spp. were for the non-diabetes patients (1, 5, 20, 21). K. pneumonia is considered to contribute to immune system collapse and increment of gram negative bacilli colonization number (20, 22). Clindamycin and metronidazole are lack of sensitivity on K. pneumonia. We should be cautious when using empiric antibiotics like clindamycin or metronidazole to diabetes patients. There was no meaningful difference about number of Incision and drainage between two groups.

Ⅴ. CONCLUSION

Infections are more common in diabetic patients, and some occur typically in them. HbA1c level is a reliable diagnostic tool for diabetes and we divided facial space infection patients into diabetes group and non-diabetes group. There are meaningful differences on hospitalization period, WBC and CRP level, etc. between diabetes group and non-diabetes group. Diabetic patients had more spaces involved, had longer hospital stays, and developed more complications. Main causative microorganism of each group was Streptococcus spp. and Klebsiella pneumonia, respectively. We should consider that empiric antibiotics like clindamycin and metronidazole have no sensitivity to Klebsiella pneumonia.