Authors:Linda Veidere, Rīga Stradiņš UniversityMarks Ronis, Rīga Stradiņš University

 Scientific research supervisor:

Gunta Sumeraga MD, Otorinolaryngologist, P.Stradins Clinical University hospital

A RETROSPECTIVE ANALYSIS OF DEEP NECK INFECTION PATIENTS PROFILE IN P. STRADINS CLINICAL UNIVERSITY HOSPITAL

IntroductionDeep neck space infections are life threatening infections which occur in the spaces between the muscles of the neck.

Fast antibacterial and surgical treatment can prevent serious complications such as mediastinitis, thrombosis of the jugular vein and sepsis.

There is no statistical data about the situation in Latvia. World data does not give accurate epidemiological view (Sichel JY et al, 2006) or are outdated and with small population (C. Stan, C. Drӑgulescu, N. Bacalbaşa, 2014).

Aim• To obtain information about incidence of deep neck

infection in CUH (2012-2014) and find out if it is statistically correct to adjust results to Latvia’s population.

• To find out :

—age and gender of patients,—duration of hospitalisation , —used treatment, —bacterial culture, —antibacterial sensitivity/resistance—comorbidities that could have had a connection with the

development of the infection.

Materials and Methods

•A retrospective study.

•Conducted at P.Stradins Clinical University hospital, Latvia, using data from 2012 to 2014.

• Statistical analysis was conducted using SPSS 19.0 – nonparametric tests as Chi-Square Tests, Mann-Whitney U Tests, Crosstabs, Spearmans correlations and descriptive statistics.

53.1%

46.9%

GenderMaleFemale

Results – Age and Gender

Age:•Minimum 20 years.•Maximum 86 years.•Mean 51 years.•Median 56 years.• Std. Deviation 19 years.Gender:•Male 34, 53,1%.• Female 30, 46,9%.

• Patients with dental infection most frequently were males (p=0,037) – 20,6% males, 3,3% females.

Age

Leng

ht o

f hos

pita

l st

ayPhysical therapy

Results – Lenght of Hospital Stay

•Minimum 2 days.•Maximum 54 days.•Mean 14 days.•Median 12 days.• Std. Deviation 10 days.

• Patients with tracheostomy (p<0,001) and revision and drainage of mediastinum(p=0,025) had a longer hospital stay.• Patients who received physical therapy

had a longer hospital stay (p=0,018).Le

nght

of h

ospi

tal

stay

Results – Lenght of Hospital Stay and Diagnosis and Complications

•Patients with acute tonsillitis (p=0,0013) or laryngeal stenosis (p=0,02) had a longer hospital stay.

•Patients with pneumonia (p=0,016), mediastinitis (p<0,001), phlegmon of the base of the mouth (p=0,035) or paraphayngeal abscess (p=0,030) as complication had a longer hospital stay.

Results – Month of Hospitalisation

•Most frequent month – July (11 times).

•P=0,544 – there was no statistical differece between months of hospitalisation.

Results – Most Frequent Diagnosis of Hospitalisation

1. Acute phlegmonous laryngitis 43,8% (28 patients):—Age minimum 20 years—Age maximum 74 years—Mean age 54 years—Std. Deviation 15 years

2. Chronic decompensated tonsillitis 21,9% (14 patients):—Age minimum 28 years—Age maximum 86 years—Mean age 53 years—Std. Deviation 19 years

3. Dental infection 12,5% (8 patients):—Age minimum 27 years—Age maximum 82 years—Mean age 42 years—Std. Deviation 19 years

Results – Most Frequent Complications

1.Deep neck infection 85,9% (55 patients)2.Peritonsillar abscess 26,6% (17

patients)3.Mediastinitis 12,5% (8 patients)4. Pneumonia 6,3% (4 patients)5. Phlegmon of the floor of the mouth 6,3%

(4 patients)6. Parapharyngeal abscess 6,3% (4 patients)7. Retropharyngeal abscess 6,3% (4 patients)

Results – Most Frequent Comorbidities

1. Primary arterial hypertension 21,9% (14 patients)2. Diabetes mellitus 12,5% (8 patients)3. Coronary heart disease 12,5% (8 patients)4. Atrial fibrillation 7,8% (5 patients)5. Chronic heart failure 6,3% (4 patients)

• Patients with primary arterial hypertension (p<0,001), chronic heart failure (p=0,038), atrial fibrillation (p=0,014) were of older age.

•There was a tendency that women most frequently had primary arterial hypertension (30%, p=0,140), diabetes (20%, p=0,088), coronary heart disease (20%, p=0,088), atrial fibrillation (13,3%, p=0,122) and chronic heart failure (13,3%, p=0,028) as a comorbidity.

Coun

t of

rec

eive

d an

tibi

otic

s

Lenght of hospital stay

Results – Count of Most Frequent Used Antibiotics per Patient

During the hospitalisation period the usage of the antibiotics varied from 1 to 8 per patient.• 2 antibiotics 37,5% (24 patients)

—Minimal lenght of hospital stay 2 days—Maximum 8 days—Mean 6 days

• 3 antibiotics 29,7% (19 patients)—Minimal lenght of hospital stay 6 days—Maximum 24 days—Mean 13 days

• 5 antibiotics 10,9% (7 patients)—Minimal lenght of hospital stay 14 days—Maximum 31 days—Mean 19 days

• Patients with longer hospital stay (p<0,001, correlation coeficient 0,794-close correlation) received a larger number of antibiotics.

Results – Most Frequently Used Antibiotics

1. Sol.Metronidazoli 300mg/24h 48,4% (31 patients, mean for 8 days).

2. Sol.Amoxicillini/Acidi clavulanici 3,6g/24h 46,9% (28 patients, mean for 5 days).

3. Sol.Ceftriaxoni 4g/24h 40,6% (26 patients, mean for 7 days).

4. Sol.Metronidazoli 1,5g 37,5% (24 patients, mean for 8 days).

5. Sol.Ceftriaxoni 2g 32,8% (21 patients, mean for 10 days).

Results – Most Frequent First Surgical Treatment

•61 out of 64 patients received surgical treatment.

• Incision and drainage of deep neck infection 76,6% (49 patients)•Tonsillectomy 34,4% (22 patients)•Tracheostomy 31,3% (20 patients)•Revision and drainage of mediastinum 6,3% (4 patients)

•Patients with tracheostomy were admitted to the ICU (p=0,051).

Results – Reoperation

•48 patients received surgical treatment for deep neck infection as soon as they were admitted to the hospital.•13 of them had reoperation.•Patients with reoperation had a longer hospital stay (p<0,001), received more antibiotics (p<0,001) and were admitted to the ICU(p<0,001). •60% of the patients with reoperation were admitted to the ICU.

•There was a tendency that patients who had reopeation were of older age (p=0,135).

Results – Bacterial Culture

•Bacterial culture was taken from all the patients who received surgical treatment.

•19 patients had a positive result (microorganism and antibacterial sensitivity).

• In 15 cases out of 19 there was a change of the antibacterial treatment after the results of bacterial culture.

• In 4 cases there was no change in antibacterial treatment.

Results – Most Frequent Microorganisms

1. Acinetobacter baumanii (8 patients, 12 times)2. Methicillin-sensitive coagulase negative Staphylococcus

aureus (7 patients, 8 times)3. Methicillin-sensitive Staphylococcus (4 patients, 4 times)4. Enterococcus species (4 patients, 4 times)5. Candida albicans (4 patients, 5 times)

• Patients with Acinetobacter baumanii (p<0,001), methicillin-sensitive coagulase negative Staphylococcus aureus (p=0,035), Candida albicans (p=0,001), Enterococcus species (p=0,001) and Pseudomonas aeruginosa (p=0,001) had been at the ICU.

•There was no correlations between patients who had diabetes as comorbidity and any of these microorganisms (p=0,253-0,587).

Results – Most Frequent Antibacterial Resistance

1. Ceftazidime (17 bacterial cultures)1. Trimethoprim/Sulfamethoxazole (17 bacterial cultures)2. Piperacin/Tazobactam (14 bacterial cultures)2. Gentamicin (14 bacterial cultures)3. Imipenem (12 bacterial cultures)4. Ciprofloxacin (10 bacterial cultures)Additional resistance:• Acinetobacter baumanii – Cefepime, Amikacin, Gentamicin,

Ampicillin/Sulbactam.—Previous resistance against Trimetoprim/Sulfametaxozole, Ceftazidime, Imipenem,

Piperacin/Tazobactam.• Methicillin-resistant coagulase negative Staphylococcus aureus –

Meticilin, Gentamicin, Erythromycin, Ciprofloxacin, Clindamycin, Trimethoprim/Sulfamethoxazole.—Previous methicillin-sensitive coagulase negative Staphylococcus aureus, no

resistance.• Enterobacter cloacae – Piperacin/Tazobactam.

—Previous resistance against Ampicillin, Amoxicillin/Clavulanate, Ceftazidime, Cefotaxime, Trimethoprim/Sulfamethoxazole.

Costs• Stay at the hospital per day 13,52 EUR• CT 14,23 EUR• MRI 28,46 EUR• IV contrast 7,11 EUR• Patients payment for surgery 42,69 EUR.

—11 patients didn’t pay for the surgery although 8 of them had a surgery.

• Total discount 3135,37 EUR (13 patients). —3 patients had 100% discount.

• Sum that patients actually paid 12804,80 EUR. —Mean 203,25 EUR.

• From government budget:—For 1 patient who had a surgery 597,32 EUR.—For 1 patient who had a surgery since 2014 – 629,56 EUR.—For 1 patient from foreign country who had a surgery 3476,79 EUR.—For 1 patient who didn’t have a surgery till 2014 – 264,51 EUR.

Total missing from bills 590,42 EUR.

Neck CT 14,23EUR

Chest CT14,23EUR

Head CT 14,23EUR

Abdominal CT 14,23EUR

Breast CT 14,23EUR

Neck MRI 28,46EUR

Chest MRI 28,46EUR

IV contrast 7,11EUR

Investigation

Status86 43 9 2 1 2 2 93 Actually

performed

62 42 7 2 1 1 1 68 In the bill

24 1 2 0 0 1 1 25 Missing from the bill

341,52

14,23

28,46 0 0 14,23

14,23

177,75 Unpaid

Conclusions• Incidence of deep neck infections in CUH is about 21 patients per year and affects both genders equaly.• Patients are middle age.• There is no statistical difference between months of

hospitalisation.• The most frequent diagnosis are acute phlegmonous laryngitis, chronic decompensated tonsillitis and dental infection.• Patients with acute tonsillitis or laryngeal stenosis have a

longer hospital stay althought these are not the most frequent diagnosis.• The most frequent complications (except deep neck infection)

are peritonsillar abscess and mediastinitis.•Dental infection is not Nr.1 diagnosis in CUH (as it is in other

country data).• There are no correlations between patients who have diabetes

and any of cultivated microorganisms.

Thank You!