Odontogenic Cervicofacial Necrotizing Fasciitis: Microbiological Characterization and Management of Four Clinical Cases.

Sebastian Böttger,Markus Weigel,Hans-Peter Howaldt,Eugen Domann,Can Imirzalioglu,Michael Knitschke,Philipp Streckbein,Jan-Falco Wilbrand,Sameh Attia,Daniel Schmermund,Torsten Hain,Silke Zechel-Gran,Jörn Pons-Kühnemann

doi:10.3390/pathogens11010078

Sebastian Böttger, Markus Weigel + Show 11 more

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https://doi.org/10.3390/pathogens11010078

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Abstract

Necrotizing fasciitis of the head and neck is a rare, very severe disease, which, in most cases, originates from odontogenic infections and frequently ends with the death of the patient. Rapid surgical intervention in combination with a preferably pathogen-specific antibiotic therapy can ensure patients’ survival. The question arises concerning which pathogens are causative for the necrotizing course of odontogenic inflammations. Experimental 16S-rRNA gene analysis with next-generation sequencing and bioinformatics was used to identify the microbiome of patients treated with an odontogenic necrotizing infection and compared to the result of the routine culture. Three of four patients survived the severe infection, and one patient died due to septic multiorgan failure. Microbiome determination revealed findings comparable to typical odontogenic abscesses. A specific pathogen which could be causative for the necrotizing course could not be identified. Early diagnosis and rapid surgical intervention and a preferably pathogen-specific antibiotic therapy, also covering the anaerobic spectrum of odontogenic infections, are the treatments of choice. The 16S-rRNA gene analysis detected significantly more bacteria than conventional methods; therefore, molecular methods should become a part of routine diagnostics in medical microbiology.

Highlights

Necrotizing fasciitis is a severe, life-threatening disease that can lead to a highly septic clinical presentation with extensive tissue necrosis in various areas of the body, and a poor outcome [1]
Many authors have observed that odontogenic cervicofacial necrotizing fasciitis, similar to odontogenic abscesses, is caused polymicrobially by aerobic and anaerobic bacteria of the oral cavity [13]
In the period from April 2009 to December 2020, four extensive odontogenic infections with a severe course of disease and extensive formation of skin necrosis were treated in the Clinic for Oral and Maxillofacial Surgery of the university hospital

Summary

Introduction

Necrotizing fasciitis is a severe, life-threatening disease that can lead to a highly septic clinical presentation with extensive tissue necrosis in various areas of the body, and a poor outcome [1]. It is defined as a bacterial infection of the superficial fascial layer and the adjacent cutaneous tissues leading to fulminant, devastating and rapidly progressive necrosis of the affected tissues [2,3]. Advanced stages show the almost pathognomonic picture of necrotizing fasciitis with small purple spots [2], dark hemorrhagic blisters, crepitus, complete anesthesia and dusky necrosis of the affected skin [9,10,11] Concomitant septic symptoms such as hypotension, tachypnea and impaired consciousness usually already indicate a life-threatening condition [7]. Using more recent molecular biological methods, it has been possible to detect a much larger number of bacteria in the root canals of non-vital teeth [14] and in odontogenic abscesses [15,16] than was previously possible using only cultural methods alone [17,18]

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