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Postoperative Infection Caused by Methicillin-Resistant Coagulase- Negative Staphylococci in the Oral and Maxillofacial Region: A Case Report
J Oral Med Pain 2020;45:17-21
Published online March 30, 2020;  https://doi.org/10.14476/jomp.2020.45.1.17
© 2020 Korean Academy of Orofacial Pain and Oral Medicine

Hye-Jung Lee, Jae-Seak You

Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Korea
Correspondence to: Jae-Seak You
Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea
Tel: +82-62-220-3816 Fax: +82-62-222-3810 E-mail: applit375@chosun.ac.kr https://orcid.org/0000-0001-7638-9583

This study was supported by research funds from Education and Cultural Foundation of College of Dentistry, Chosun University, 2019.
Received February 17, 2020; Revised March 10, 2020; Accepted March 16, 2020.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Osteomyelitis of the jaw infected with Coagulase-Negative Staphylococci (CNS) is rarely reported in the Oral and Maxillofacial Region. Staphylococcus is a part of the normal body flora, but it may be cause severe infections and CNS are often described as the important pathogens in nosocomial infections. Although many studies on prevalence and antibiotics of Staphylococcus aureus have been done, but many of these studies focus only on Methicillin- resistant S. aureus and not on methicillin-resistant coagulase-negative Staphylococci (MRCNS). There was a less study about CNS or MRCNS infections in the Oral and Maxillofacial Region. This report describes a case of a 41-year-old male patient who developed osteomyelitis caused by MRCNS on condyle after open reduction and internal fixation and suggests guideline for the prevention of postoperative infection and appropriate recommendation for treatment and control.
Keywords : Antibiotic therapy; Coagulase-negative staphylococci; Drug resistance; Methicillin-resistant coagulase-negative Staphylococci; Methicillin-resistant Staphylococcus aureus
INTRODUCTION

The most frequent complication of operation in the Oral and Maxillofacial part is infection. Especially postoperative infections associated with fractures include a range of soft tissues around the fracture site, or more severe infections can cause osteomyelitis [1]. Osteomyelitis of the jaw is an inflammatory process that begins in the medullary space and, with progression, extends to involvement of the cortex, the harversian system, the periosteum [2]. The risk factors for these infections are associated with systemic diseases and physiological, clinical conditions, and clinical causing factors including the recent surgery or trauma and the inappropriate systemic antimicrobial therapy [1-4].

Staphylococcus is a part of the normal body flora, but it may be cause severe infections and coagulase-negative Staphylococci (CNS) belonging to S. epidermidis, S. saprophyticus, and S. lugdenensis are often described as the important pathogens, especially in people with prolonged hospital admissions. At first, the pathogen was penicillin-susceptible, but resistance began due to the expression of penicillinase and Methicillin-resistant Staphylococcus aureus (MRSA) was described in 1961 [5]. MRSA infections were initially acquired nosocomially and have increased over the past decades. This is because third generation cephalosporins that do not active strongly against S. aureus are often used to treat infections. With recent researches, MRSA have a high proportion of S. aureus infections in healthcare-associated patients and about 60% to 70% of the S. aureus isolated in tertiary hospitals of Korea, are identified as MRSA [4, 6]. CNS are also the cause of hospital and community infections worldwide. In addition, CNS has developed resistance to various antimicrobials, making it difficult to make treatment strategies. And the prevalence of methicillin-resistant coagulase-negative Staphylococci (MRCNS) has been reported [7]. Although many studies on prevalence and antibiotics of S. aureus have been done, but many of these studies focus only on MRSA and not on CNS or MRCNS which are equally important.

This report describes a case of postoperative infection leading to acute osteomyelitis caused by MRCNS in patient with an open reduction and internal fixation surgery of mandibular condylar fracture.

CASE REPORT

A 41-year-old male patient presented to department of oral and maxillofacial surgery, Chosun University Dental Hospital with complaints of trismus after right mandibular condylar fracture on September 21, 2018. The patient with no medical history had been struck in the face by fist. The physical and clinical examination on first visit revealed normal occlusion, limitation of mouth opening to 30 mm and poor oral hygiene. The radiographic examinations with panoramic radiograph and cone-beam computed tomography (CBCT) were taken to confirm the state and fracture pattern of condyle (Fig. 1). Radiographic examinations showed fractured line on condylar neck area and deviation of fragment of condylar head.

After 10 days, Surgical intervention for internal derangement was decided because nonsurgical therapy had been ineffective and mouth opening was still limited. On October 2, 2018, under the general anesthesia, Open reduction was performed for the correction of arthrographically confirmed internal derangements using a preauricular approach and internal fixation was done with a 4-hole plate at the fractured site of condylar head and neck. An Amoxicillin-clavulanic acid (augmentin; Ilsung Pharma Co., Seoul, Korea) was administered in an intravenous dosage of 1.2 g three times daily during admission. A 15 days after the operation, no infection sign was observed on surgical site and he was discharged with a prescription of oral dosage of augmentin (Amoxicillin-clavulanic acid) 625 mg, twice daily after wound stitch removal on preauricular operation site.

Four weeks after the operation, the patient complained of pain and swelling, and had purulent exudate from the surgical site with wound dehiscence. Surgical incision and drainage was done under local anesthesia with pus culture for routine drug-resistance and anaerobic drug-sensitivity tests. Augmentin (Amoxicillin-clavulanic acid) was administerd, and abscess cavity was daily treated with saline irrigation. The symptoms were not improved for week and the pus culture drawn on drainage grew CNS. Sensitivity studies showed the organism to be methicillin-resistant but sensitive to vancomycin. According to the drug-sensitivity results, the patient was admitted to the hospital and treated with vancomycin intravenously. On hospital day three, vancomycin was discontinued, and the patient was discharged with Tremethoprim-sulfamethoxazole (trimethoprim 80 mg and sulfamethoxazole 400 mg [Septrin; Samil Pharmaceutical Co., Seoul, Korea], twice a day) for 40 days.

Panoramic radiograph and CBCT taken right after the antibiotic change showed destroyed cortical bones of condylar head at the surgical site and the screw loosening was detected (Fig. 2). At 2 month follow-up appointment, the patient reported no pain and no other complaint of the surgical site. Follow-up CBCT was taken and it was found that the bone destruction had not progressed further (Fig. 3).

The patient have stable occlusion and normal mouth opening length. However the shape of right condyle is abnormal because of the osteomyelitis, Partial or total joint reconstruction (e.g., autogenous graft, alloplastic total joint replacement) will be implemented.

DISCUSSION

With the rapid rise in various antibiotic-resistance has resulted in strains of Staphylococcus strains that are resistant to almost all currently available antibiotics, making treatment difficult clinically [8]. Also, substantial increases in MRSA and MRCNS infections are infections are being reported. Today, MRCNS represent one of the major nosocomial pathogens, having a substantial impact on life and health [9]. Given all Staphylococcus strains, CNS have lower toxicity than other species [10]. This means that infections that caused by CNS are less severe than other bacterial types. However, some people may experience serious infections associated with CNS [11]. In the case of this report, failure to early treat the causative bacteria had resulted in infection and other complications such as osteomyelitis. Because resistance to multiple antibiotics of CNS makes difficult to treat infections.

The empirical antibiotic selected for CNS-induced infection is vancomycin, which is usually the main treatment for MRSA infection [11, 13]. In previous studies, MRCNS isolates tested for antimicrobial susceptibility against 14 antibiotics showed the resistance to at least one antibiotic class [14]. They were resistant to penicillin, cefoxitin, erythromycin, clindamycin, sulfamethoxazole/trimethoprim, ciprofloxacin, gentamicin, rifampicin, mupirocin, chloramphenicol, novobiocin, and linezolid, but all isolates were sensitive to vancomycin.

It is important to diagnose bacterial infection early and accurately with careful monitoring and observation of the patient. If patients represent to sign of bacterial infections such as fever, pneumonia, or local infection of surgical site, antibiotic-susceptibility test should be performed in addition to antibiotic therapy until detection of causing bacteria [15]. If antimicrobial-sensitivity test is no available, vancomycin should be used because of the high frequency of methicillin-resistant strains and because of concerns about heterogeneous resistance [16].

The prevalence of infections caused by various antibiotic-resistant bacteria and postoperative surgical site infections is increasing [17]. Appropriate antibiotic therapy is associated with a marginally decreased concerns about cost and morbidity, and risk of the long-term consequences of complication involving osteomyelitis in all therapeutic areas as well as Oral and Maxillofacial region [18]. Moreover, the bacterial infection was associated with a low hygiene condition of patient [19]. Consequently, frequent exposure of the surgical wound to contaminations before the site not completely healed may result in bacterial infection of surgical sites. The patient of this report had poor personal hygiene and the surgical site was not clean at the first follow up visit after hospital discharge. These hygiene score and environmental conditions might be parts of the causing factors for infection.

Therefore, maintenance of good personal hygiene and proper implementation of personal health care in conjunction with antibiotic therapy may decrease the risk factors for infection, and prevent and interrupt bacterial outbreaks. More research and further clinical investigations into the more diverse patterns of postoperative antibiotic administration, standardized postoperative follow-up and evaluation will be in place for proper treatment and prevention of infections.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Figures
Fig. 1. Radiographic examinations of preoperation show right condylar fracture and deviation of fragment of condylar head. (A) Panoramic view. (B) Three-dimensional-cone-beam computed tomography view.
Fig. 2. Radiographic examinations of right after the antibiotic change show destroyed cortical bones of right condylar head and the screw loosening. (A) Panoramic view. (B) Cone-beam computed tomography coronal view.
Fig. 3. Radiographic examinations of 2-month follow-up show the bone destruction had not progressed further. (A) Panoramic view. (B) Cone-beam computed tomography coronal view.
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