Spreading odontogenic infections with severe or systemic features (including Ludwig angina)

Severe features of a spreading odontogenic infection include significant facial swelling and pain, trismus, swelling of the neck, difficulty swallowing and difficulty breathing. Systemic features include pallor, sweating, tachycardia, and an axillary temperature above 38°C (oral temperatures are unreliable for infections originating in the mouth). The infection can rapidly become life threatening because of the risk of airway obstruction and sepsis. Ludwig angina is a severe spreading infection involving the bilateral submandibular, sublingual and submental spaces, with cellulitis.

Arrange urgent transfer of patients who have a spreading infection with severe or systemic features to a hospital that has an oral and maxillofacial surgeon or another appropriate expert.

Management of spreading infection with severe or systemic features involves:

• maintaining a patent airway (do not lie the patient flat)
• resuscitation
• draining pus by incising affected spaces and placing drains
• removing the tooth or otherwise addressing the source of infection
• obtaining blood and other samples for culture and susceptibility testing
• intravenous antibiotic therapy.

Spreading odontogenic infections can be associated with sepsis (for definitions, see here). For patients with sepsis, start antibiotic therapy within 1 hour of presentation to medical care; antibiotics should be given immediately after appropriate samples are taken for culture. Obtain blood samples and other relevant samples as soon as possible, but not if doing so will delay antibiotic administration. For nonantibiotic management of sepsis, see Early intervention for sepsis or septic shock.

For empirical antibiotic therapy of spreading odontogenic infection with severe or systemic features (including Ludwig angina), in conjunction with surgical intervention, use:

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use:

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin, cefazolin plus metronidazole (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred to clindamycin; for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins.

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin in whom cefazolin plus metronidazole is not used, or for patients who have had a severe delayed³ hypersensitivity reaction to a penicillin, use:

Modify therapy based on the results of cultures and susceptibility testing. Switch to oral therapy once swelling and trismus subside (and the patient can swallow) and purulent discharge from the drains slows. If results of susceptibility testing are not available for oral continuation therapy, use the appropriate regimen here.

Stop oral antibiotic therapy once the drains are not producing any purulent discharge, signs and symptoms have resolved, the white cell count has returned to normal and the patient is afebrile.