Journal of Otology & Rhinology

Steehler et al., J Otol Rhinol 2015, 4:2
http://dx.doi.org/10.4172/2324-8785.1000219
Journal of Otology &
Rhinology
Research Article
A SCITECHNOL JOURNAL
Current Bacteriology and
Antibiotic Management of Acute
Suppurative Parotitis in the
Hospitalized Patient: A
Retrospective Study and Literature
Review
Mark W Steehler1,2*, Andrew W Agnew1 and Jack B Anon2
1Lake
2Ear
Erie College of Osteopathic Medicine, Erie, Pennsylvania, USA
Nose & Throat Specialists of Northwestern Pennsylvania, Erie, Pennsylvania,
USA
*Corresponding
author: Dr. Mark W Steehler, Lake Erie College of Osteopathic
Medicine, Millcreek Community Hospital, Ear Nose & Throat Specialists of
Northwestern Pennsylvania, 1645 West 8th Street Erie, PA, USA 16505, Tel:
814-864-9994; Fax: 814-864-1909; E-mail: marksteehler@gmail.com
Rec date: Sept 02, 2014 Acc date: Sept 18, 2014, Pub date: March 25, 2015
Abstract
Background: Acute bacterial suppurative parotitis warrants
prompt diagnosis and efficacious treatment with empiric broad
spectrum antibiotics and maintenance of hydration. Patients
can quickly deteriorate leading to increased morbidity and
mortality. Bacterial parotitis has increasingly shown resistance
to many traditionally recommended empiric antimicrobial
agents.
Aim: The aim of this study was to analyze empiric treatment for
patients hospitalized with acute bacterial suppurative parotitis.
Methods: A retrospective chart review was conducted over a
one year time period on all patients hospitalized with acute
bacterial suppurative parotitis, analyzing patient demographics,
bacterial cultures, and antibiotic sensitivities.
Findings: Nine patients were identified over a one year time
period hospitalized with acute bacterial suppurative parotitis.
Fourteen cultures were isolated made up of eight unique
bacterial species. Staphylococcus aureus made up 43% (6/14)
of all pathogenic bacteria, four of which were methicillinresistant Staphylococcus aureus. Three patients in the cohort
failed antibiotic treatment at some point due to bacterial
resistance. Multi-drug resistant organisms made up 75% (6/8)
of all isolates in which sensitivities were obtained.
Conclusion: As multidrug-resistant organisms, specifically
Staphylococcus aureus, continue to become more prevalent,
empiric antibiotics must be appropriately selected to treat for
these organisms until culture and sensitivity results become
available.
Keywords: Acute bacterial suppurative parotitis (ABSP);
Methicillin-resistant Staphylococcus aureus (MRSA); Multi-drug
resistant organisms (MDROs)
Introduction
The parotid gland is the largest salivary gland of the human body,
and consequently, the most commonly affected by inflammation [1].
The first known description of parotitis in the literature dates back to
800 BCE by Hippocrates, with the first English-language account of
the disease coming in 1834 by Sir Benjamin Collins Brodie [2,3].
Parotitis is characterized by facial pain, swelling, and erythema
overlying the parotid gland. Acute bacterial parotitis can be
differentiated from other diseases of the parotid by the ability to
express purulent drainage from Stensen's duct through massage of the
gland [1,4,5]. Among adults, bacterial parotitis tends to occur more
often in the elderly [1]. It can often lead to sepsis, defined as systemic
inflammatory response to an infectious process resulting in two or
more of the following: abnormal body temperature, heart rate,
respiratory rate or blood gas, and white blood cell count. If left
untreated, bacterial parotitis can progress to severe problems such as
deep neck space infection, Lemierre's syndrome, mediastinitis,
necrotizing fasciitis, and death in some cases [4-7].
The bacterial etiology of parotitis is thought to be from retrograde
flow of oral flora through Stensen's duct, hematogenous seeding, or
xerostomia [1,4,5,8]. Xerostomia can be the result of dehydration, or
from a multitude of drugs, including antidepressants, antihistamines,
anticholinergics, and diuretics [1,4,5]. Other risk factors include
malnutrition, immunosuppression, surgery, and obstruction from
either sialolithiasis, neoplasm, or stricture [1,2,4,5,9].
Prevention remains key in the management of acute bacterial
suppurative parotitis, especially among the elderly population. This
includes, adequate hydration, good oral hygiene, and limiting
offending medications whenever possible [1]. Treatment includes
volume repletion, sialogogues, warm compress, and frequent massage
[1,4,5].
Staphylococcus aureus is the most common bacterial pathogen
causing acute bacterial suppurative parotitis, both historically and in
recent studies [1,4,8,10]. While antibiotics should be tailored to
specific bacterial cultures and sensitivities once available, proper
empiric antibiotic treatment is critical in successfully treating the
disease [4]. Traditionally a penicillin with a beta-lactamase inhibitor or
first-generation cephalosporin has been recommended [1,4,5]. Other
antibiotic recommendations have included clindamycin. Despite these
recommendations, multidrug-resistant organisms are becoming more
prevalent, rendering the aforementioned antibiotics useless.
The purpose of this study is to evaluate bacterial etiology and
determine appropriate antibiotic management of acute suppurative
parotitis. A retrospective chart review was conducted on all patients
hospitalized at our institutions in Erie, Pennsylvania. Bacterial cultures
and antibiotic sensitivities were analyzed in addition to
clinicopathologic findings. A review of the literature is also presented.
Methods
With Institutional Review Board approval, we performed a
retrospective review of all hospitalized patients diagnosed with acute
bacterial parotitis seen in consultation from February 2013 to February
2014. Various data was gathered, including patient demographics such
as age, race, and gender, along with hospital duration, discharge
disposition, bacteremia, and consultation with Infectious Disease,
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Citation:
Steehler M, Agnew AW, Anon JB (2015) Current Bacteriology and Antibiotic Management of Acute Suppurative Parotitis in the Hospitalized
Patient: A Retrospective Study and Literature Review. J Otol Rhinol 4:2.
doi:http://dx.doi.org/10.4172/2324-8785.1000219
bacterial etiology, antibiotic treatment, antibiotic sensitivities, and
minimum inhibitory concentrations.
Results
A total of nine patients were hospitalized over a one year time
period. The average age was approximately 75 years old. Infectious
disease was consulted 78% of the time (7/9). Sepsis was present in 66%
of the cohort (6/9). Bacteremia from parotitis was found to be present
in 50% of patients in which blood cultures were obtained (3/6). All
positive blood cultures were found to be Staphylococcus aureus, which
correlated directly with their corresponding parotid swab cultures and
sensitivities. Relevant comorbidities that may have attributed to acute
bacterial suppurative parotitis included, parotid neoplasm, prerenal
azotemia, diabetes mellitus, Sjögren's syndrome, parotid calculi
history, and prior surgery in a patient, who was postoperative week-1
from sialodochoplasty. All patients in the study were found to be
immunocompetent and able to mount an appropriate immune
response. Patients presented to the hospital from home 78% of the
time (7/9), with the other 22% (2/9) presenting from a skilled nursing
facility. Discharge disposition varied greatly among the cohort,
including home, skilled nursing facility, transitional care unit, home
hospice, and palliative care arrest. The average length of hospital stay
was 10 days (Table 1 and 2).
Patient
Age (y/o)
Race
Admit
Discharge
Hospital Days
Relevant Comorbidities
1
74
Caucasian
Home
TCU
6
Parotid neoplasm (2.2 cm)
2
89
Caucasian
SNF
DNR-CC
8
Prerenal azotemia
3
77
Caucasian
SNF
SNF
7
None
4
85
Caucasian
Home
TCU
10
Diabetes mellitus
5
70
Caucasian
Home
Home
2
Diabetes mellitus
6
85
Caucasian
Home
Hospice
37
Diabetes mellitus
Prenal azotemia
7
51
Caucasian
Home
Home
3
Sjögren's syndrome
Parotid calculi history
Sialodocoplasty postoperative week-1
8
88
Caucasian
Home
SNF
12
Prerenal azotemia
9
58
Caucasian
Home
Home
5
Diabetes mellitus
Parotid calculi history
Avg 75.2
Avg 10
Table 1: Patient demographics. Abbreviations: Avg, average; DNR-CC, do not resuscitate – comfort care; ID, infectious disease; SNF, skilled
nursing facility; TCU, transitional care unit; y/o, years old.
Patient
ID Consult
Bacteremia
Tmax
HRmax
RRmax
WBCmax
Sepsis
1
Yes
Staphylococcus aureus
98.7
97
18
19.6
Yes
2
No
[Not performed]
99.3
134
40
35.1
Yes
3
Yes
Staphylococcus aureus
100.6
106
20
15
Yes
4
No
None detected
99.1
90
23
14.1
Yes
5
Yes
None detected
98.4
88
18
9.6
No
6
Yes
Staphylococcus aureus
100
169
45
36.4
Yes
7
Yes
[Not performed]
99.1
95
18
7.1
No
8
Yes
None detected
100.6
145
55
26.4
Yes
9
Yes
[Not performed]
98.8
93
20
16.1
No
77.8% (7/9)
50% (3/6)
66.6% (6/9)
Table 2: Clinical data. Abbreviations: Tmax, maximum temperature; HRmax, maximum heart rate; RRmax, maximum respiratory rate;
WBCmax, maximum white blood cell count.
Volume 4 • Issue 2 • 1000219
• Page 2 of 5 •
Citation:
Steehler M, Agnew AW, Anon JB (2015) Current Bacteriology and Antibiotic Management of Acute Suppurative Parotitis in the Hospitalized
Patient: A Retrospective Study and Literature Review. J Otol Rhinol 4:2.
doi:http://dx.doi.org/10.4172/2324-8785.1000219
Of the nine patients diagnosed with acute parotitis, fourteen
bacterial cultures were isolated. These bacterial cultures were obtained
from purulence expressed through Stensen’s duct. The fourteen
cultures obtained were made up of eight unique bacterial species.
Sensitivities with minimum inhibitory concentrations were obtained
on eight of the fourteen bacterial cultures. Staphylococcus aureus
made up 43% (6/14) of all pathogenic bacteria. All patients with
clinical sepsis in this study were found to have Staphylococcus aureus
parotitis. Other bacteria identified were ß-hemolytic Streptococcus
groups B and F, viridans group Streptococcus, Lactobacillus species,
Serratia marcescens, Stenotrophomonas maltophilia, and diptheroids.
Multi-drug resistant organisms made up 75% (6/8) of all isolates in
which sensitivities were obtained. Staphylococcus aureus made up 67%
(4/6) of all multi-drug resistant organisms; the other two being
Serratia marcescens and Stenotrophomonas maltophilia. Of the
Staphylococcus aureus strains identified as multi-drug resistant
organisms, 100% (4/4) were methicillin-resistant Staphylococcus
aureus (Figure 1).
Figure 1: Bacterial cultures and sensitivities with minimum inhibitory concentrations. Abbreviations: Abx, antibiotics; Pt, patient; S, sensitive;
R, resistant.
Among patients diagnosed with Staphylococcus aureus parotitis,
50% showed resistance to at least one of the antibiotics used over the
course of treatment (3/6). Two patients were treated with intravenous
clindamycin as an inpatient, and one was treated with oral cephalexin
as an outpatient, all of which were later found to be ineffective
antibiotics based on sensitivities. Cultures of Staphylococcus aureus
were found to be resistant to cefazolin 67% (4/6) of the time,
clindamycin 33% (2/6), erythromycin 67% (4/6), oxacillin 67% (4/6)
and tetracycline 17% (1/6) (Figure 2).
Discussion
Our otolaryngology practice has noted an increasing number of
hospitalized patients with multi-drug resistant organism parotitis.
Over a 12 month span, we’ve identified nine adults seen in hospital
consultation by our otolaryngology service with acute bacterial
suppurative parotitis, six of which were due to multi-drug resistant
organisms; methicillin-resistant Staphylococcus aureus being the most
common bacterial etiology. Historically, multi-drug resistant
organisms have been a rare cause of parotitis. These findings have
prompted us to further investigate the bacterial etiology of adults
hospitalized with acute bacterial suppurative parotitis. To our
knowledge, this is the first retrospective study analyzing sensitivities
and minimum inhibitory concentrations of pathologic bacteria
cultured from acute suppurative parotitis.
Volume 4 • Issue 2 • 1000219
A review of the literature conducted for all English-language
original research published over the last thirty years on the
microbiology of adult parotitis, excluding case reports and articles
related to mumps, revealed two studies of more than three patients.
Brooks et al reviewed 32 specimens collected through needle
aspiration of the parotid gland, from 1975 to 1999 in patients with
acute bacterial suppurative parotitis [11]. Fifty five bacterial isolates
were identified, 25 being aerobic and 30 anaerobic, with the most
common organism being Staphylococcus aureus. In a retrospective
review conducted from 1970 to 1987, Raad et al identified 10 patients
diagnosed with acute suppurative parotitis of which organisms were
isolated from pus expressed from Stensen's duct. Raad et al. found
Staphylococcus aureus to be isolated from 50% of cultures for patients
with acute suppurative parotitis. Organism data was incomplete or not
available in some patients however [12]. In our study, we found
Staphylococcus aureus to make up nearly half of all isolated bacteria.
While Staphylococcus aureus is the most common bacterial
pathogen causing acute suppurative parotitis, methicillin-resistant
Staphylococcus aureus is of increasing prevalence.12 A literature
review revealed twelve reported cases of adult acute bacterial
suppurative parotitis caused by methicillin-resistant Staphylococcus
aureus. Outcomes varied widely from complete resolution without
sequelae to death [13-22]. Methicillin-resistant Staphylococcus aureus
comprised 67% of all cultured Staphylococcus aureus in our study.
• Page 3 of 5 •
Citation:
Steehler M, Agnew AW, Anon JB (2015) Current Bacteriology and Antibiotic Management of Acute Suppurative Parotitis in the Hospitalized
Patient: A Retrospective Study and Literature Review. J Otol Rhinol 4:2.
doi:http://dx.doi.org/10.4172/2324-8785.1000219
Figure 2: Bacteria isolates and corresponding antibiotic treatment course. Antibiotics with resistance to cultured bacteria are highlighted in
black; PO, per os (by mouth); IV, intravenous.
Traditionally, a penicillinase-resistant penicillin or first-generation
cephalosporin has been recommended in the treatment of acute
bacterial suppurative parotitis [1,4,5]. Our previous practice was to
treat hospitalized patients with parotitis empirically with intravenous
ampicillin/sulbactam or clindamycin while awaiting cultures and
sensitivities in order to cover for the most common pathogens.
However, acute bacterial suppurative parotitis has increasingly shown
resistance to many of these traditionally recommended empiric
antimicrobial agents. Three bacterial isolates in this study showed
resistance to at least one antibiotic used over the course of treatment,
leading to increased morbitidity, and in the case of one particular
patient, transfer from a general floor to the intensive care unit. Given
its prevalence, clinicians should carry a high level of suspicion for
methicillin-resistant Staphylococcus aureus and multi-drug resistant
organism colonization in patients unresponsive to traditional
antibiotic treatment. An early transition to vancomycin or linezolid
should be considered if a patient is found to have sepsis or fails to
respond to other agents. While vancomycin is an excellent choice to
treat acute bacterial suppurative parotitis based on the findings of this
study, the cohort itself is limited to a retrospective review of nine
patients.
Also,
vancomycin
resistant
methicillin-resistant
Volume 4 • Issue 2 • 1000219
Staphylococcus aureus is increasing in incidence, along with upward
creep in vancomycin minimum inhibitory concentrations. Thus,
vancomycin and linezolide administration should be done cautiously
to decrease the risk of promoting bacterial resistance [23]. A recent
study by Troeltzch et al. has found cephalosporins and
fluorquinolones to display superior pharmacokinetics in saliva and
cover the spectrum of all bacteria implicated in sialadenitis, which may
be more appropriate before choosing vancomycin [24].
While Brooks et al. advocates’ needle aspiration of the parotid gland
as the best method to identify the causative organism, the bacterial
cultures obtained in this study were from purulence expressed through
Stensen’s duct [1]. It has been said that cultures from Stensen’s duct
are certain to be contaminated with oropharyngel bacteria. However,
we found that the cultures in this study correlated with blood cultures
whenever bacteremia was present. Potential future research would
include a larger sample size with increased geographic diversity. As
there are only adults in our cohort, we limited the study and literature
review to the adult population. However, microbial data may similarly
hold true to the pediatric population as well. Further studies are
needed to verify this. Lastly, this study analyzes only patients
hospitalized with acute parotitis. Obviously intravenous antibiotics are
• Page 4 of 5 •
Citation:
Steehler M, Agnew AW, Anon JB (2015) Current Bacteriology and Antibiotic Management of Acute Suppurative Parotitis in the Hospitalized
Patient: A Retrospective Study and Literature Review. J Otol Rhinol 4:2.
doi:http://dx.doi.org/10.4172/2324-8785.1000219
not a reasonable choice for empiric antibiotic therapy in the outpatient
setting. Moreover, the bacterial etiology and resistance level of patients
treated in an outpatient setting may be significantly different to those
hospitalized with parotitis. Future studies in this area are merited as
well.
Conclusion
Acute bacterial suppurative parotitis warrants prompt diagnosis
and efficacious treatment with empiric broad spectrum antibiotics and
maintenance of hydration. Patients can quickly deteriorate leading to
increased morbidity and mortality. Bacterial parotitis has increasingly
shown resistance to many traditionally recommended empiric
antimicrobial agents. As multidrug-resistant organisms, specifically
Staphylococcus aureus, continue to become more prevalent, empiric
antibiotics must be appropriately selected to treat for these organisms
until culture and sensitivity results become available. Due to this high
prevalence of multi-drug resistant organism parotitis, vancomycin
should be considered early in the treatment course, in some cases
before cultures are reported, if a patient is found to have sepsis or fails
to respond to other agents. If the patient is allergic to vancomycin,
then intravenous linezolid should be considered.
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