Non-tuberculous Mycobacterial Infection of the Retropharyngeal Space.

We report a case of Mycobacterium avium complex infection of the retropharyngeal space in a 20-month-old girl. We also summarize the published literature on the pathogenesis and management of nontuberculous mycobacterial infections of the retropharynx.

Evolution of surviving Streptoccocus pyogenes from pharyngotonsillitis patients submit to multiple cycles of antimicrobial photodynamic therapy.

It is estimated over 600 million pharyngotonsillitis (PT) cases worldwide per year and 30% of this total are caused by Streptococcus pyogenes with standard antibiotic treatment. Antimicrobial Photodynamic Therapy (aPDT) has been studied for the clinical research in infectious diseases. The study aim was to analyze the evolution of aPDT on inactivation of clinical strains of multiple cycles. S. pyogenes and clinical strains isolated from patients with PT were incubated with curcumin in formulation (2.25 mg/ml) and irradiated at 450 nm in Light fluence rates. A mortality was a measure of the counting colony forming units per milliliter (CFU/ml) surviving. Parameters of bacterial biofilm formation, uptake of photosensitizer (PS) and efficacy of antibiotics on survival of bacteria of each cycle were tested. The bacteria profile remains unchanged between 10 aPDT cycles was observed. The bacterial colony survival presented a reduction in capacity to form biofilm due adhesion of strains and PS uptake rate. The antibiotic remained efficient after aPDT cycles. Our in vitro results suggested a low-level of development of PDT resistance, however a decrease of photosensitizer uptake was observed. Furthermore, there is no cross effect on aPDT cycles and the first application of antibiotics.

Opportunistic Fungal Infections in the Epidemic Area of COVID-19: A Clinical and Diagnostic Perspective from Iran.

The coronavirus disease 2019 (COVID-19) pandemic emerged in Wuhan, China, in late 2109, and has rapidly spread around the world. Until May 25, 2020, there were 133,521 confirmed COVID-19 cases and 7359 deaths in Iran. The role of opportunistic fungal infections in the morbidity and mortality of COVID-19 patients remains less defined. Based on our multicenter experiences, we categorized the risks of opportunistic fungal infections in COVID-19 patients in Iran. The COVID-19 patients at high risk included those with acute respiratory distress syndrome, in intensive care units, receiving broad-spectrum antibiotics, immunosuppressants or corticosteroid, and supported by invasive or noninvasive ventilation. The patients were most likely to develop pulmonary aspergillosis, oral candidiasis, or pneumocystis pneumonia. Most diagnoses were probable as the accurate diagnosis of opportunistic fungal infections remains challenging in resource-poor settings. We summarize the clinical signs and laboratory tests needed to confirm candidiasis, aspergillosis, or pneumocystosis in our COVID-19 patients.

Perillaldehyde: A promising antifungal agent to treat oropharyngeal candidiasis.

Perillaldehyde (PAE), a natural monoterpenoid agent extracted from Perilla frutescence, PAE has been reported to present various physiological capabilities, such as anti-inflammation, anti-oxidative and anti-fungal. In this study, we show that PAE exhibits strong antifungal activity against Candida albicans (C. albicans). C. albicans, a fungal pathogen with high incidence of antifungal resistance in clinical settings, is the major cause of oropharyngeal candidiasis (OPC). OPC is characterized by inflammatory immunological responses to fungal infections. Our in vitro results show PAE inhibited several virulence attributes of C. albicans including biofilm formation, yeast-to-hyphal transition and secreted aspartic proteinases (SAPs) gene expression. Using an experimental murine model of OPC, we found that PAE inhibited NLRP3 inflammasome assembly, reduced the excessive accumulation of ROS and prevented the p65 transfer in nuclear; processes all leading to reduced inflammation burden in the host. Together, this supports use PAE as a promising new agent to improve OPC.

emm Types and clusters and macrolide resistance of pediatric group A streptococcal isolates in Central Greece during 2011-2017.

BACKGROUND: The surveillance of emm types and macrolide susceptibility of group A streptococcus (GAS) in various areas and time periods enhances the understanding of the epidemiology of GAS infections and may guide treatment strategies and the formulation of type-specific vaccines. Greece has emerged as a country with high macrolide use. However, studies suggest a gradual reduction in macrolide consumption after 2007. METHODS: During a 7-year period (2011-2017), 604 GAS isolates were recovered from consecutive children presenting with pharyngeal or nonpharyngeal infections in Central Greece; 517 viable isolates underwent molecular analysis, including emm typing. RESULTS: Isolates belonged to 20 different emm types (in decreasing order of prevalence: 1, 89, 4, 12, 28, 3, 75 and 6, accounting for 88.2% of total isolates). The emm types comprised 10 emm clusters (five most common clusters: E4, A-C3, E1, A-C4 and A-C5). The emm89 isolates were acapsular ('new clade'). Overall macrolide resistance rate was 15.4%, and cMLSB emerged as the predominant resistance phenotype (56.4%). The lowest annual resistance rates occurred in 2014 (13.1%), 2016 (5.5%) and 2017(8.0%) (P for trend = 0.002). Consumption of macrolide/lincosamide/streptogramin B declined by 22.6% during 2011-2017. Macrolide resistance and emm28 and emm77 types were associated (both P<0.001). The most frequently identified genetic lineages of macrolide-resistant GAS included emm28/ST52, emm77/ST63, emm12/ST36, emm89/ST101 and emm4/ST39. We estimated that 98.8% of the isolates belonged to emm types incorporated into a novel 30-valent M protein vaccine. CONCLUSIONS: In Central Greece during 2011-2017, the acapsular emm89 isolates comprised the second most prevalent type. Susceptibility testing and molecular analyses revealed decreasing GAS macrolide resistance rates, which may be attributed to the reduction in the consumption of macrolides and/or the reduced circulation of macrolide-resistant clones in recent years. Such data may provide valuable baseline information in targeting therapeutic intervention and the formulation of type-specific GAS vaccines.

Extragenital Gonorrhea and Chlamydia Positivity and the Potential for Missed Extragenital Gonorrhea With Concurrent Urethral Chlamydia Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, 2015-2019.

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 sexually transmitted disease clinics in 10 jurisdictions during January 1, 2015, and June 30, 2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC, 16.7% [95% CI, 14.4-19.1]; CT, 13.3% [95% CI, 12.7-13.9]); urethral positivity (GC, 7.5% [95% CI, 5.7-9.3]; CT, 5.2% [95% CI, 4.6-5.8]); rectal positivity (GC, 11.8% [95% CI, 10.4-13.2]; CT, 12.6% [95% CI, 11.8-13.4]); and pharyngeal positivity (GC, 9.1% [95% CI, 7.9-10.3]; CT, 1.8% [95% CI, 1.6-2.0]). Of 4566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI, 10.9-14.1). CONCLUSIONS: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in approximately 13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

Neutrophil gelatinase associated lipocalin a biomarker for bacterial-induced pharyngeal infection-A pilot study.

OBJECTIVES: Neutrophil gelatinase associated lipocalin (NGAL) is secreted from activated neutrophil granulocytes and is considered an acute phase protein. The aim of this pilot study was to determine whether the NGAL concentration in saliva increases in response to a bacterial throat infection and identify pitfalls, which shall be taken into account in a protocol in a larger hypothesis testing study. METHODS: Saliva samples for measurement of NGAL concentration where obtained from cases with an acute throat infection (n = 21) and controls (n = 24). Among cases, plasma NGAL, plasma CRP, and whole blood leukocytes, were measured as well. RESULTS: There was no significant difference in NGAL saliva concentration between cases and controls overall (p = .31). For both cases and controls, the saliva NGAL concentration decreased significantly after cleansing the mouth with tap water (cases p = .01; controls p = .01). Among cases, a significant positive correlation between saliva NGAL concentrations before mouth cleansing and plasma CRP concentrations (p = .001) was observed. Blood neutrophil granulocyte count presented a nonsignificant positive correlation to saliva NGAL (p = .07). CONCLUSION: We could not demonstrate a simple association between the salivary NGAL concentration and pharyngeal bacterial infection. Furthermore, the salivary NGAL concentrations were higher among some controls than cases, suggesting that cofounders for example, periodontitis, uneven salivary dilution level, or other exogenous factors affect salivary NGAL content.

Pharyngeal microbiome alterations during Neisseria gonorrhoeae infection.

Pharyngeal gonorrhoea is a common sexually transmitted infection among 'men having sex with other men' (MSM). Neisseria gonorrhoeae (NG) pharyngeal infections are usually characterized by the absence of symptoms, acting as an important reservoir for their further spread. To the best of our knowledge, no information about the composition of the pharyngeal microbiome during an ongoing NG infection is currently available. Therefore, in this study, we characterized the pharyngeal bacterial community profiles associated with NG infection in a well-selected cohort of HIV-negative MSM reporting unsafe oral intercourse. A total of 70 pharyngeal swabs were considered, comparing non-infected subjects (n = 45) versus patients with pharyngeal gonorrhoea (n = 25) whose microbiota composition was analyzed from pharyngeal swabs through sequencing of hypervariable V3-V4 regions of the 16S rRNA gene. The pharyngeal microbiome of all subjects was dominated by Prevotellaceae, Veillonellaceae and Streptococcaceae families. Patients with pharyngeal gonorrhoea harboured a pharyngeal microbiome quite similar to negative subjects. Nevertheless, when looking to less-represented bacterial species (relative abundance approximately 1% or less), an imbalance between aerobe and anaerobe microorganisms was observed in NG-infected patients. In particular, the pharyngeal microbiome of NG-positive individuals was richer in several anaerobes (e.g. Treponema, Parvimonas, Peptococcus, Catonella, Filifactor) and poorer in various aerobe genera (i.e. Pseudomonas, Escherichia), compared to non-infected controls. No significant differences were noticed in the distribution of commensal Neisseria species of the oropharynx between NG-positive and negative subjects. Metabolic variations induced by changes in the microbiome abundance were assessed by a functional prediction of the bacterial metabolic pathways: a more abundant involvement of D-glutamine and D-glutamate metabolism, carbohydrate metabolism, as well as a greater activation of the energy metabolism was observed in patients with pharyngeal gonorrhoea compared to non-infected individuals. Information about the bacterial composition of the pharyngeal microbiome in case of gonorrhoea could shed light on the pathogenesis of the infection and open new perspectives for the prevention and control of this condition.

Reduced sensitivity from pooled urine, pharyngeal and rectal specimens when using a molecular assay for the detection of chlamydia and gonorrhoea near the point of care.

Background The aim of this study was to compare the performance of pooled self-collected urogenital, pharyngeal and anorectal specimens to that of individual specimen results for the molecular detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) near the point of care (POC) for diagnostic sensitivity. METHODS: Clients (mostly men who have sex with men) attending an urban community testing service and three sex-on-premises venues in Brisbane, Australia, were offered CT and NG testing by trained lay providers. Participants provided three self-collected specimens (urine, pharyngeal and rectal) for testing by GeneXpert (Cepheid, Sunnyvale, CA, USA). If any of the individual specimens from a participant were positive, all three specimens were pooled and retested. RESULTS: Of the 388 participants who provided three individual anatomical specimens, 76 (19.6%) were found to be positive for CT and/or NG at one or more sites. The pooling approach failed to detect five CT rectal and four NG pharyngeal infections. The overall performance (sensitivity) of the pooling approach compared with individual specimen testing and Cohen's κ were 90.0% and 0.86 respectively for CT and 89.7% and 0.89 respectively for NG. CONCLUSIONS: Reduced sensitivity was observed when using pooled specimens for the detection of CT and NG using GeneXpert near the POC, similar to results reported in laboratory-based CT and NG pooling studies. These data suggest specimen pooling is feasible near to the POC, potentially saving time and costs when screening at-risk populations for CT and NG. Our data also suggest a reduction in pooled urine could improve overall test sensitivity.

Pediatric Emergency Provider Sexually Transmitted Infection Screening Practices in Adolescents With Oropharyngeal or Anorectal Chief Complaints.

OBJECTIVES: Sexually transmitted infections (STIs) may present with oropharyngeal or anorectal symptoms. Little is known about the evaluation of adolescents with these complaints in the pediatric emergency department (PED). This study aimed to determine the frequency of and factors associated with STI consideration and testing in this population. METHODS: Retrospective chart review of patients aged 13 to 18 years who presented to an urban PED with oropharyngeal or anorectal chief complaints between June 2014 and May 2015. Sexually transmitted infection consideration was defined as sexual history documentation, documentation of STI in differential diagnosis, and/or diagnostic testing. Multivariate logistic regression models were used to identify factors associated with consideration. RESULTS: Of 767 visits for oropharyngeal (89.4%), anorectal (10.4%), or both complaints, 153 (19.9%) had STI consideration. Of the 35 visits (4.6%) that included gonorrhea and/or chlamydia testing, 12 (34.3%) included testing at the anatomic site of complaint. Of those 12 tests, 50.0% were the incorrect test. Patients with older age (adjusted odds ratio [aOR] = 1.5, 95% confidence interval [CI] = 1.3-1.7), female sex (aOR = 1.6, 95% CI = 1.03-2.5), or anorectal complaints (aOR = 2.4, 95% CI = 1.3-4.3) were more likely to have STI consideration. CONCLUSIONS: In an urban PED, only 20% of visits for adolescents with oropharyngeal or anorectal symptoms included STI consideration. Testing was performed in only 5% of cases and often at an inappropriate anatomic site or with the incorrect test. Interventions to increase awareness of appropriate STI consideration and testing for individuals presenting with possible extragenital complaints may help reduce STIs among adolescents.

Clinical predictors of descending necrotizing mediastinitis after deep neck infections.

OBJECTIVES/HYPOTHESIS: To identify the clinical predictors of descending necrotizing mediastinitis (DNM) secondary to deep neck infections (DNIs) before treatment. STUDY DESIGN: Retrospective case series. METHODS: We reviewed 73 patients with DNIs who had been treated with external drainage at our institute between April 2009 and March 2019. We divided these patients into either a DNI group without mediastinitis (n = 55) or a DNM group secondary to DNI (n = 18). We collected clinical data and compared them between the groups, conducting univariate and multiple logistic regression analysis to identify the predictors of DNM. RESULTS: We identified age, C-reactive protein (CRP), neutrophil percentage, lymphocyte percentage, neutrophil to lymphocyte ratio (NLR), presence of comorbidities, presence of gas, and abscess extension below the hyoid bone as statistically significant by univariate analysis. Moreover, multiple logistic regression analysis showed that age ≥55 years, NLR ≥13, and CRP ≥30 mg/dL were statistically significant. CONCLUSIONS: We identified age ≥55, NLR ≥13, and CRP ≥30 before DNI treatment as clinical predictors of a DNM complication. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E567-E572, 2020.

Paediatric oropharyngeal tularaemia requiring surgical intervention.

Tularaemia is a rare infectious disease endemic in most European countries caused by the bacterium Francisella tularensis 1 Patients often show acute non-specific symptoms, which causes a delay in diagnosis and proper treatment, potentially resulting in significant morbidities such as deep neck abscess, meningitis, endocarditis and septic shock. The authors present a case of a 5-year old boy with a 4-day history of fever, sore throat and painful cervical lymphadenopathy, whose clinical progression worsened despite being treated with recommended antibiotics as per WHO guidelines once the diagnosis of Tularaemia was confirmed by serologic tests. He developed a parapharyngeal abscess and a persistent left necrotic cervical lymph node, which both were surgically drained and excised, respectively, and an extended course of antibiotic was given. Subsequently, the patient fully recovered from the illness and the follow-up was negative for relapse.

Correlations of chlamydia and gonorrhoea among pharyngeal, rectal and urethral sites among Thai men who have sex with men: multicentre community-led test and treat cohort in Thailand.

OBJECTIVE: Routine screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections in sexually exposed anatomical sites may be challenging in resource-limited settings. The objective of this study was to determine the proportion of missed CT/NG diagnoses if a single anatomical site screening was performed among men who have sex with men (MSM) by examining the pattern of anatomical sites of CT/NG infections. METHODS: Thai MSM were enrolled to the community-led test and treat cohort. Screening for CT/NG infections was performed from pharyngeal swab, rectal swab and urine using nucleic acid amplification testing. The correlations of CT/NG among the three anatomical sites were analysed. RESULTS: Among 1610 MSM included in the analysis, 21.7% had CT and 15.5% had NG infection at any anatomical site. Among those tested negative for CT or NG infection at either pharyngeal, rectal or urethral site, 8%-19% had CT infection and 7%-12% had NG infection at the remaining two sites. Of the total 349 CT infections, 85.9%, 30.6% and 67.8% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. Of the total 249 NG infection, 55.7%, 39.6% and 77.4% would have been missed if only pharyngeal, rectal or urethral screening was performed, respectively. The majority of each anatomical site of CT/NG infection was isolated to their respective site, with rectal site having the highest proportion of isolation: 78.9% of rectal CT and 62.7% of rectal NG infection. CONCLUSIONS: A high proportion of CT/NG infections would be missed if single anatomical site screening was performed among MSM. All-site screening is highly recommended, but if not feasible, rectal screening provides the highest yield of CT/NG diagnoses. Effort in lowering the cost of the CT/NG screening test or developing affordable molecular technologies for CT/NG detection is needed for MSM in resource-limited settings. TRIAL REGISTRATION NUMBER: NCT03580512; Results.

Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial.

BACKGROUND: Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea. METHODS: G-ToG was a multicentre, parallel-group, pragmatic, randomised, non-inferiority trial comparing treatment with gentamicin to treatment with ceftriaxone for patients with gonorrhoea. The patients, treating physician, and assessing physician were masked to treatment but the treating nurse was not. The trial took place at 14 sexual health clinics in England. Adults aged 16-70 years were eligible for participation if they had a diagnosis of uncomplicated genital, pharyngeal, or rectal gonorrhoea. Participants were randomly assigned to receive a single intramuscular dose of either gentamicin 240 mg (gentamicin group) or ceftriaxone 500 mg (ceftriaxone group). All participants also received a single 1 g dose of oral azithromycin. Randomisation (1:1) was stratified by clinic and performed using a secure web-based system. The primary outcome was clearance of Neisseria gonorrhoeae at all initially infected sites, defined as a negative nucleic acid amplification test 2 weeks post treatment. Primary outcome analyses included only participants who had follow-up data, irrespective of the baseline visit N gonorrhoeae test result. The margin used to establish non-inferiority was a lower confidence limit of 5% for the risk difference. This trial is registered with ISRCTN, number ISRCTN51783227. FINDINGS: Of 1762 patients assessed, we enrolled 720 participants between Oct 7, 2014, and Nov 14, 2016, and randomly assigned 358 to gentamicin and 362 to ceftriaxone. Primary outcome data were available for 306 (85%) of 362 participants allocated to ceftriaxone and 292 (82%) of 358 participants allocated to gentamicin. At 2 weeks after treatment, infection had cleared for 299 (98%) of 306 participants in the ceftriaxone group compared with 267 (91%) of 292 participants in the gentamicin group (adjusted risk difference -6·4%, 95% CI -10·4% to -2·4%). Of the 328 participants who had a genital infection, 151 (98%) of 154 in the ceftriaxone group and 163 (94%) of 174 in the gentamicin group had clearance at follow-up (adjusted risk difference -4·4%, -8·7 to 0). For participants with a pharyngeal infection, a greater proportion receiving ceftriaxone had clearance at follow-up (108 [96%] in the ceftriaxone group compared with 82 [80%] in the gentamicin group; adjusted risk difference -15·3%, -24·0 to -6·5). Similarly, a greater proportion of participants with rectal infection in the ceftriaxone group had clearance (134 [98%] in the ceftriaxone group compared with 107 [90%] in the gentamicin group; adjusted risk difference -7·8%, -13·6 to -2·0). Thus, we did not find that a single dose of gentamicin 240 mg was non-inferior to a single dose of ceftriaxone 500 mg for the treatment of gonorrhoea, when both drugs were combined with a 1 g dose of oral azithromycin. The side-effect profiles were similar between groups, although severity of pain at the injection site was higher for gentamicin (mean visual analogue pain score 36 of 100 in the gentamicin group vs 21 of 100 in the ceftriaxone group). INTERPRETATION: Gentamicin is not appropriate as first-line treatment for gonorrhoea but remains potentially useful for patients with isolated genital infection, or for patients who are allergic or intolerant to ceftriaxone, or harbour a ceftriaxone-resistant isolate. Further research is required to identify and test new alternatives to ceftriaxone for the treatment of gonorrhoea. FUNDING: UK National Institute for Health Research.

Syphilitic Cervicitis with Cervical Cancer Presenting as Oropharyngeal Syphilis.

We herein report a patient with syphilitic cervicitis and cervical cancer presenting as oropharyngeal syphilis. A 31-year-old Japanese woman with a history of unprotected vaginal and oral sex visited our hospital with right submandibular adenomas and erythema in the extremities. The fornix uteri was red, with a nodule noted. The rapid plasma reagin ratio was 1:3. She was diagnosed with syphilitic cervicitis and treated with amoxicillin for four weeks. Initial cervical cytology showed cells with mild nuclear enlargement, which was thought to be metaplasia associated with syphilis. Repeated cytology a month later showed a high-grade squamous intraepithelial lesion. A punch biopsy of the lesion led to the pathological diagnosis of cervical carcinoma in situ. We performed cervical conization, and no recurrence occurred. Human papillomavirus (HPV) immunostaining was positive in the lesion. Mucosal lesions are an infrequently reported symptom of syphilis. When oropharyngeal lesions are found, the sexual history should be ascertained, and the patient should be screened for sexually transmitted diseases. HPV is especially significant because of its association with cervical cancer. Coinfection of HPV with cervical cancer must be ruled out during follow-up for women when oropharyngeal syphilis involves genital lesions.

Adherence to antibiotic guidelines in the treatment of acute pharyngeal infections.

INTRODUCTION: We aimed to investigate doctors' ad-herence to the local antibiotic guidelines for treatment of patients admitted with acute pharyngeal infections and to identify patient-related risk factors for non-adherence. METHODS: All patients with acute tonsillitis, peritonsillar abscess (PTA), and parapharyngeal abscess admitted to the Ear-Nose-Throat Department, Aarhus University Hospital, in the 2001-2014 period were included in the study. RESULTS: In total, 2,567 patients were hospitalised with acute pharyngeal infection. In non-allergic patients, penicillin was prescribed to 81%, either alone (48%) or in combination with metronidazole (33%). Macrolides (54%) and cefuroxime (44%) were the drugs of choice in 85 (98%) patients who were allergic to penicillin. Patients were prescribed antibiotics according to guidelines in 63% of cases. The addition of metronidazole to penicillin was the main (75% of cases) reason for non-adherence. Increasing patient age and male gender were independent risk factors for non-adherence. PTA patients treated according to the guidelines had a significantly shorter hospital stay than patients treated with additional metronidazole or broad-spectrum antibiotics. CONCLUSIONS: A significant (37%) proportion of patients with acute pharyngeal infections were treated non-adherently to antibiotic guidelines, mainly because of (inappropriate) addition of metronidazole to penicillin. FUNDING: This work was supported by the Lundbeck Foundation (Grant number R185-2014-2482). TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency.

Deep neck infection in patients with and without human immunodeficiency virus: a comparison of clinical features, complications, and outcomes.

We retrospectively studied the clinical features, complications, and outcomes of deep neck infections in 31 adult patients with the human immunodeficiency virus (HIV) (HIV group) and 192 patients without (non-HIV group). In the HIV group, the cause was more likely to be odontogenic (21 (68%) compared with 90 (47%); odds ratio (OR) 2.38; 95% CI 1.06 to 5.32). In both groups, the parapharyngeal, submandibular, and masticator spaces, were those most often involved. However, in the HIV group, Ludwig's angina was common, and was the main cause of airway obstruction. Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa were most often isolated in the HIV group. Upper airway obstruction tended to be more common in the HIV group (5/31 compared with 13/192). These patients also had a higher risk of other complications (sepsis, mediastinitis, jugular vein thrombosis, and pneumonia) (6/31 compared with 12/192; OR 3.60; 95% CI 1.24 to 10.45), a higher mortality rate (3/31 compared with 2/192), and longer hospital stay (19days compared with 16 days). Factors associated with an increased risk of complications in this group were an age of 55 years or over and a CD4 count of less than 350 cells/mm3. Deep neck infections in these patients are more severe. Dental health care, appropriate empirical antibiotics, early detection, and management of the airway and complications, may improve outcomes.