Management of spreading or systemic infection
Health care providers need to be aware of the characteristics of the occasional patient who presents with spreading or systemic infection. There is, for example, an association between cervicofacial infection, such as Ludwig’s angina, and acute morbidity and mortality.10,11
It is important to check for and recognise the cardinal signs and symptoms of spreading infection (cellulitis, lymph node involvement, swelling, trismus) and systemic infection (fever and malaise) in patients presenting with acute dental problems.
Antibiotics are only appropriate for oral infections where there is evidence of spreading or systemic infection or for a patient who is immunocompromised. Immunocompromised patients are at higher risk of complications from infections including sepsis, and there is a lower threshold for prescribing antibiotics. Considering whether the patient looks or feels unwell might be helpful in assessing the likelihood of systemic infection.
Local measures (e.g. drainage of a dental abscess) are the recommended first option in cases of bacterial infection where there is no spreading or systemic infection. However, in rare cases it might be necessary to prescribe an antibiotic, for example when swelling is severe and drainage cannot be achieved. In addition, antibiotic prophylaxis might be required prior to local measures for some patients at risk of infective endocarditis (see SDCEP Antibiotic Prophylaxis Against Infective Endocarditis implementation advice).
Sepsis
Health care providers assessing a patient with spreading or systemic infection should be alert to signs of sepsis indicating that the infection is causing significant illness or deterioration. These might be non-specific and non-localised, such as general malaise, agitation, behavioural change or confusion.12 Other signs and symptoms might include rigors or fever, dehydration (reduced urine output in previous 18 hours), breathlessness, mottled or discoloured skin.12,13 People who are very young, older, frail, pregnant, have had a recent trauma, surgery or invasive procedure, or have a weakened immune system, are more vulnerable to sepsis.12,14-16
If sepsis is suspected, the patient should be urgently assessed in a clinical setting for identification of markers of increased risk of severe illness or death, and appropriate management (see NICE Clinical Knowledge Summary - Sepsis for more information).
The UK Sepsis Trust provides sepsis assessment tools for use by healthcare professionals, including in primary dental care, general medical practice and community services.