On hospital day 4, the patient was taken to surgery for exploration, drainage, and debridement of the right axilla and breast; cultures were taken, and lack of organism growth was noted. While in the MICU, she was followed by the infectious disease service as her WBC remained elevated and peaking at 32.6 x 103, while blood cultures were negative for bacterial growth.
The dental service was consulted on hospital day 5 to evaluate for other possible sources of infection. Upon examination, the patient’s oral condition was noted as having advanced chronic periodontal disease that required full-mouth extraction. The patient remained hemodynamically unstable with platelet counts below 50 x 109/L until hospital day 7, at which time she was taken for surgery for full mouth extraction and associated alveoloplasty. Upon extraction, the patient continued to improve and was extubated on day 11 with platelets and WBC returning to normal levels by day 13 of her hospital stay. The patient remained hospitalized for a total MICU stay of 20 days and rehabilitation stay of more than 2 weeks.
Discussion
Oral infections most often present with acute onset and noted oral-facial cellulitis or abscess. Oral source of septicemia often are considered after ruling out most other potential sources. Although it is not certain that this case is directly related to the advanced chronic periodontal disease, S pyogenes has been noted to be a pathogen in periodontal disease progression.
According to the American Dental Association in 2012, dental visits to the ED cost the US health care system $1.6 billion and an average cost of $749 per visit. There are more than 2 million ED visits each year for dental pain and infection, and 39% return due to nonresolution of the dental problem. Patients return to the ED due to lack of access and resources to routine and emergent dental care. 2 The average daily cost of an MICU stay with mechanical ventilation was $2,193 in 2002. This particular case consisted of 11 days of mechanical ventilation, 20 MICU days, and an additional 20 days of inpatient rehabilitation which resulted in costs that exceeded $50,000. 3