Pre-operative Assessment of Oral Staphylococcus and Candida Species in a Group of Sri Lankans with Cleft Lip and Palate

INTRODUCTION

Cleft lip and palate (CLP), the commonest developmental anomaly of the head and neck region, requires surgical correction during early childhood. In an extensive review, Vanderas ^[1] has reported that the incidence of CLP per 1000 births varied among diverse ethnic groups: 0.79-3.74 in the American Indians, 1.45-4.04 in the Chinese and 0.85-2.68 in the Japanese. In India, the incidence of CLP has been approximately 1.1-1.35 per 1000 births.^[2] Moreover, an early study demonstrated that the incidence of CLP in a group of Sri Lankans was 0.83 per 1000 births.^[3] This indicates that CLP is a universal health problem across many parts of the world.

Management of patients with CLP involves contributions by multiple specialties, including oral and maxillofacial surgery, orthodontics, speech therapy, along with proper nutrition care.^[4] The success of the above interventions is indirectly affected by the oral microflora, which could transform into pathogens. According to Schonmeyr et al.^[5] dehiscence (3.2%) and infection (1.1%) were the most common types of postoperative complication in CLP patients.

Staphylococci are common inhabitants of the oral cavity of CLP patients.^[6–8] Supporting the above, it has been reported that the overall prevalence of bacteremia in CLP surgery was 38.1%, and it was largely due to staphylococci.^[9] Further, Marzoni and Kelly^[10] have found that the predominant organism responsible for bacteremia following CLP surgery was S. epidermidis, a common member of the coagulase-negative staphylococci (CoNS). The foregoing information illustrates the clinical importance of oral staphylococci in CLP surgery.

Commensal yeast, Candida, also may affect the management of CLP patients due to its opportunistic nature. Rawashdeh et al.^[11] in a prospective study have reported that the colonization rate of Candida in CLP patients was significantly higher than that in the healthy subjects. Another Brazilian study has reported that Candida prevalence was as high as 89.5% in cleft palate patients.^[12] However, there are no previous reports regarding the oral prevalence of Staphylococcus and Candida in CLP patients from Sri Lanka. Therefore, this study aimed to assess the prevalence of oral Staphylococcus and Candida in a group of Sri Lankan CLP patients prior to reconstructive surgery.

MATERIAL AND METHODS

RESULTS

The study sample consisted of 52 CLP patients, 27 males and 25 females. Their mean age was 9.4 ± 3.6 months (range, 4-18 months). Overall, there were 26 patients with cleft lip, 14 patients with cleft palate, and 12 patients with cleft lip and palate [Table 1].

The oral prevalence of Staphylococcus species was 65.4% (34/52), and Candida species was 23.1% (12/52). At the same time, 11.5% (6/52) of the samples carried both Staphylococcus and Candida and another 11.5% (6/52) of the samples produced neither Staphylococcus nor Candida in culture.

Staphylococcus species consisted of 41.2% (14/34) of S. aureus and 58.8% (20/34) CoNS. Methicillin resistance was detected in 57.1% (8/14) of S. aureus (MRSA) and 55% (11/20) of CoNS isolates.

Candida species included 58.3% (7/12) C. albicans and 41.7% (5/12) non-C. albicans Candida.

DISCUSSION

Nearly 65% of patients in this study harbored oral staphylococci, corroborating the previous studies that have reported increased oral prevalence of staphylococci in CLP patients.^[6,8,13,15] It is important to note that staphylococci are frequent skin and nasal commensals. CLP involves oral communication with the facial skin and the nasal mucosa, which may often lead to contamination and subsequent oral colonization of staphylococci, resulting in high oral prevalence in CLP patients. Moreover, staphylococci isolated in the current study included both S. aureus 41.2% (14/34) and CoNS 58.8% (20/34), denoting a predominance of CoNS in the oral microflora of CLP patients. Resembling the above findings, Marzoni and Kelly^[10] have found an increased prevalence of bacteremia due to coagulase-negative S. epidermidis in a group of CLP patients following reconstructive surgery. Furthermore, it has been reported that the overall prevalence of bacteremia during and after CLP surgery was 38.1%, and the responsible bacteria included both CoNS and S. aureus.^[9] As such, based on the preceding information, it is conceivable that many CLP patients carry oral staphylococci, both S. aureus and CoNS, posing a threat of postoperative bacteremia.

However, only a few studies have assessed the preoperative microflora and the postoperative infections in CLP patients. According to Schonmeyr et al.^[5] the incidence of postoperative infection in CLP patients was as low as 1%, even without antibiotics. Several other investigators have observed no perfect correlation between the microbiological culture results with the postoperative outcome, regardless of antibiotic therapy.^[13,16] Current study also was limited to the preoperative assessment of oral microflora of the CLP patients. Therefore, further prospective studies are warranted to explore the relationship between the oral microflora and the postoperative outcome of CLP patients.

Remarkably, more than 50% of S. aureus and CoNS isolated in our study demonstrated methicillin resistance (MR). In contrast, Chuo and Timmons^[15] found only 2 isolates (1.7%) with MR within a collection of 86 S. aureus isolates from CLP patients previously. Moreover, Tuna et al.^[7] who have investigated a group of 32 CLP patients with oronasal communication observed no MRSA but MSSA. In a group of 44 CLP patients, there was a significantly higher rate of colonization by staphylococci without any MRSA.^[9] Accordingly, the increased prevalence of MRSA among CLP patients in the current sample indicates the necessity for strict infection control, judicial antibiotic use, and meticulous follow-up of the patients in order to avoid postoperative complications.

Candida prevalence was approximately 23%, which included both C. albicans (58%) and non-C. albicans Candida (42%). In a similar study, Candida species in CLP patients was found to be 89.5%, and C. albicans was the leading species compared with non-C. albicans Candida.^[12] Furthermore, in a group of 46 CLP patients, Candida prevalence amounted to 39% and included both C. albicans and non-C. albicans Candida.^[17] Another study has revealed that 65.9% of CLP patients had oral Candida predominantly with C. albicans.^[18] Though the prevalence of oral Candida in our sample is lesser than that in the above reports, the majority harbored C. albicans, which is known to be the primary pathogen and efficient biofilm producer. Hence, it would be pertinent to promote oral hygiene in CLP patients to avoid Candida overgrowth, considering the capability of Candida to create biofilm-associated infections.^[19]

Intriguingly, there were 06 (11.5%) CLP patients carrying both staphylococci and Candida species in their oral cavities. Symbiotic relationships with regard to the pathogenesis of these commensals have already been uncovered, and it has been suggested that C. albicans facilitates the invasion of S. aureus across breached mucosal barriers, leading to systemic infection in co-colonized patients.^[20] Accordingly, the concomitant presence of staphylococci and Candida in CLP patients may increase the risk of postoperative bacteremia, leading to complications, and warrants further investigation on the clinical implications.

One of the drawbacks of this study is that it included only a limited number of participants, and the postoperative follow-ups were not reported. However, the findings showed that potentially pathogenic Staphylococci with MR and Candida exist in the preoperative microflora of CLP patients. The clinical impact of such microbiological findings would have been better elucidated by assessing the postoperative complications of such patients. Hence, further studies with a bigger sample size and postoperative clinical follow-ups would be beneficial to demonstrate the significance of the oral microflora of CLP patients in this clinical setting.

CONCLUSION

In conclusion, CLP patients undergoing reconstructive surgery may carry potential pathogens such as staphylococci and Candida in their oral microflora, with or without antibiotic resistance. Proper oral hygiene, asepsis, and close monitoring after reconstructive surgery may be imperative to avoid postoperative infections in CLP patients.