Introduction

Ludwig’s Angina is a condition caused by a bacterial infection that can sometimes be mistaken for heart disease. While it's an easy mix-up, they are quite different. Angina refers to a situation where the heart isn’t functioning properly and isn’t supplying enough blood.

Ludwig’s Angina is a bacterial infection in the lower part of the floor of the mouth, extending to the neck. It is a rare yet life-threatening infection that spreads slowly, making it difficult to breathe, swallow, and speak. Its treatment includes antibiotics, both targeted and empiric. If antibiotics fail to treat, then surgery is considered the last option.

Ludwig’s angina

Ludwig’s angina is a serious bacterial infection or cellulitis that originates in the floor of the mouth, particularly the area around the last premolars at the back of the mouth and spreads to the neck and other surrounding tissues.

The primary cause of this disease is poor dental hygiene, which accounts for approximately 90% of reported cases.¹ People with Ludwig’s Angina have difficulty breathing properly due to airway obstruction, and they also suffer from pneumonia.

What causes ludwig’s angina?

Microbial bacteria

The most common cause of Ludwig’s Angina is Bacteria or pathogens. The two types of bacteria responsible for Ludwig's Angina include:

Aerobes

Aerobes are bacteria that require oxygen to grow, such as Streptococcus viridans and Staphylococcus aureus. Aerobes are the most common pathogen causing Ludwig’s Angina. They are found in the back of the mouth or the upper respiratory tract. People suffering from dental infection are at high risk of developing the disease.²

Anaerobes

Anaerobes are those bacteria that do not require oxygen to grow. They include Bacteroides species and Fusobacterium species. They also reside in the mouth and cause dental infections, and can worsen tissue damage in the mouth; decrease immunity, and show resistance to antibiotics,  thus slowing the treatment.

Other causes include

• Periapical abscesses
• Trauma or Injury
• Tonsillitis
• Weak immunity
• Diabetes, HIV/AIDS
• Alcohol Abuse
• Malnutrition (poor nutrition)

Signs and symptoms of ludwig’s angina

The signs and symptoms of Ludwig’s Angina may range from mild to severe. Here are some of the most common symptoms found in people diagnosed with Ludwig’s Angina³

• Fever
• Drooling
• Hoarse voice
• Difficulty swallowing food
• Difficulty breathing
• Limited tongue movement
• Swelling in the back of the mouth and neck 

Antibiotic treatment of ludwig’s angina

There are two types of antibiotic therapy given in Ludwig’s Angina. They are 

1. Empiric Antibiotic Therapy
2. Targeted Antibiotic Therapy

Both of them have the same purpose, i.e, to treat the disease; the only difference between them is in their selectivity and duration.

Empiric antibiotic therapy

It is the initial antibiotic therapy given to a patient based on the signs and symptoms of Ludwig's disease when the causative agent is not yet identified. The main goal of this therapy is to control the spread of the bacterial infection. 

Ludwig’s disease is a serious condition, and the potential bacteria may grow rapidly in a very short time; therefore, to slow down the progress and prevent any complications, the doctors advise starting the empiric therapy course. ⁴It is given in the beginning as a precaution when the pathogen causing the disease is unknown. Empiric Therapy contains a broad-spectrum antibiotic, which kills a wide range of potential bacteria which could be causing the disease. 

Common empiric antibiotic regimens

Penicillin + metronidazole

Ludwig’s disease is a polymicrobial infection, and this combination ensures broad-spectrum effects. Penicillin targets the aerobic bacteria while metronidazole targets the anaerobic bacteria. 

Penicillin kills the bacteria by breaking down their cell wall, while metronidazole is responsible for the destruction of the DNA of the bacteria; both of them function by killing different types of pathogens. Since the actual causative agent is not identified, this regimen allows targeting both types of bacteria, thus acting as a broad-spectrum antibiotic.

Amoxicillin+ clavulanic acid

Amoxicillin is also a penicillin that targets aerobes, but it is given in combination with clavulanic Acid, which inhibits the beta-lactamases released by anaerobes. Clavulanic acid protects amoxicillin from degradation by bacteria and allows it to exert its antibacterial effect. ⁵

Clindamycin

Clindamycin is the first line of treatment for patients who show resistance to penicillin. It is a common broad-spectrum drug prescribed. It inhibits the protein synthesis of bacteria, thus exerting an antibacterial effect. It treats a wide range of diseases such as acne, osteomyelitis, bone and joint infections, and respiratory infections etc.⁶

Some other broad-spectrum drugs include

• Cefepime
• Meropenem
• Ampicillin-sulbactam
• Piperacillin-tazobactam

Advantages of empiric therapy

• It provides a rapid effect and slows down bacterial growth
• It reduces the risks of complications

Limitations of empiric therapy

• Empiric therapy raises concerns over antibiotic resistance. When bacteria become resistant to antibiotics, they can no longer be killed by the antibiotics, which can lead to an increase in complications, increased healthcare costs, and decreased chances of survival
• Since it is not a targeted therapy, it might be possible that the actual causative agent is unaffected and continues to grow despite the empiric treatment, thus it is ineffective and also continues to contribute to antibiotic resistance

Targeted antibiotic therapy

Targeted antibiotic therapy is the use of specific antibiotics to kill the bacteria. The specific bacteria responsible for Ludwig’s Angina are identified through culture and sensitivity testing, which takes around 48-72 hours.⁷ It is a test performed in the laboratories to identify the causative bacteria and suitable antibiotics to stop their growth.

Once the culture and sensitivity test results are received, a diagnosis is made, and the person is given specific antibiotics. Additionally, broad-spectrum drugs are discontinued as they may be ineffective. Long-term use of broad-spectrum drugs can have side effects, so it is important to switch to targeted antibiotic therapy at the earliest possible time.

Advantages of targeted antibiotic therapy

• Targeted therapy only kills the specific bacteria that are identified by the culture and sensitivity test. This targeted therapy differs from empiric therapy as it does not use broad-spectrum antibiotics but rather uses specific antibiotics to eliminate the pathogen responsible for the disease. Targeted therapy allows for the development of specific treatment plans for more focused care
• Targeted antibiotic therapy decreases the risk of antibiotic resistance as the person is only exposed to one specific type of antibiotic, which is not the case with empiric therapy. Targeted antibiotic therapy offers real benefit and decreases the chances of antibiotic resistance
• Targeted antibiotic therapy shows fewer side effects since the drugs are narrow-spectrum and specific to the identified bacteria

Limitations

• Targeted therapy is a delayed therapy because the culture test of the bacteria takes time, and if empirical therapy is not initiated, then the bacteria might grow rapidly and colonise, which may further complicate the condition
• In emergency cases, targeted therapy is not a suitable treatment as it is time-consuming, and empiric therapy provides instant treatment with broad-spectrum antibiotics

Clinical guidelines 

• The empiric therapy is started immediately if the person shows extreme symptoms such as fever, difficulty breathing, neck pain, drooling, and rapid swelling. Since the condition is severe and there is no time to wait for culture results, the person is administered broad-spectrum antibiotics to prevent any further complications
• Once the bacterial culture results are back and the bacteria causing the disease are identified, the treatment is switched to targeted antibiotic therapy to show action against the specific bacteria. The unnecessary broad-spectrum antibiotics are discontinued and reducing the risks of side effects and antibiotic resistance
• The doctor or pharmacist will decide the best treatment plan depending on your condition. In most cases, people are advised to follow empiric therapy, as some cases are resolved in early stages with no need for targeted therapy

Summary

Ludwig’s Angina is a serious condition where the floor of the mouth and the neck become inflamed, swollen, and painful due to bacterial infection, which can be gram-negative, gram-positive, aerobes, and anaerobes. The most common reason for bacterial infection is poor dental hygiene. The other less common causes include malnutrition, HIV, and alcohol abuse. 

The most common signs and symptoms include: swelling of the neck, fever, airway obstruction, difficulty swallowing food, and hoarse voice. Since Ludwig’s Angina is a bacterial infection, it is treated with antibiotics. There are two types of antibiotic therapy, i.e., Empiric Therapy and Targeted Therapy.

Empiric Antibiotic therapy is a broad-spectrum therapy, given in the early stage when the exact bacteria causing the symptoms are unknown. It is given in emergencies and also as a precaution to control the spread of the bacterial infection. It includes clindamycin and penicillin+metronidazole.

Once the pathogen causing Ludwig’s Angina is identified, the doctors switch the therapy to targeted antibiotic therapy to eliminate the relevant bacteria causing symptoms. This therapy offers more focused and safe treatment with a lower risk of antibiotic resistance.

Ludwig’s Angina is a very severe health condition; it is important to visit the doctor immediately to develop an appropriate antibiotic treatment plan. You must follow all the instructions given by the doctor for a quick and successful recovery.