Osteomyelitis and Hemimandible resection

Question
Dr. Krempels,

Our pet bunny Seymour had a lower jaw abscess drained and enucleated by our veterinarian last Thursday 16th. We initially tried 3 wks of Bicillin injections every other day to reduce the abscess but it just kept getting bigger until it broke open on Tuesday 14th (2 days b/f the scheduled surgery).  I'm honestly still unsure waiting to drain the abscess was the right thing to do.  He has been currently taking the following drugs:

Baytril 100mg/ml 2xdaily 0.1 mls
Metacam 1.5mg/ml 1xdaily 0.2 mls
Bicillin 300000u/ml 1xdaily 0.25 mls

He handled the pre-surgery Bicillin injections every other day very well but the daily Baytril and Bicillin antibiotics I fear are what is causing him to quickly lose his appetite.

He weighs about 4 lbs. The Pasteurella culture has not come back yet. He did, however, test positive for actinomyces, staph and a stapholococcus.

The vet called me today and is now recommending he see a 'specialist' that will be in the area next week. This doctor believes the best way to treat Seymour is to remove all of the involved teeth (which I agree with) and also to remove the entire hemimandible affected w/ osteomyelitis (this part I'm skeptical about).  I am partly doubting this procedure b/c I am not convinced the lesion is true osteomyelitis.  Thus, I am not convinced that long-term antibiotic therapy is not a good alternative treatment.  I am also doubting the decision b/c I have a feeling that the resulting lesion was made much worse by waiting for 3 weeks b/f draining the abscess.

Do you have prior experience w/ such an aggressive procedure? Will Seymour be able to adapt and have a good life with only one side of his mandible? Money is not an issue nor is the time required to care for a 'handicapped' bunny. I'd do anything for this little guy and I just want him to have a quality life!  His bonded bunny friend would be heartbroken as well :(

I appreciate any advice you can give me.  Seymour has an appointment for surgery on Tuesday Feb 28 and I will not allow the specialist to do more than extract the teeth if I can't be convinced it's the right thing to do.

Thank you again,

Tom

Answer
Dear Tom,

Wow, Seymour is lucky to have such a great advocate who really checks into everything!

I have no personal experience with hemimandibulectomies, but know of a few people who have had bunnies with this procedure.  Some do well, others not so well.  It depends on the infection, the overall health of the bunny, and the bunny's personality. Some are really tough fighters, and others are a bit more delicate.  Seymour will benefit from having his mate by his side *at all times*, even (or perhaps especially) when he goes to the vet.  Never leave him there alone in a cage.  Make sure his mate stays, too.  It will be better for both of them.

It sounds as if Seymour's immune system isn't doing its job, if he has such a massive ecosystem of pathogens in that jaw abscess (the definition of osteomyelitis is inflammation/infection of the bone and--if present--the marrow inside it, to he almost certainly does have that, since teeth can't become infected on their own).  You might already be aware of the following, but please see:

www.bio.miami.edu/hare/jawabscess.html

and be sure to link to the article by Tyrrell, et al.  It's got some excellent information that you might wish to share with your vets.

If the hemimandibulectomy is successful, and he heals up well, there's no reason Seymour can't do well afterwards. He'll have to have his food cut up into tiny bits, and his pellets will have to be soaked and fluffed so he won't have to chew them, but he could do fine.  I know this only secondhand, since I've never had a bunny with a mandible (or half) removed myself.

If you'd like to talk to some people who might have personal experience with this (including some vets on the list!), please consider joining EtherBun, a free listserve (I'm the owner of the list) about rabbit health, care, and behavior.  There are more than 4000 subscribers, and I'd be surprised if you got no input at all if you posed that question there.  You can join from here:

www.bio.miami.edu/hare/etherbun.html

I think you're wise to exhaust all options before considering the radical procedure.  It *might* be enough to remove the infected teeth--or it might not.  And if the jaw bone is really infected, removal of the teeth without shattering the jaw might be impossible.

I'd be curious to see the results of the pending culture.  If this bacterium is so resistant that not even a combination of Baytril and bicillin will touch it, then there are other options.  Are any of the pathogens sensitive to chloramphenicol?  Amikacin?  As a last resort, clindamycin beads could be considered as implants, though that's definitely a drug you don't want to use unless all else has failed. (And you do NOT want to use injectable or oral clindamycin or lincosamines of any kind on a rabbit.)

Not sure any of this will be helpful, but I'm glad to see you're doing everything possible for your pal.  Please write back if you have any other questions.

Dana