Hrev_master [page 66] [Healthcare in Low-resource Settings 2023; 11:11527] Clinical manifestation and microbial profiling of recurrent MDR microorganisms associated with head and neck infection- a retrospective study Smarita Lenka,1 Debasmita Dubey,2 Shakti Rath,3 Somadatta Das,4 Santosh Kumar Swain5 1Department of Otorhinolaryngology, IMS & SUM Hospital, Siksha O Anusandhan deemed to be University, Kalinga Nagar, Bhubaneswar, Odisha; 2Department of Medical Research, IMS and SUM Hospital, Siksha ‘O’ Anusandhan Deemed to be University, Kalinga Nagar, Bhubaneswar, Odisha; 3Central Research Laboratory, Institute of Dental Sciences, Siksha ‘O’ Anusandhan Deemed to be University, Kalinga Nagar, Bhubaneswar, Odisha; 4Central Research Laboratory, IMS and SUM Hospital, Siksha ‘O’ Anusandhan Deemed to be University, Kalinga Nagar, Bhubaneswar, Odisha; 5Department of Otorhinolaryngology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India Abstract Head and neck infection (HNI) can lead to life-threatening complications, including death. The purpose of this study is to look at the entire clinico-demographic profile of patients with HNI as well as the microbio- logic profile of recurring bacterial infection cases with a variety of symptoms. A retro- spective cross-sectional study was conduct- ed on 1080 HNI patients in a tertiary care hospital in Bhubaneswar, Odisha, India, from January 2018 to December 2022. Of the 1080 cases, 771 (71.39%) were males, 309 (28.61%) were females, and 603 (55.83%) were from rural areas reporting to a tertiary care hospital. 62% of the cases were between the ages of 31 and 60. Neck abscesses account for 570 (52.78%) of all cases, with parotid abscesses accounting for 233 (21.57%), peritonsillar abscesses accounting for 170 (15.74%), otitis media 32 (2.96%), and oral cavity infection accounting for 26 (2.41%). In 854 (79.07%) cases, the etiology was odontogenic, fol- lowed by sinus in 188 (17.41%) and oto- genic in 38 (3.52%). The most common pre- senting features were neck swelling in 537 (49.72%) cases and face swelling in 238 (22.04%) cases, followed by jaw pain in 26 (2.41%) cases and others. Patients were hospitalized for an average of 11.82±4.38 days. Treatment and recurrence had a strong significant relationship (p 0.001). Microbio- logic investigation of recurrent patients revealed 12 microorganisms, including bac- teria and fungus, mainly multidrug-resistant in given ascending order Staphylococcus aureus (26.74%), Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Candida albi- cans (4.65%), Aspergillus fumigatus, A. flavus, A. niger, C. tropicalis, C. glabrata, C. krusei. Apart from colistin, almost all antibiotics were highly resistant to gram- negative bacteria, whereas against S. aureus, benzylpenicillin, and oxacillin showed 100% resistance, followed by ery- thromycin (91.3%), levofloxacin (86.96%), and ciprofloxacin (82.61%). This explorato- ry study would aid in determining the HNI burden and epidemiology, as well as their treatment status. Introduction Head and neck infections (HNI) com- monly arise through the odontogenic, oral, or otological region and come up with vari- ous complications.1-3 The treatment proce- dure is developing, but the infection rate is also increasing instead of its downfall. It may be initiated by poor hygienic habits, smoking, alcohol consumption, or environ- mental factors like polluted air and water.4 Different studies have shown the mirror of these factors to society, but there have yet to be successful mass effects. Infections involving the sites are initially much more complicated to diagnose as their anatomical construction is a little complex. Patients of all ages, particularly children and young adults, frequently have facial and cervical infectious processes, which pose a clinical concern. A complication of infection increases when it spreads beyond the prima- ry site of origin, like the oral cavity, odonto- genic region, rhinitis, or otitis media, where the infection is only at cellulitis or abscess formation adjacent to the sites of infec- tion.5,6 Infection symptoms and signs are clini- cally apparent in the head and neck, allow- ing for a presumptive diagnosis. The most frequent cause in children and young people is a tonsillar infection, but the most frequent cause in older is an odontogenic infection. The other potential head and neck infection sources are salivary glands, nasal sinuses, middle ear, mastoids, cervical lymph nodes, and trauma.7 Head and neck infections are becoming more common and have signifi- cant death rates and consequences. It can migrate from the skull base to the medi- astinum and affect the other spaces. Nevertheless, it is clinically difficult to identify the implications, such as acute air- Healthcare in Low-resource Settings 2023; volume 11:11527 Correspondence: Shakti Rath, Central Research Laboratory, Institute of Dental Sciences, Siksha ‘O’ Anusandhan Deemed to be University, Kalinga Nagar, Bhubaneswar, Odisha, India. E-mail: dr.shaktirath@gmail.com Key words:head and neck infection; manifes- tation; recurrence, multi-drug resistance. Contributions: All authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpreta- tion of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current jour- nal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work. All the authors are eligi- ble to be an author as per the International Committee of Medical Journal Editors (ICMJE) requirements/guidelines. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: Appropriate ethical clearance has been obtained from the Institute Ethical Committee, IMS, and Sum Hospital, Siksha O Anusandhan (deemed to be) University, Bhubaneswar, Odisha, India. Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received for publication: Accepted for publication: This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11527 doi:10.4081/hls.2023.11527 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. No n- co mm er cia l u se on ly way obstruction and mastoids, cervical lymph nodes, and trauma.8-11 Patients with diabetes, compromised immune systems, and advanced age are more susceptible to complex head and neck infections.4 According to a study conducted in the US, 11% adult population is diag- nosed with sinusitis, and 2.1% of the popu- lation accounts for sore throat, which is an early sign of a significant head and neck infection.12 Particularly in diabetic individu- als, it has been demonstrated that there is a higher risk of suppuration, multi-space infections, and the requirement for numer- ous surgical treatments. Refusing to have head and neck abscesses surgically treated sooner increases the risk of complications and lengthens hospital stays.5,13 In these populations, for the prompt identification of clinical problems, better analysis of epi- demiology, and to fix problems regarding treatment failure, there should be analytical, clinical profiling of recent year visiting patients for a new step towards better treat- ment. Various analyses were done world- wide to estimate the overall clinical profil- ing of head and neck infections. Still, in some regions, it needs to be addressed by people underestimating the severity beyond the infection or sometimes by self-medica- tions which may increase infected cases and recurrence and tend to mild to moderate and then severe.15 Moreover, most infectious diseases re-occurred due to the multidrug resistance activity of associated microor- ganisms.16-18 In this case, the infection can be controlled only through region-specific epidemiology of pathogen identification and their drug susceptibility pattern for early diagnosis and therapeutic purposes. Literature regarding individual head and neck infection sites is readily available as most studies aim to solve it independent- ly concerning their expertise area. But this retrospective study covers almost all clini- cal profiles and other necessary information of patients suffering from any sites of HNI attending the Department of Otorhinolaryngology, IMS & SUM Hospital, Bhubaneswar, Odisha, India. Materials And Methods Study subjects This hospital-based retrospective study was conducted with all age groups of head and neck infection patients who attended both the out-patient department (OPD) and in-patients department (IPD) of Otorhinolaryngology (ENT) in this hospital from January 2018 to August 2022. Patients only suspected of infection were included and associated with thyroid gland cysts, infection due to external cervical injury (traumatic or surgical), neoplastic patholo- gy, tumor-associated cases, and clinical cases with insufficient information were excluded from this study. Patients were cat- egorized into four groups that were com- pared: pediatric (aged 1-14 years), young (aged 15-30 years), adult (aged 31-60 years), and seniors (aged 61 years above). A comparison of data from patients with dif- ferent sites of infection and their associated factors was performed. Sample collection and processing Using Stuart’s transport medium, swab samples were collected and transported from recurrent patients from infection sites. They were cultured using blood agar for bacterial growth and Sabouraud dextrose agar for growing fungus. The cul- ture was subjected to Vitek 2 for accurately identifying and analyzing antibiotics’ mini- mum inhibitory concentration (MIC) against individual microorganisms. Statistical analysis The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS, version 29.0.0.0). Comparisons between groups of categorical variables were made using the Chi-square test, and a multiple linear regression model was performed using Graph pad Prism 9 to predict or analyze other variables like sites of infection and annual distribution. The significance p value <0.05 was considered statistically significant. Results Demographic details of patients According to their clinical manifesta- tion, 1080 head and neck infection patients were selected during the five years of the study period. Out of the total head and neck infection registered patients, 771 (71.39%) were male, and 309 (28.61%) were female in a ratio of (247:301), where males pre- dominated in all infected age groups. Out of 1080 cases, 28 (2.59%) patients belonged to the pediatrics age group, 275 (25.46%) to the young age group, 674 (62.41%) to the adult age group, and 103 (9.54%) of senior citizens (Figure 1) and the mean ±SD of all age group of patients are 41.18±15.04 (Table 1). Yearly, seasonal, and regional infor- mation The highest peak of head and neck infection patients was throughout the study period 309 (28.61%) in 2021 (Figure 2). The distribution of patients with head and neck infection revealed seasonal variation: Article Figure 1. Age distribution of patients. Table 1. Demographic, social status of patients suffering from head and neck infection. Demographic Social status Gender Number Percentage Mean±SD Male 771 71.39 - Female 309 28.61 - Age Pediatric (1-14) 28 2.59 6.64±4.75 Young (15-30) 275 25.46 24.57±3.77 Adult (31-60) 674 62.41 45.39±8.18 Seniors (> 61) 103 9.54 67.15±6.15 Locality Urban 477 44.17 - Rural 603 55.83 - Figure 2. Yearly distribution of patients diagnosed with head and neck infection. [Healthcare in Low-resource Settings 2023; 11:11527] [page 67] No n- co mm er cia l u se on ly 395 (36.57%) during summer > 303 (28.06%) during rainy > 277 (25.65%) in spring > and 105 (9.72 %) in winter (Table 2). There 603 (55.74%) HNI patients enrolled were from rural areas, and 477 (44.17%) were from the urban population of patients (Table 3). Detail evidence on sites and origins of infection For easier infection distribution, infec- tion locations associated with HNI were divided into compartments such as the ear, nasal, neck, and oral. But individual sites of infection were analyzed individually from the complete data set. Neck abscess was the most prevalently diagnosed with 570 (52.78%) patients, followed by parotid abscess 233 (21.57%) and peritonsillar abscess 170 (15.74%). The location of HNI varied among the different age groups. Neck abscesses occurred in all age groups, but the average group of age mean±SD (41.38±14.71) suffered from neck abscesses which are near to the mean±SD of the over- all age group 41.18±15.04. Therefore, neck abscess was diagnosed higher times than other infection sites in all age groups (Table 4). The predisposing cause of HNI was determined that otological infection 38 (3.52%), sinus infection 188 (17.41%), and odontogenic infection 854 (79.07%) were the origin of initiation, where the odonto- genic infection was the highest cause of origination of HNI that includes dental infections and oropharyngeal infection as well (Table 4). Clinical manifestation, including all symptoms of HNI, indicated infection at which the diagnosis process started. Face swelling, ear pain, headache, jaw pain, neck pain, sore mouth, swollen neck, and throat pain were the common clinical characteris- tics with all populations where most of the patients were highly symptomatic with swollen neck 537 (49.72%), followed by face swelling 238 (22.04%) and throat pain 180 (16.67%) (Table 3). In the sites of Article Table 3. Clinical manifestation in accordance with internal and external symptoms. Clinical manifestation Number Percentage Internal symptoms Airway blockage 2 0.19 Fever 3 0.28 Jaw pain 26 2.41 External jaw swelling 1 0.09 Sore throat 4 0.37 Throat pain 180 16.67 Ear pain 32 2.96 Headache 8 0.74 Neck pain 29 2.69 External symptoms Face swelling 238 22.04 Jaw swelling 1 0.09 Sore mouth 19 1.76 Swollen neck 537 49.72 Swollen throat 1 0.09 Table 4. Origin, complications, and diagnosis of infections. Origin of infection Number Percentage Otological infection 38 3.52 Odontogenic infection 854 79.07 Sinus infection 188 17.41 Complication Biofilm formation 276 25.56 Mold formation 38 3.52 Pus deposit 766 70.93 Diagnosis Number Percentage Hypopharyngeal abscess 2 0.19 Laryngitis 4 0.37 Neck abscess 570 52.78 Oral cavity infection 26 2.41 Otitis media 32 2.96 Parapharyngeal abscess 1 0.09 Parotid abscess 233 21.57 Parotid gland infection 8 0.74 Peritonsillar abscess 170 15.74 Retropharyngeal abscess 6 0.56 Sinusitis 10 0.93 Submandibular gland infection 18 1.67 Figure 3. Frequency of microorganisms isolated from recurrence patients. Table 2. Seasonal and monthly distribution of patients. Seasonal distribution Monthly distribution Number Percentage Spring Jan 59 5.46 Feb 77 7.13 Mar 141 13.06 277 25.65 Summer April 135 12.50 May 120 11.11 Jun 140 12.96 395 36.57 Rainy July 162 15.00 Aug 97 8.98 Sep 44 4.07 303 28.06 Winter Oct 40 3.70 Nov 38 3.52 Dec 27 2.50 105 9.72 [page 68] [Healthcare in Low-resource Settings 2023; 11:11527] No n- co mm er cia l u se on ly infection, complications like biofilm forma- tion were 276 (25.56%), mold formation was 38 (3.52%), and pus deposit was 766 (70.93%; Table 4). Rate of severity, implementation of treatment, and recurrence The majority of populations, 695 (64.35%), had a moderate rate of infection in the same way 311 (28.80%) were a mild rate, and 74 (6.85%) had a severe rate of infection. Hospitalization was needed by 650 (60.19%) patients having a severe and moderate rate of infections, and 430 (39.81%) were not hospitalized as some of them were treated with minor surgery, 142 (13.15%) and empirical antibiotic therapy 297 (27.50%). Nearly all patients who underwent surgical drainage (59.35%) were hospitalized for a mean±SD, 14.03±3.23 period. Recurrent HNI was observed in 86 (7.96%) patients, 5 in the pediatric group, 19 in the young age group, 53 in the adult group, and 8 in the old age (senior) group (Table 5). Patients who underwent surgical treatment had a more significant number of days of hospitalization compared to minor surgery and those who were implicated by empirical antibiotics. There was a signifi- cant association (p<0.001) between sites of infection (compartments) and all treatment procedures. 7.96% of recurrences were noted after completion of treatment, where- as 6.11% of recurrences were patients with treated empirical antibiotics, and there was also a significant association (p<0.001) between treatment and recurrence. However, no significant difference in gen- der (p=0.5), local status (p=0.8), and age group (p=0.2) with recurrence. Among 86 (7.96%) recurrence patients, 66 (6.11%) patients were implemented with empirical therapy, and 20 (1.85%) patients went through surgical drainage (both minor and major surgery). The microbiological investigation (through Vitek 2) of recurrent patients revealed 12 different types of microorganisms (Figure 3), including bacte- ria and fungus, and according to their drug susceptibility pattern, almost all antibiotics are resistant to most patients. Article Table 5. Treatment and management details of HNI patients. Treatment and management Number Percentage Procedure Surgical drainage 641 59.35 Minor surgery 142 13.15 Empirical antibiotic 297 27.50 Severity Mild 311 28.80 Moderate 695 64.35 Severe 74 6.85 Hospital stay Yes 650 60.19 No 430 39.81 Recurrence Yes 86 7.96 No 994 92.04 Observation period (1-5) 149 13.80 (5-10) 265 24.54 (11-15) 509 47.13 (16-20) 142 13.15 (21-25) 14 1.30 (26-30) 1 0.09 [Healthcare in Low-resource Settings 2023; 11:11527] [page 69] Table 6. Details of all organisms isolated with antibiotic susceptibility pattern. Sl.No. Name of organisms Frequency (n) Percentage Resistance to Antibiotics/antifungals drugs in percentage 1 Staphylococcus aureus 23 26.74 BEN-PEN -100; OX -100; GEN -26.09; CIP -82.61; LE -86.96; E -91.3; CD -60.87; LZ -17.39; DAP -17.39; TEI -13.04; VA -4.35; TE - 21.74; TGC -0; NIT -0; RIF -21.74; TMP -65.22 2 Klebsiella pneumoniae 20 23.26 AMP -ND; AMX -ND; TI -100; PI -100; CEF -100; CEFAX -ND; CIS -100; CFS -ND; CPM -100; ETP –ND; IMP -60; MRP -100; AK -85; GEN -60; NA -ND; CIP –95; TGC -85; NIT -ND; CL-20; TMP-90 3 Pseudomonas aeruginosa 13 15.12 AMP -ND; AMX -ND; TI -100; PI -92.3; CEF -100; CEFAX -ND; CIS -92.3; CFS -ND; CPM -84.61; ETP –ND; IMP -92.3; MRP -92.3; AK -84.61; G EN -84.61; NA -ND; CIP –84.61; TGC -100; NIT -ND; CL-30.76; TMP-ND 4 Acinetobacter baumannii 10 11.63 AMP -ND; AMX -ND; TI -100; PI -100; CEF -100; CEFAX -ND; CIS -100; CFS -ND; CPM -100; ETP –ND; IMP -100; MRP -100; AK -90; GEN -100; NA -ND; CIP –100; TGC -0; NIT -ND; CL-10; TMP-80 5 Escherichia Coli 8 9.30 AMP -100; AMX-100; TI -100; PI-100; CEF-100; CEFAX -100; CIS-100; CFS -100; CPM -100; ETP – 100; IMP-100; MRP-100; AK-100; GEN-100; NA-100; CIP – 100; TGC -12.5; NIT -37.5; CL-50; TR-75 6 Candida albicans 4 4.65 KT -75; IT- 100; FLC-75; AMP- 75; COT-100; MIC- 100; NS-50 7 Candida tropicalis 2 2.33 KT -100; IT- 100; FLC-100; AMP- 100; COT-100; MIC- 100; NS-100 8 Candida glabrata 2 2.33 KT -100; IT- 100; FLC-0; AMP- 100; COT-100; MIC- 100; NS-100 9 Candida krusei 1 1.16 KT -100; IT- 100; FLC-100; AMP- 0; COT-0; MIC- 100; NS-100 10 Aspergillus fumigatus 1 1.16 KT -100; IT- 100; FLC-0; AMP- 50; COT-100; MIC- 100; NS-100 11 Aspergillus flavus 1 1.16 KT -50; IT- 100; FLC-100; AMP-100; COT-100; MIC- 100; NS-100 12 Aspergillus niger 1 1.16 KT -100; IT- 100; FLC- 0; AMP-0 COT- 100; MIC- 100; NS-100 Antibiotics used: AK, Amikacin, AMP, Ampicillin, AMX, Amoxicillin, BEN-P- Benzylpenicillin, CD, Clindamycin, CEF, Cefuroxime, CEF-AX, Cefuroxime Axetil, CFS, Cefoperazone, CIP, Ciprofloxacin, CIS, Ceftriaxone, CL, Colistin, CPM, Cefepime, DAP, Daptomycin, E, Erythromycin, ETP, Ertapenem, GEN, Gentamicin, IMP, Imipenem, LE, Levofloxacin, LZ, Linezolid, MRP, Meropenem, NA, Nalidixic Acid, NIT, Nitrofurantoin, OX, Oxacillin, PI, Piperacillin, RIF, Rifampicin, TE, Tetracycline, TEI, Teicoplanin, TGC, Tigecycline, TI, Ticarcillin, TMP, Trimethoprim, VA, Vancomycin. Antifungals used: AMP, Amphotericin B, COT, Clotrimazole, FLC, Fluconazole, IT, Itraconazole, KT, Ketoconazole, MIC, Miconazole, NS, Nystatin. No n- co mm er cia l u se on ly [page 70] [Healthcare in Low-resource Settings 2023; 11:11527] Investigation of microbial specimens collected from recurrent patients Investigation of microbiologic speci- mens through the Vitek 2 identification pro- cedure gives five different genera and species of bacteria. Only S. aureus was gram-positive, and the rest 4 were gram- negative. But the prevalence of S. aureus (n=23) was higher than other bacterial and fungal isolates (Table 6). The prevalence of bacterial isolates was high compared to fun- gal isolates. Only 12 (n=12) cases were identified with fungal cultures, which include Candida spp.(n=7) and Aspergillus spp. (n=5) (Figure 3). A maximum number of antimicrobial agents were resistant to their respective bacteria/fungi. Apart from Colistin, almost all antibiotics were highly resistant against gram-negative bacteria, whereas in the case of S. aureus, ben- zylpenicillin, and oxacillin revealed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%) and ciprofloxacin (82.61%) (Table 6). Among 12 fungal isolates, there were 4 (n) C. albi- cans, and the rest of 3 (n) Candida spp. were identified with single species such as C. tropicalis (n=1), C. glabrata (n=1), C. krusei (n=1). There were 5 (n) Aspergillus spp. including A. fumigatus (n=2), A.flavus (n=2) and A. niger(n=1). All fungal isolates were resistant to most of the antifungals (ketoconazole, itraconazole) rather than some of the antifungals like fluconazole and amphotericin B were intermediate against two isolates of A. fumigatus, and one isolate of A. niger (Table 6). Discussion Head and neck infections are an uncom- mon but severe problem in all age groups. Although intravenous antimicrobial therapy might help reducing the incidence of prima- ry and secondary HNIs, life-threatening complications may arise if not diagnosed or treated promptly. At an early stage, it may have very subtle signs and symptoms, which demand a high index of suspicion and specific diagnostic examination, which may reduce the severity and significant complications. Around 57% of the cases in the age group of 11 to 40 years were report- ed with HNI by Dudhe P et al., 2022,19 whereas a mean±SD of age 41.18±15.04 was reported in our closely relevant study. Distribution of patients according to sea- sonal variation revealed a higher number in summer, but this can be different in a differ- ent climate. No significant differences were found in demographic distributions on the HNI of our study with other studies. Unlike our study, there was a high prevalence of male patients (55.26%) compared to females (44.74%) and primarily admitted from a rural background.20 It is reasonable that HNIs may predominate in specific anatomic spaces according to the initiation of infec- tion. As such, studies21,22 showed that odon- togenic and otogenic etiological factors are responsible for spreading HNI, and pain and swelling were the most common presenting features, followed by fever. This may not be the proportion in the present study, but the association was valid in all clinical presen- tations. Previously reported that retropha- ryngeal infection and peritonsillar abscesses are frequently diagnosed in children and the young.23,24 Due to potentially life-threaten- ing complications, hospitalization is advised for patients at a severe stage. The duration of treatment should be individual- ized depending on the clinical response, like pus deposition, biofilm formation, or mold formation. Empirical broad-spectrum antibiotic treatment should be started imme- diately to prevent the infection, and micro- bial diagnosis takes 24 to 72 hours, depend- ing on the availability of the nearest labora- tories. Still, some cases might not respond as they would be at their moderate to severe stage of infection and need surgical drainage. It was supported by Boscolo- Rizzo et al., 201210 that only 61.9% of their patients responded to intravenous antimi- crobial therapy, and 38.1% were gone for surgical drainage. Here, 59.35% of our reg- istered patients were treated with surgical drainage, which was closely relevant to the previous study. However, 27.50 % were treated with antimicrobial therapy, which needs to be considered as a future problem of the resistance mechanism of intravenous antimicrobials. Following Carbone et al., 2012,25 we found that those cases who underwent surgery had a greater length of hospitaliza- tion than those who did only medical treat- ment. Along with clinico-demographic pro- filing, close follow-up is mandatory as some patients often show recurrence, which would be challenging for recent treatment procedures. In this study, 7.96% of recur- rences occurred, and most of the patients treated with empirical antibiotics were under them, and there was found a signifi- cance (p<0.001) between treatment and recurrence. Multiple infection sites have been pre- viously associated with complicated clinical courses and to stated significant multiple space involvement (p<0.001).7 However, there was no statistically significant associ- ation between gender (p=0.5), local status (p=0.8), and age group (p=0.2) with recur- rence to treatment. But, for those prescribed only antibiotics and those who underwent surgery concerning sites of infection, there was a significant association (p<0.001). Unlike all spaces, brain abscess or infection also is part of HNI,26 but no cases were found in the duration of this study regarding this. The previously reported mortality rate of HNI was 0.3%,10 which was not recorded in our study. According to the present evaluation, the incidence of recurrence was n=86 (7.96%) among 1080 attended cases during the five years of retrospective study, which was undoubtedly an increasing point of recur- rence compared to past studies.27-29 The dis- ease and syndromes associated with the respective infection remain the same with the recurrency and their clinical, pathologic, and microbiologic features.30 In the present study, recurrent patients’ complications were more severe than in their last visit. According to Yu et al., S. aureus has a prominent genetic cause of biofilm forma- tion, contributing to virulence and immune evasion,31 and our study got the highest number of recurrent patients identified with S. aureus (Table 6). Almost all antibiotics and antifungals were resistant to all bacteri- al and fungal isolates. Moreover, S. aureus, with the highest prevalence among recur- rent patients, was 100% oxacillin-resistant, and methicillin/oxacillin-resistant S. aureus is a significant pathogen resulting in hospi- tal-acquired infection.32-35 In this study, the antibiotic susceptibility pattern was ana- lyzed through MIC (minimum inhibitory concentration) of the Vitek 2 system, as MIC can report the breakpoint of antibiotic therapy. However, empirical therapy can only eradicate the infection in the initial stage of colonization with the patient’s immune response. Despite their importance, the early recognition of infection still repre- sents an unmet need in clinical microbiolo- gy. The present study was based entirely on patients’ clinico-demographic profile, and it seems worth underlining that the more severe the complication, the more difficult it may become to treat, but some exception- al cases needed to be considered either for their long-term hospitalization, delay in treatment, or recurrence. Conclusions The present study exhibited that diag- nosing and treating HNI can sometimes be complicated and confusing. Moreover, treating such infections has become an uphill task with the advent of MDR microorganisms. However, successful results can be achieved without significant complications if the infections are diag- Article No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:11527] [page 71] nosed sooner. It is evident from the study that the location and duration of infection vary in different age groups according to their immune response. Minute symptoms like toothache and neck pain admission can be identified as possible predictors of com- plications. There should be a quick attempt at treatment in all age groups who present only fever, or oral or neck mass, even with- out more specific findings. Intravenous antimicrobial treatment is still one of the most helpful treatment procedures. Still, a quick step with microbial identification with their susceptibility pattern towards iso- lated microbes is a better way to combat drug resistance and failure of drug therapy. Epidemiology of HNI by their demographic and clinical history is essential to look for- ward to a bright step of diagnosis and treat- ment, supporting future research to eradi- cate any gap. References 1. Duarte MJ, Ket al Reinshagen K, Knoll RM, Abdullah KG, Welling DB, Jung DH. Otogenic brain abscesses A sys- tematic review. Laryngoscope Investigative Otolaryngol 2018;3:198- 208. 2. Brożek-Mądryz E, Waniewska- Łęczycka M, Robert B, Krzeski A. 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