Head and Neck Infections and Stewardship Practices - A Call for an ENT Surgeon (HEAD-NECK AmSp Model)

Introduction Head and neck infections form a major proportion of outpatient and inpatient visits in otorhinolaryngology. Common entities include tonsillopharyngitis, sinusitis, otitis media, otitis externa, mastoiditis, peritonsillar and parapharyngeal abscesses, deep neck space infections, and post-surgical wound infections.[1] While most upper respiratory tract infections are viral, antibiotic overuse remains pervasive, often driven by patient expectation and diagnostic uncertainty.[2] The head and neck region’s complex microbiome further complicates clinical decision-making, as culture results often reflect commensals rather than true pathogens.[3] Globally, increasing resistance among Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa threatens the effectiveness of standard therapy.[4] Misuse of macrolides, β-lactams, and fluoroquinolones contributes to resistance selection both locally and systemically.[5] In India, the Society of Antimicrobial Stewardship PractIces (SASPI) recently issued 42 IAS (Integrated Antimicrobial Stewardship) practice points providing a comprehensive national framework for rational antibiotic use in tertiary care hospitals.[6] This editorial contextualizes these principles for ENT surgeons, linking clinical stewardship with infection control and diagnostic interpretation to address AMR at its clinical interface; they can practice their own HEAD-NECK AmSp Model. Head and Neck Infections Contributing to AMR Tonsillopharyngitis and upper respiratory infections Most cases are viral, yet antibiotics are frequently prescribed. Streptococcus pyogenes remains the primary bacterial cause, but indiscriminate penicillin or macrolide use has promoted macrolide resistance.[7] Inappropriate empiric uses of cephalosporins and fluoroquinolones further compounds resistance selection in community flora. Otitis media and otitis externa Chronic suppurative otitis media (CSOM) and recurrent otitis externa are persistent AMR challenges. Pseudomonas aeruginosa and Staphylococcus aureus often show resistance to quinolones and aminoglycosides due to prior empirical exposure.[8] In CSOM, topical antibiotics should be guided by culture, and systemic agents restricted to severe or invasive disease.[9] Rhinosinusitis The majority of acute rhinosinusitis cases are viral, yet broad-spectrum antibiotics remain common. Repeated or prolonged courses for presumed bacterial sinusitis have been associated with increased resistance among S. pneumoniae and H. influenzae.[10] Culture-guided therapy and avoidance of unnecessary imaging or prolonged prophylaxis are critical stewardship imperatives. Deep neck space infections These infections are often polymicrobial, involving anaerobes and oral commensals. Delay in surgical drainage or inappropriate broad-spectrum empiric therapy without culture sampling fuels AMR.[11] Source control with targeted therapy remains the stewardship cornerstone. Surgical site infections and postoperative prophylaxis ENT surgical procedures — such as tonsillectomy, mastoidectomy, or endoscopic sinus surgery — are increasingly guided by prophylactic protocols. However, studies show that perioperative antibiotic use often extends beyond 48 hours without added benefit.[12] Prolonged prophylaxis increases resistance and disrupts the nasopharyngeal microbiome. Fungal and opportunistic infections Candida and Aspergillus species may colonize the external ear or paranasal sinuses, particularly after repeated topical antibiotic or steroid exposure. Differentiating colonization from invasive disease requires clinical correlation and histopathology to avoid unnecessary antifungal therapy.[13] Collectively, these infection patterns illustrate that excessive empiricism, extended prophylaxis, and misinterpretation of colonizers as pathogens create an accelerating cycle of antimicrobial resistance across ENT practice. Stewardship: ENT Surgeons as Problem Solvers Diagnostic stewardship: ENT surgeons must ensure microbiological sampling is appropriate, timely, and clinically relevant. Swabs from superficial or non-sterile sites (ear canal, nasal cavity, throat) often yield commensals such as Corynebacterium spp., Staphylococcus epidermidis, or Candida albicans that do not require treatment.[3,14] As emphasized by Panda et al, distinguishing pathogen vs. non-pathogen is fundamental for rational therapy interpretation.[3] Clinical correlation, host immune status, inflammatory markers, and sterile-site sampling should guide the classification. Laboratories should be encouraged to comment on likely colonizers versus pathogens in culture reports. This interpretative stewardship prevents reflexive antimicrobial initiation and preserves normal commensal balance. Therapeutic Stewardship: Empiric antibiotic selection should follow local antibiograms and clinical diagnosis rather than culture growth from colonized sites. De-escalation to narrow-spectrum agents based on clinical response and culture confirmation should be routine. Prolonged or combination therapy without indication must be avoided. Regular audits of prophylactic duration and topical antibiotic use help maintain rationality. Surgical and preventive stewardship: Surgical source control remains vital—timely drainage of abscesses, removal of necrotic tissue, and postoperative asepsis can prevent prolonged therapy. Perioperative prophylaxis should not exceed 24–48 hours.[12] Nasal and ear dressing care protocols, sterile suction techniques, and environment hygiene in operating theatres and wards are essential. Vaccination for influenza and pneumococcus in high-risk populations can reduce ENT infection burden.[10] Organizational stewardship: Embedding ENT representation in hospital AMS committees, auditing antimicrobial consumption, and training residents in microbiology interpretation foster sustainable change. Pharmacist involvement in reviewing ENT antibiotic prescriptions in wards or outpatient settings enhances compliance with SASPI principles. Saspi Practice Points for ENT Surgeons SASPI’s 42 integrated practice points offer an actionable framework that can be adapted for otolaryngology practice.[6] Key adaptations include: Antimicrobial stewardship: Formulate local empiric and definitive therapy guidelines for sinusitis, otitis, and post-surgical infections using antibiogram data. Restrict fluoroquinolone and third-generation cephalosporin use, and review all courses >7 days. Diagnostic stewardship: Mandate proper sample collection—deep aspirates or sterile fluids over swabs. Promote use of Gram stain and targeted cultures. Ensure differentiation between colonizers and pathogens through clinician-laboratory communication. Infection prevention stewardship: Standardize perioperative prophylaxis for clean-contaminated ENT procedures, limit duration to ≤48 h, and monitor adherence. Implement surgical bundle care including hand hygiene, sterilization protocols, and environmental cleaning. Administrative stewardship: Appoint AMS champions within ENT units to track culture-positive results, antibiotic duration, and outcomes. Conduct multidisciplinary review meetings to evaluate prescribing trends. Educational stewardship: Educate clinicians and patients regarding rational antibiotic use, the benign nature of many viral infections, and the risks of overuse. Implementation of these SASPI-aligned interventions within ENT departments can substantially reduce antibiotic misuse and sustain microbial sensitivity patterns. Conclusion Head and neck infections present unique stewardship challenges because they arise in microbiota-rich, colonizer-dense environments. The temptation to treat all positive cultures risks perpetuating AMR and microbiome disruption. ENT surgeons occupy a pivotal position at the clinical–microbial interface, capable of leading diagnostic and therapeutic stewardship. By integrating SASPI practice points into routine decision-making, ENT departments/clinician can implement structured antimicrobial audits, ensure culture-guided therapy, restrict prophylaxis duration, and prioritize pathogen–non-pathogen distinction [HEAD-NECK AmSp Model, Box 1]. Institutional AMS teams must embed ENT specialists in policy design, ensuring interventions align with real-world surgical and outpatient contexts. Ultimately, stewardship in head and neck infections is not merely a regulatory exercise; it is a clinical responsibility to balance infection control, patient outcomes, and antimicrobial sustainability for future generations.Box 1: The 10 core elements of the IAS framework — the “HEAD-NECK AmSp Model”Authors’ contributions PKP, and SP designed, wrote, reviewed, and approved the manuscript. Data availability Everything is provided in the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.