Severe pediatric head and neck infections, including periorbital cellulitis, otomastoiditis, and retropharyngeal abscesses, increased sevenfold in Sicily following the COVID pandemic.

While public attention to COVID has largely faded, indirect consequences of COVID may emerge as new clinical challenges in pediatric care.

For clinicians, these findings highlight the importance of renewed vigilance regarding the complications of upper respiratory tract infections in children, particularly in the post-pandemic setting.

A Sicilian Hospital Review

Researchers at the Pediatrics unit and Pediatric Emergency Department of Cannizzaro Hospital in Catania, Italy, conducted a retrospective observational study to assess changes in the epidemiology of pediatric head and neck infections.

Two 3-year periods were compared: a pre-pandemic period (2017-2019) and a post-pandemic period (2022-2024), excluding the lockdown years of 2020-2021. Pediatric cases were classified into four diagnostic groups: otomastoiditis, periorbital cellulitis, retropharyngeal abscesses, and other abscesses (including intracranial complications).

For each patient, demographic, microbiological, and clinical data were collected, including bacterial isolation, treatment type, need for surgical intervention, and short-term outcomes.

Among 4834 pediatric hospitalizations over 8 years, 64 were due to septic complications of head and neck infections: eight during the pre-pandemic period and 56 in the post-pandemic period. The incidence increased from 0.32% to 2.42%, reaching a peak of 3.3% in 2024.

Periorbital cellulitis was the most frequent complication, followed by otomastoiditis and retropharyngeal abscesses.

A particularly notable case involved brain abscess in a pediatric patient that required ICU admission, illustrating the potential for rapid clinical deterioration when such infections are not promptly recognized.

The patient was a boy younger than 6 years. Medical records have shown the growth of classic bacterial pathogens, including Streptococcus pyogenes, S pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa, often following an upper respiratory tract infection.

“Although these infections follow their own bacterial epidemiology, independent of viral pathogens, our data revealed a frequent association with either viral co-infections or secondary bacterial infections following viral upper respiratory illnesses,” the authors wrote.

Disease severity was greater in the post-pandemic period, with more hospital admissions, an increased need for surgical intervention, and a longer hospital stay.

Why Now?

Lockdowns, school closures, and widespread mask use during the pandemic have markedly reduced the circulation of common respiratory viruses. Experts said that this led to an “immunity gap” by limiting natural immune exposure and immune training, which has been associated with a rebound increase in respiratory infections in children after the restrictions were lifted. When social interactions resumed, the children were exposed to waves of viral and bacterial infections with more severe clinical manifestations than those previously observed.

“Another key factor identified in our study is the potential impact of increasing antimicrobial resistance. During the COVID pandemic, antibiotic use was at times inappropriate, often being prescribed empirically, frequently without microbiological confirmation,” the authors noted. This trend may have contributed to the selection of multidrug-resistant bacterial strains, thereby reducing the effectiveness of first-line antibiotic therapies for upper respiratory tract infections.

Consequently, the risk for treatment failure may have increased, allowing more rapid progression to severe and complicated infections, such as those observed in this study.

Clinical Implications

The return of septic complications of pediatric head and neck infections indicates that conditions once considered part of the past are no longer rare. Early recognition of warning signs, such as persistent fever, neck stiffness, facial or cervical swelling, or ocular symptoms, is critical.

Delays in diagnosis can lead to neurologic complications and may necessitate surgical drainage. Therefore, active surveillance, timely consultation with ENT or infectious disease specialists, and awareness of evolving epidemiologic trends are essential in routine clinical practice.

This story was translated from Univadis Italy, part of the Medscape Professional Network.