Chronic suppurative otitis media (CSOM) is a chronic infection of the middle ear in which the tympanic membrane is ruptured, resulting in purulent ear discharge lasting more than two weeks. It is a serious public health concern, especially for children, and its effects are more noticeable in areas with limited resources.1-2 In order to avoid long-term problems, early diagnosis and timely intervention are crucial since improper management of CSOM might result in irreversible hearing loss.3 Tympanic membrane perforation, ossicular disruption, & conductive hearing loss are caused by persistent infection in CSOM, with inflammation resulting in sensor neural damage.4-5 The multifaceted interactions among microbial infections, antibiotic resistance, and biofilm development in the middle ear further complicate its therapy. Both Gram-positive and Gram-negative bacteria are involved in CSOM, with Pseudomonas aeruginosa & Staphylococcus aureus identified as the primary pathogens. While Klebsiell, Proteus & Escherichia coli are less commonly linked with CSOM, the presence of anaerobic bacteria is uncommon. Furthermore, fungal infections in instances with CSOM are relatively rare and can exacerbate the clinical presentation.6-7 Notably, the microbial makeup & antibiotic susceptibility patterns in CSOM differ by area and evolve over time, with rising resistance rates documented, particularly in developing nations. The increasing incidence of antimicrobial-resistant varieties of P. aeruginosa & S. aureus poses considerable hurdles to efficient treatment. The advent of antibiotic resistance among infections caused by bacteria linked with CSOM complicates treatment problems and raises healthcare expenses.8-9 Biofilms containing antibiotic-resistant bacteria can shield vulnerable strains, allowing them to endure antibiotic therapy.10   This underscores the critical need for novel diagnostic and therapeutic approaches to managing infections associated with biofilm in CSOM. Early diagnosis of biofilm development can greatly enhance treatment results.11-12. The present study was carried out to find out the Prevalence and antibiotic resistance patterns of pathogens causing chronic suppurative otitis media (CSOM) in pediatric patients.

The present cross-sectional was carried out at the department of ENT and head and neck department, Bolan Medical College Quetta from August 2025 to January 2026 after taking approval from the ethical committee of the hospital. A total of 150 children of both gender and different age groups (ranged 1-2 years) diagnosed with CSOM were enrolled. Children with acute otitis media, cholesteatoma and those who used antibiotics before sample collection were excluded from the study. Pus samples were collected from both ears using an aseptic swab for microscopic assessment & bacterial culture. The external ear canal was washed with an alcohol swab, & a cotton tip swab was gently placed into the external auditory canal with a specula to prevent contact with the skin around it. The stick was then inserted in the tube, & the cap was placed. Each sample was prepared by creating a homogenous, thin smear and air-drying it. Gram staining was done to examine bacteria's morphology and organization under a microscope. The samples were placed in several media, including nutrient agar, blood agar, and MacConkey's agar and maintained aerobically at 37°C for 18-24 hours. Using biochemical tests (TSI, citrate and urease) and colony morphology bacteria were identified. A modified Kirby Bauer disk diffusion technique was used for antibiogram, accordance with CLSI 2024 recommendations. We generated a colony suspension for each isolate using distilled water or a swab stick, then inoculated it into Mueller-Hinton agar. We used commercially manufactured antibiotic disks and incubated them in media for 24 hours at 37 degrees Celsius. Based on the CLSI standards the bacteria were classified as sensitive or resistant. Clinical and demographic features from each the participants were collected using a well-structured proforma. The study participants were followed up at one-month intervals to assess their progress and compliance with antibiotics. For data analysis SPSS version 16 was used and GraphPad Prism was used for making figures. Quantitative variables were expressed as frequencies and percentages.

A total of 150 children with CSOM were enrolled in this study out of which 82(54.6%) were male and 68(45.4%) were female. The predominant age was 5-8 years 62(41.35%).  All the participants had ear discharge (100%) and 101(67%) of the patients had hearing issue. The demographic features of the study population is shown in table 1. Overall growth was seen in 128 samples (85.3%), with 125 (97%) being monomicrobial and only 3(2.3%) had poly microbial growth. The most prevalent bacteria isolated was P. aeruginosa (38%) followed by S.aureus (25%), Proteus spp(14%), CON Staphylococcus (8.5%), Providencia spp (3.7%). Citrobacter spp (3.7%). Enterobacter spp(2.2%) and E.coli(1.4%) respectively as presented in figure 1.Antibiotic susceptibility evaluated that  P. aeruginosa was highly resistant  Co-amoxicalve , Ceftriaxone and Ciprofloxacin respectively and was sensitive to cefoperazone/sulbactam, Piperacillin/tazobactam Meropenem and Imipenem. Similarly S.aureus was resistant to Amikacin, Ciprofloxacin, Ceftriaxone, Co-amoxicalve and ampicillin and was sensitive to linzolied, Imipenem, cefoperazone/sulbactam and Piperacillin/tazobactam. Proteus spp species were resistant to Ciprofloxacin and intermediate resistant to Ceftazidime but sensitive to all the remaining antibiotics used as shown in Table 2.

CSOM is a frequent pediatric condition, especially in underdeveloped nations. The infection causes persistent inflammation of the middle ear & mastoid cavity, including tympanic membrane perforation. It is most common in the first 6 years of life and causes a large illness burden worldwide, affecting 65-330 million individuals and resulting in 28 000 deaths each year.13-14 It affects hearing and can have serious consequences if not treated promptly. Antimicrobial agents have significantly decreased the number of problems. An excessive intake of antibiotics can create resistant organisms.15 Controlling CSOM is challenging due to its recurrence and the emergence of resistant pathogens. Understanding the common causal organisms is crucial for effective treatment of this illness. The microbial studies performed on CSOM have identified common bacteria such as E. coli, P. aeruginosa, S. aureus, Proteus spp., and Klebsiella spp. MRSA has also been isolated in rare cases. The bacteria related with CSOM vary based on geography and other variables.16 It is vital to understand the primary bacterial causes of CSOM and their antibiotic resistance patterns, both for selecting the most effective treatment regimen and preventing the formation of resistant strains. The present study was carried out to find out the Prevalence and antibiotic resistance patterns of pathogens causing chronic suppurative otitis media (CSOM) in pediatric patients. A total of 150 children with CSOM were enrolled in this study. The predominant age was 5-8 years 62(41.35%). These findings are similar to the study conducted by Nazir A, Kadri, they reported that CSOM is most prevalent in the first 6 years of age.14 In our study 85.3% of samples revealed growth. Of which 97% was monomicrobial and only 2.3% had poly microbial growth. Our research findings are similar to the study completed by Taha et al 17 Our results are not comparable to the study conducted by Mofatteh et al.18 They found bacterial growth in 97.3% of CSOM patients. These differences is due the changed in sample type, they enrolled individuals of different ages (ranged 4-86 years) and we studied children (up to 12 years) in our research. The most prevalent bacteria isolated in our study was P. aeruginosa followed by S.aureus, Proteus spp, CON Staphylococcus, Providencia spp Citrobacter spp (3.7%), Enterobacter spp, and E.coli respectively.our study results are comparable to the study of Taha et al.17 In their study P. aeruginosa was the most common Gram-negative bacteria, whereas Staph. aurous was the dominant Gram-positive pathogen. Our study findings are also similar to the study of Mofatteh et al.18 in which Pseudomonas aeruginosa was the commonest bacteria isolated, followed by S. aureus and Proteus species which further support our findings. Antibiotic susceptibility evaluated that P. aeruginosa was highly resistant Co-amoxicalve, Ceftriaxone and Ciprofloxacin respectively and was sensitive to cefoperazone/sulbactam, Piperacillin/tazobactam Meropenem and Imipenem. Similarly S.aureus was resistant to Amikacin, Ciprofloxacin, Ceftriaxone, Co-amoxicalve and ampicillin and was sensitive to linzolied, Imipenem, cefoperazone/sulbactam and Piperacillin/tazobactam. Proteus spp species were resistant to Ciprofloxacin and intermediate resistant to Ceftazidime but sensitive to all the remaining antibiotics. Similar pattern of antibiotic susceptibility was reported by Khan et al.19 Our findings are consistent with a comprehensive review and meta-analysis that found considerable resistance to Ampicillin, Amoxicillin/Clavulanate, Cotrimoxazole, Amoxicillin, and Cefuroxime.20 Antimicrobial resistance profiles of bacteria causing CSOM vary among studies and may be influenced by location, local prescription patterns, and the presence of resistant strains. The proliferation of multidrug resistant microorganisms are raising serious concerns. The prevalence of antibiotic resistance across different classes highlights the need for immediate action. Research suggests that patients who participate in rehabilitation programs experience better health outcomes, indicating the importance of continued assistance. Some patients may have difficulties to adherence, such as socioeconomic status or lack of support, hindering appropriate follow-up and management of CSOM. This study highlights the need for prudent antibiotic administration based on culture findings and compliance with patients to enhance outcomes for CSOM. In Pakistan, unethical antibiotic prescriptions for minor diseases, unrestricted over-the-counter availability, and limited access to bacterial culture facilities all contribute to the development of antimicrobial resistance (AMR). Developing awareness about the graveness of AMR through focused educational programs is vital for effectively combating the epidemic. Implementing antibiotic stewardship programs (ASPs) at tertiary care institutions is crucial for improving antimicrobial prescription practices in both inpatient and outpatient environments. These activities are crucial to maintain the efficacy of antibiotics in managing CSOM and limit the spread of resistance.

The study concluded that both Gram-negative and Gram-positive are involved to cause CSOM in children Pseudomonas aeruginosa & Staphylococcus aureus identified as the primary pathogens. The increasing incidence of antimicrobial-resistant strain   of these bacteria poses considerable hurdles to efficient treatment.