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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 19  |  Issue : 1  |  Page : 5-8

Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge


1 Department of Microbiology, S. N. Medical College, Agra, India
2 Department of ENT, S. N. Medical College, Agra, India
3 Technical Officer, S. N. Medical College, Agra, India
4 S. N. Medical College, Agra, India

Date of Web Publication6-Mar-2013

Correspondence Address:
Arti Agrawal
96/A, Sector 13, Avas Vikas Colony, Agra - 282 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.108149

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  Abstract 

Objective: Our aim is to study the microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge in tertiary care teaching centre in Agra region and its application in the empirical treatment of chronic suppurative otitis media (CSOM). Place and Duration : The study was conducted from March 2012 to July 2012 on 125 patients attending the ENT OPD and Microbiology Department having ear inflammation history for more than 3 months. Materials and Methods: Samples were taken from 125 patients (both male and female) in all age groups suffering from CSOM and having ear discharge. Their gram staining, direct microscopy with KOH, culture sensitivity, and biochemical tests were carried out to identify the organisms and to know their sensitivity pattern. Results: It showed the predominance by Staphylococcus species (37.6%), followed by Pseudomonas aeruginosa (32.8%), Klebsiella pneumoniae (4%), and Escherichia coli (3.2%). The susceptibility of Staphylococcus species was high (80-85%) with moxifloxacin, levofloxacin, and doxycycline among the commonly used antibiotics. Sensitivity of Staphylococcus species was low (<50%) with beta-lactam drugs. Pseudomonas aeruginosa was 100% sensitive with colistin, polymyxin B, and carbapenems. It is highly sensitive (80%-90%) to aminoglycosides and piperacillin/tazobactam. Its sensitivity was about 60-70% with the commonly used antibiotics, viz. cephalosporins and fluoroquinolones . Conclusion : The study of microbial pattern and their antibiotic sensitivity determines the prevalent bacterial organisms causing CSOM in local area and to start empirical treatment of otitis media and its complications for successful outcome, thus to prevent the emergence of resistant strains.

Keywords: Chronic suppurative otitis media, Ear discharge, Methicillin-resistant Staphylococcus aureus, Microbiology, Sensitivity


How to cite this article:
Agrawal A, Kumar D, Goyal A, Goyal S, Singh N, Khandelwal G. Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge. Indian J Otol 2013;19:5-8

How to cite this URL:
Agrawal A, Kumar D, Goyal A, Goyal S, Singh N, Khandelwal G. Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge. Indian J Otol [serial online] 2013 [cited 2020 Feb 18];19:5-8. Available from: http://www.indianjotol.org/text.asp?2013/19/1/5/108149


  Introduction Top


Otitis media is an inflammation of the middle ear cleft without reference to etiology or pathogenesis. Sources of infection in otitis media is mainly dependent on the route by which infection reaches the middle ear and the chief route by which this occurs is the  Eustachian tube More Details. [1],[2] The causes of infection in such cases are nasopharyngeal disease and in children this usually means the adenoids. The causative infections may be in the nose, paranasal sinuses, or in the oropharynx. All these conditions are ascending infection of the eustachian tube. [3] According to Senturia, et al., the acute phase of otitis media is considered to be the initial 3 weeks of inflammation, chronic phase 3 months, following the onset of inflammation and sub-acute phase is said to be between 3 weeks and 3 months. [4]

Since the introduction of antibiotics, the complications have become less common. However, due to increased and irrational use of wide-spectrum antibiotics, the resistance in the bacterial isolates has become very common. Therefore, the microbial culture and sensitivity will help in appropriate management of otitis media and its complications and thus preventing the emergence of resistant bacterial strains.


  Materials and Methods Top


After obtaining approval from the ethical committee, the study was carried out on 125 patients attending the ENT OPD and Microbiology Department of a tertiary care teaching centre having ear discharge with signs and symptoms of chronic suppurative otitis media (CSOM). The ear discharge was collected under aseptic precautions with the aid of an aural speculum, prior to the instillation of any topical medication. The first swab was used to make a smear on clean grease-free glass slide for bacterial differentiation by gram stain examination and direct microscopy of specimen in KOH for fungal examination. The second swab was used for the bacterial culture on blood agar and MacConkey's agar which is then incubated for 24 h at 37°C in CO 2 desiccators, and the isolates were identified by using colony morphology and standard biochemical tests. After identifying the isolate, their antibiotic sensitivity test was done on Muller Hilton Agar using Kirby-Bauer method. The plates were read out after overnight incubation, by measuring the zone of inhibition around the antibiotic discs (HiMedia Laboratories Private Ltd., Mumbai, India) as per Clinical Laboratory Research Institute (CLSI) standards.


  Results Top


The tests were performed on a total of 125 patients comprising 67 (53.6%) males and 58 (46.4%) females, out of which 70 (56.0%) were from rural and 55 (44.0%) from urban citation.

The monomicrobial bacterial isolate was seen in 100 (80%) cases. The mixed growth (contamination) was observed in 10 (8%) cases, while among three fungal isolates 2 (1.6%) were Candida species and 1 (0.8%) was Aspergillus spp. The 12 (9.6%) cases were found sterile.

Staphylococcus species was the most predominant organism in 47 (37.6%), followed by Pseudomonas aeruginosa 41 (32.8%), Klebsiella pneumoniae 5 (4%),  Escherichia More Details coli 4 (3.2%), Streptococcus pneumoniae 2 (1.6%), and Proteus mirabilis 1 (0.8%).

Among 47 Staphylococcus spp., 40 (85.1%) Staphylococcus aureus Scientific Name Search  were coagulase positive. Out of 40 coagulase positive, 8 (20%) were MRSA positive. Higher sensitivity (75%-95%) was observed with cefuroxime (76.6%), piperacillin/tazobactam (78.7%), doxycycline (85.1%), amikacin (89.4%), and moxifloxacin (93.6%). It showed 38.3% sensitivity with ampicillin, 55.3% with ciprofloxacin, and 61.7% with macrolides. Levofloxacin (85.1%) was more sensitive than ciprofloxacin. The overall antibiotic sensitivity pattern of Staphylococcus spp. is shown in [Figure 1].
Figure 1: Graphical representation of antibiotic sensitivity/resistance pattern of Staphylococcus aureus

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Pseudomonas aeruginosa was 100% sensitive to colistin, meropenem, imepenem, and polymyxin B. Susceptibility pattern of Pseudomonas aeruginosa showed 63.4% sensitivity with cephalosporins, 87.8% with aminoglycosides, and 61.0%-68.3% with fluoroquinolones. [Figure 2] shows the antibiotic sensitivity pattern for Pseudomonas aeruginosa.
Figure 2: Graphical representation of sensitivity/resistance pattern of Pseudomonas aeruginosa

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The other gram-negative (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis) bacteria were 70%-80% sensitive with cephalosporins, doxycycline, aminoglycosides, and levofloxacin.


  Discussion Top


The most common pathogen isolated around the world in chronic otitis media is Pseudomonas aeruginosa and less commonly Staphylococcus aureus.[5],[6] Occasionally, otitis media may be caused by fungi (Aspergillus or Candida) or by other viral pathogens.

The incidence (62.4%) of otitis media was the highest in 0 to 20 years age group [Table 1] and this finding corresponds with the work published by other authors Shyamala et al.[7] and Gulati et al. [8] The study reveals that the otitis media is more common in male patient, as shown in [Table 2]. Some studies have found males to have a higher and more recurrent episode of otitis media than females, [9] but others have found females preponderance. [10]
Table 1: Age distribution (n=125)

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Table 2: Sex distribution (n=125)

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In 12 cases no bacterial isolates were seen which might be as a result of prior antibiotic use.

The 10 cases were found contaminated which could be due to improper collection of specimen and the organisms of external auditory meatus may be the contaminants. Mixed growth of Staphylococcus species, Enterobacteriaceae, and Pseudomonas species are usually associated with contamination in external meatus.

In our study, the most common organism was Staphylococcus species (37.6%), followed by Pseudomonas aeruginosa (32.8%), Escherichia coli, Klebsiella species, Streptococcus species, and Proteus mirabilis. Similar pattern of organisms were also isolated in various studies by different authors. [11],[12] Shyamala et al.[7] have found that Pseudomonas aeruginosa and Staphylococcus species are the commonest organism isolated from otitis media. In a study by Giebink, [13] 23 bacterial species are isolated from 51 ears of 36 patient with CSOM disorder having Pseudomonas aeruginosa in 67% of cases.

Staphylococcus species were resistant with ampicillin in 61.7% cases in our study. In study at Rawalpindi by Aslam et al.[14] resistance with ampicillin and amoxycillin was found to be 77.2%. Sensitivity with ciprofloxacin was 55.3% in our study. In some of the study, [12],[15],[16] the Staphylococcus species sensitivity with ciprofloxacin was higher (83.0%-95.0%). Vancomycin, linezolid, and teicoplanin were 100% sensitive and also against MRSA positive, thus making these agents as the drug of choice for same.

Pseudomonas aeruginosa showed 58.5% sensitivity with gentamicin, 87.8% with amikacin, 85.4% sensitivity with piperacillin/tazobactam, and 100% sensitivity with imepenem, meropenem, colistin, and polymyxin B in our study. Sensitivity with amikacin (87.8%) was in concordance with study by Madana. [16] Tahir, et al.[15] observed sensitivity of 60% with gentamicin, 70% with amikacin, 95% sensitivity with imepenem, and 100% sensitivity with piperacillin/tazobactam. Mirza, et al.[17] found sensitivity of 45% with getamicin and 48% with amikacin. Sensitivity with quinolones was 61-68% in our study. These observations are in contrast to the other studies showing higher sensitivity of 90-92%. [15],[16] The declining sensitivity trend with quinolones may be due to number of factors including injudicious use, inappropriate doses, and easy accessibility and developing enzymatic resistance of organisms.

In our study Escherichia coli showed 100% sensitivity with carbapenems and amikacin. Resistance with ampicillin and ciprofloxacin was 100% and 75%, respectively.

The sensitivity of Proteus mirabilis was good with ciprofloxacin and gentamicin. Klebsiella pneumoniae showed good sensitivity with amoxyclav, ciprofloxacin, and gentamicin.


  Conclusions Top


Monomicrobial etiology, especially Staphylococcus species and Pseudomonas aeruginosa, was found to be the most common in our study. Staphylococcus species are highly resistant to ampicillin and ciprofloxacin. Pseudomonas aeruginosa is becoming less sensitive against commonly used antimicrobials, viz. ciprofloxacin, ofloxacin, cephalosporins, and gentamicin. Therefore, evaluation of microbiological pattern and their antibiotic sensitivity pattern in local area become helpful in prescribing empirical antibiotics for successful treatment of otitis media and thus minimizing its complications and emergence of resistant strains.

 
  References Top

1.Healy GB, Teele DW. The Microbiology of chronic middle ear effusions in children. Laryngoscope 1977;8:1472.  Back to cited text no. 1
    
2.Daly A. Knowledge and attitude about otitis media risk: implication for prevention. J Paediatrics 1997;100:93-6.  Back to cited text no. 2
    
3.Aroll B. Antibiotics for upper respiratory tract infection. J Resipir Med 2005;99:250-5.  Back to cited text no. 3
    
4.Senturia BH, Bluestone CD, Klein JO, Lim DJ, Paradise JL. Report of the AD HOC committee on definition and classification of otitis media and otitis media with effusion. Ann Otol Rhinol Laryngol Suppl 1980;89:3.  Back to cited text no. 4
    
5.Indudharan R, Haq JA, Aiyar S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Ann Otol Rhinol Laryngol 1999;108:440-5.  Back to cited text no. 5
    
6.Kenna MA, Bluestone CD, Reilly J. Medical management of chronic suppurative otitis media without cholesteatoma in children. Laryngoscope 1986;96:146-51.  Back to cited text no. 6
    
7.Shyamala R, Reddy PS. The study of becteriologigal agents of chronic suppurative otitis media: Aerobic culture and evaluation. J Microbiol biotech Res 2012;2:152-62.  Back to cited text no. 7
    
8.Gulati J, Tondon PL, Singh W, Bias AS. Study of Bacterial Flora in Chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg 1969;21:198.  Back to cited text no. 8
    
9.Teele DW, Klein JO, Rosner B; Greater Boston Otitis Media Study Group. Epidemiology of otitis media during the first seven years of life in children in greater Boston: A prospective, cohort study. J Infect Dis 1989;160:83-94.  Back to cited text no. 9
    
10.Casselbrant ML, Mandel EM, Kurs-Lasky M, Rockette HE, Bluestone CD. Otitis media in a population of black American and white American infants, 0-2 years of age. Int J Pediatr Otorhinolaryngol 1995;33:1-16.  Back to cited text no. 10
    
11.Alo MN, Anyim C, Okonkwo EC, Orji JO. Prevalence, antibiogram of bacterial pathogens associated with otitis media among primary school children in Ebonyi State. IOSR J Pharm Biol Sci 2012;1:17-20.  Back to cited text no. 11
    
12.Nia KM, Sepehri G, Khatmi H, Shakibaie MR. Isolation and antimicrobial susceptibility of bacteria from chronic suppurative otitis media patients in Kerman, Iran. Iran Red Crescent Med J 2011;13:891-4.  Back to cited text no. 12
    
13.Giebink GS. The microbiology of otitis media. Paediatr Infect Dis J 1989;8:S18-20.  Back to cited text no. 13
    
14.Aslam NA, Ahmad Z, Azim R. Microbiology and drug sensitivity pattern of chronic suppurative otitis media. J Coll Physicians Surg Pak 2004;14:459-61.  Back to cited text no. 14
    
15.Tahir M, Jawaid A, Abdullah A, Najam MA. Bacterial culture and sensitivity in active chronic otitis media: 500 cases in combined military hospital Rawalpindi. Pak J Otolaryngol 2012;28:56-8.  Back to cited text no. 15
    
16.Madana J, Yolmo D, Kalaiarasi R, Gopalakrishnan S, Sujata S. Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J Pediatr Otorhinolaryngol 2011;75:1104-8.  Back to cited text no. 16
    
17.Mirza IA, Ali L, Arshad M. Microbiology of chronic suppurative otitis media-experience at Bahawalpur. Pak Armed Forces Med J 2008;58:372-6.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]


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