|Year : 2015 | Volume
| Issue : 2 | Page : 107-110
Clinicomicrobiological evaluation and antibiotic susceptibility in cases of chronic suppurative otitis media
Vijay Kumar Poorey, Pooja Thakur
Department of Otolaryngorhinology and Head and Neck Surgery, Gandhi Medical College, Bhopal, Madhya Pradesh, India
|Date of Web Publication||20-Apr-2015|
Dr. Pooja Thakur
Department of Otolaryngorhinology, B-14, Shalimar Gardens, Kolar Road, Bhopal - 462 042, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Aims: The present study was aimed to identify the bacterial isolates causing chronic suppurative otitis media (CSOM) and to study their antimicrobial susceptibility pattern. Subjects and Methods : Totally, 120 patients of CSOM complaining of ear discharge were included in the study. Aural swabs were taken and sent immediately to the microbiology laboratory and processed. Bacterial isolates were identified using standard methods, and antibiotic susceptibility testing was done. Results: In the present study, from 120 cases of tubo-tympanic type of CSOM, majority that is, 82 (63.56%) were Gram-negative; Pseudomonas sp. 48 (37.21%) were the most common bacteria isolated followed by Staphylococcus aureus 32 (24.81%). Among Pseudomonas aeruginosa, the most common isolated bacteria, meropenem has the highest susceptibility rate (97.91%); among S. aureus, vancomycin has the highest susceptibility rate (100%). Conclusions: Pseudomonas sp. and S. aureus were found to be the common cause of CSOM in the present study. These organisms are found to be less susceptible to the routinely used drugs such as quinolones and aminoglycosides and also the resistance pattern of the micro-organisms usually keeps changing. Hence, judicial use of antibiotics is recommended.
Keywords: Antibiotic susceptibility, Bacteriology, Chronic suppurative otitis media
|How to cite this article:|
Poorey VK, Thakur P. Clinicomicrobiological evaluation and antibiotic susceptibility in cases of chronic suppurative otitis media. Indian J Otol 2015;21:107-10
|How to cite this URL:|
Poorey VK, Thakur P. Clinicomicrobiological evaluation and antibiotic susceptibility in cases of chronic suppurative otitis media. Indian J Otol [serial online] 2015 [cited 2020 Jan 25];21:107-10. Available from: http://www.indianjotol.org/text.asp?2015/21/2/107/155295
| Introduction|| |
Chronic suppurative otitis media (CSOM), a tremendous health predicament since time immemorial is a chronic inflammation of the middle ear cleft which may lead to serious sequelae and complications. ,, Incidence of this disease is higher in developing countries especially among low socioeconomic society because of malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infection. Infection can spread from the middle ear to vital structures leading to complications. ,, Various studies have shown both Gram-positive and negative organisms, responsible for CSOM. ,,,, Indiscriminate use of antibiotics has resulted in the emergence of multiple resistant strains of bacteria and the persistence of low-grade infections. ,, Knowledge of the prevailing flora and their susceptibility to antimicrobials will guide the clinician to prescribe an empirical regimen so that more specific management can be provided. ,,
| Subjects and Methods|| |
The present study is a prospective observation carried out on 120 patients who fulfilled the inclusion criteria that is, only those cases who complained of ear discharge, continuous or intermittent, with a nonintact tympanic membrane for at least 12 weeks and who had not taken any treatment either systemic or local in the form of ear drops for the last 7 days.
A detailed history regarding the age, duration of ear discharge and especially any antibiotic treatment received was taken, and thorough clinical examination was done to rule out acute otitis media and otitis externa. The exclusion criteria also included a patient with attico-antral type of CSOM with attic or posterior marginal perforation, who may commonly have anaerobic bacterial pathogens, as the present study did not use anaerobic culture media.
Aural swabs were taken on the 1 st day of attendance of the patients to ENT-OPD before any local medication using sterile cotton wool swabs and sterile ear speculum especially prepared and autoclaved. Samples collected were inoculated in blood agar and MacCkonkey agar and incubated aerobically overnight, and bacteria isolated. Side by side, an attempt was made to do sensitivity tests, by Kirby-Baeur method for commonly available and used drugs and the results were interpreted as per the Clinical and Laboratory Standards Institute guidelines (2013). 
| Results|| |
In the present study, from 120 cases of tubo-tympanic type of CSOM, 7 being bilateral CSOM, 127 ear swabs were collected and sent for evaluation. Of the 127 ear swabs, 11 (8.66%) were sterile, and 116 (91.34%) yielded microbial growth. Among the 116 culture positive samples, a total of 129 bacteria were cultured as 104 samples (81.89%) were monomicrobial, and 12 (09.45%) were polymicrobial [Table 1].
Of 12 polymicrobial growth, 11 cultures revealed combination of two bacteria and 1 culture possessed three bacteria. The most common combination being that of Klebsiella with Pseudomonas species in 7 (58.34%) cultures. Of 129 isolates, majority that is, 82 (63.56%) were Gram-negative, and 47 (36.44%) were Gram-positive. Of 129 isolates, Pseudomonas sp. 48 (37.21%) were the commonest bacteria isolated followed by Staphylococcus aureus 32 (24.81%), Klebsiella 20 (15.50%), coagulase-negative Staphylococcus (CONS) 12 (09.30%), Escherichia coli 09 (06.98%), Proteus sp. 05 (03.87%) and Streptococcus sp. 03 (02.33%) [Table 2] and [Table 3]. Among 120 cases, majority that is, 63 cases (52.5%) were in the age group of 16-30 years followed by 24 cases (20%) in age group of 31-45 years, 20 cases (16.66%) in the group of 46-60 years and 13 cases (10.84%) under the age of 15 years. Among the cases, 68 (56.66%) were males and 52 (43.34%) were females with male to female ratio being 1.3:1. The antibiotic sensitivity pattern (those tested at our centre) of the Gram-negative and positive organisms isolated is tabulated in [Table 2] and [Table 3] respectively. Among Pseudomonas aeruginosa, meropenem has the highest susceptibility rate (97.91%) followed by cefoperazone-sulbactam (93.75%), cefpirome (91.67%), piperacillin-tazobactam (83.34%) gentamycin (79.17%), aztreonam (75%), and amikacin (66.67%). Among S. aureus, vancomycin has the highest susceptibility rate (100%), followed by linezolid and teicoplanin (93.75% both), cefachlor (90.62%) moxifloxacin and roxithromycin (87.50% both) and clindamycin and ampicillin-sulbactam (84.37% both).
|Table 2: Gram - negative bacteria isolated and their antibiotic sensitivity|
Click here to view
|Table 3: Gram - positive bacteria isolated and their antibiotic sensitivity|
Click here to view
| Discussion|| |
Chronic suppurative otitis media is defined as infection of the middle ear cleft that lasts for >3 months and is accompanied by otorrhea and tympanic membrane perforation. ,, It is a massive health problem, and India is one of the countries with highest CSOM prevalence (>4%) where urgent attention is needed (WHO-2004).  Hence, the present study reevaluated the incidence of bacteriology implicated in CSOM with the current antibiotic susceptibility pattern in our setup.
In the present study, among the cases, ear swab of 8.66% cases were sterile, and 91.34% yielded microbial growth. This is in comparison with the results found by Vijaya and Nagarathnamma (5.28%), and Chakraborty et al. (12.6%). , Effectiveness of prior empirical antibiotic therapy, poor techniques of obtaining the ear swabs and sending swabs for cultures when the diagnosis is uncertain may account for this finding.  The most prevalent organism was a Gram-negative organism, Pseudomonas being the majority (37.21%) followed by Staphylococcus (24.81%), Klebsiella, CONS, E. coli. This can be explained by Pseudomonas being an opportunistic extracellular pathogen which thrives in the warm damp external auditory meatus of CSOM patients.  Similar conclusion was drawn by Deb and Ray, Dayasena et al., Sanjana et al, Shyamala and Reddy, Malkappa et al., Indudharan et al., and Sharma et al., who found Pseudomonas as the most common organism in CSOM. ,,,,,, This contrasts with the study by Singh, Prakash et al., Agrawal et al., Prakash and Lakshmi, Ahmed et al., Taneja et al., who found Staphylococcus as the most common isolate. ,,,,, Comparison with the recent studies is tabulated in [Table 4].
Coliforms including Klebsiella pneumoniae and E. coli were isolated from 15.50% to 06.98% cases, respectively, and these findings were tandem to the reports by Mansoor et al. and Loy et al., who reported the same to be 8% and 4%; , whereas Poorey and Lyer and Dayasena et al. reported a higher incidence of Klebsiella. , Shyamala and Reddy reported E. coli in 12% and Klebsiella in 5% of cases.  More frequent isolation of fecal bacteria like E. coli, Klebsiella and water bacteria like Pseudomonas indicates that individuals are at high-risk of infection due to poor hygiene conditions. , In the present study, highest susceptibility of Pseudomonas was for meropenem, cefoperazone-sulbactam, cefpirome, and piperacillin-tazobactam combinations. Staphylococcus was sensitive to vancomycin, teicoplanin, and linezolid. Increasing resistance was reported for the older antibiotics like quinolones and aminoglycosides. Indudharan et al., found that sensitivity to ceftazidime was 100%.  Yang et al., found Pseudomonas to be the most common organism in CSOM and its maximum sensitivity to ciprofloxacin.  Sharma et al., and Rao and Reddy found that all the isolated organisms were sensitive to ciprofloxacin and ofloxacin while most isolates were resistant to amoxicillin. , Kuchhal found Staphylococcus and Pseudomonas to be sensitive to ceftazidime and amoxicillin-clavulanic acid combination.  The male to female ratio was found to be 1.3:1. Cases of CSOM were more common in males (68) than in females (52). This observation was parallel with few authors ,,, and in contrast with other researcher. ,
The most commonly affected age group were of 16-30 years (52.5%) which is in accordance with the study by Ahmed et al., with the most commonly affected age group being 15-25 years (33%). 
There was no statistically significant sex or age predilection for a sample to become culture positive in the present study.
| Conclusion|| |
Pseudomonas sp. and S. aureus were found to be the common cause of CSOM in the present study. These organisms are found to be less susceptible to the routinely used drugs such as quinolones and aminoglycosides and also the resistance pattern of the micro-organisms usually keeps changing. Hence, judicial use of antibiotics is recommended.
Chronic suppurative otitis media like other chronic disease can limit an individual's employability and quality-of-life. Experts declare that when prevalence of CSOM is >3% it must be targeted as a high-priority disease.  In many developing countries, including India, prioritizing health-care need is a difficult task. Identification of the etiological organisms not only aids in the diagnosis and improves the management of patients, but also assists in advising the patients about the modes of spread, methods of prevention, and anticipating the possible complications. Furthermore, as certain etiological agents are more common in healthcare settings, the healthcare institutions can be directed regarding appropriate hygiene and sterility practice when relevant. , With the development and widespread use of antibiotics, the types of pathogenic micro-organisms and their resistance to antibiotics have changed. Continuous and periodic evaluation of the microbiological pattern and antibiotic sensitivity of isolates is necessary to decrease the potential risk of complications by early institution of appropriate treatment.  The authors believe that the present study may contribute to an effective management of CSOM.
| References|| |
Prayaga N, Srinivas M, Jadi L, Sudhakar K, Anil N. Clinical application of a microbiological study on chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg 2013;2:290-4.
Malkappa S, Saileela K, Rajendra B, Chakraverti T. Study of aerobic bacterial isolates and their antibiotic susceptibility pattern in chronic suppurative otitis media. Indian J Otol 2012;18:136-9.
Prakash R, Juyal D, Negi V, Pal S, Adekhandi S, Sharma M, et al.
Microbiology of chronic suppurative otitis media in a tertiary care setup of uttarakhand state, India. N Am J Med Sci 2013;5:282-7.
Rout MR, Mohanty D, Vijaylaxmi Y, Kamalesh B, Chakradhar M. Prevalence of cholesteatoma in chronic suppurative otitis media with central perforation. Indian J Otol 2012;18:7-10.
Morris PS, Leach AJ. Prevention and management of chronic suppurative otitis media in aboriginal children: A practical approach. Community Ear Hear Health 2007;4:22-5.
Taneja M, Taneja MK. CSOM - A bacteriological study. Indian J Otol 2009;15:3-7.
Prakash M, Lakshmi K, Anuradha S, Swathi GN. Bacteriological profile and their antibiotic susceptibility pattern of cases of CSOM. Asian J Pharm Clin Res 2013;6:210-2.
Poorey VK, Lyer A. Study of bacterial flora in CSOM and its clinical significance. Indian J Otolaryngol Head Neck Surg 2002;54:91-5.
Shyamala R, Reddy PS. The study of bacteriological agents of chronic suppurative otitis media: Aerobic culture and evaluation. J Microbiol Biotech Res 2012;2:152-62.
Wintermeyer SM, Nahata MC. Chronic suppurative otitis media. Ann Pharmacother 1994;28:1089-99.
Clinical and Laboratory Standard Institute Guidelines; 2013. clsi.org.
Afolabi OA, Salaudeen AG, Ologe FE, Nwabuisi C, Nwawolo CC. Pattern of bacterial isolates in the middle ear discharge of patients with chronic suppurative otitis media in a tertiary hospital in North central Nigeria. Afr Health Sci 2012;12:362-7.
Agrawal A, Dharmendra K, Ankur G, Sapna G, Namrata S, Gaurav K. Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear discharge. Indian J Otol 2013;19:1.
Rao BN, Reddy MS. Chronic suppurative otitis media - A prospective study. Indian J Otolaryngol Head Neck Surg 1994;3:72-7.
Acuin J. Global burden of disease due to chronic suppurative otitis media. Geneva: World Health Organisation; 2004.
Vijaya D, Nagarathnamma T. Microbiological study of chronic suppurative otitis media. Indian J Otol 1998;4:172-4.
Chakraborty A, Bhattacharjee A, Purkayastha P. Microbiological profile of chronic suppurative otitis media: Its significance in North-East India. Indian J Otol 2005;11:39-44.
Dayasena RP, Dayasiri MB, Jayasuriya C, Perera DS. Aetiological agents in chronic suppurative otitis media in Sri Lanka. Aust Med J 2011;4:101-4.
Deb T, Ray D. A study of the bacteriological profile of chronic suppurative otitis media in agartala. Indian J Otolaryngol Head Neck Surg 2012;64:326-9.
Sanjana RK, Singh YI, Reddy NS. Aerobic bacteriology of chronic suppurative otitis media in a tertiary care hospital: A retrospective study. J Coll Med Sci Nepal 2011;7:1-8.
Indudharan R, Haq JA, Aiyar S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Ann Otol Rhinol Laryngol 1999;108:440-5.
Sharma S, Rehan HS, Goyal A, Jha AK, Upadhyaya S, Mishra SC. Bacteriological profile in chronic suppurative otitis media in Eastern Nepal. Trop Doct 2004;34:102-4.
Singh AH, Basu R, Venkatesh A. Aerobic bacteriology of chronic suppurative otitis media in Rajahmundry, Andhra Pradesh, India. Biol Med 2012;4:73-9.
Ahmed B, Hydri AS, Ejaz A, Farooq S, Zaidi SK, Afridi AA. Microbiology of ear discharge in Quetta. J Coll Physicians Surg Pak 2005;15:583-4.
Mansoor T, Musani MA, Khalid G, Kamal M. Pseudomonas aeruginosa
in chronic suppurative otitis media: Sensitivity spectrum against various antibiotics in Karachi. J Ayub Med Coll Abbottabad 2009;21:120-3.
Loy AH, Tan AL, Lu PK. Microbiology of chronic suppurative otitis media in Singapore. Singapore Med J 2002;43:296-9.
Yang Y, Gong S, Liu Y. The clinical investigation of bacteriology of chronic suppurative otitis media. Lin Chuang Er Bi Yan Hou Ke Za Zhi 2001;15:550-2.
Kuchhal V. Antibiotic sensitivity pattern in chronic suppurative otitis media in kumoun region. Indian J Otol 2010;16:17-21.
[Table 1], [Table 2], [Table 3], [Table 4]