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ORIGINAL ARTICLE
Year : 2017  |  Volume : 23  |  Issue : 4  |  Page : 252-255

Bacteriology and drug susceptibility in chronic suppurative otitis media in Ear, Nose, and Throat outpatient and inpatient department of tertiary care Hospital, Bhavnagar


Department of ENT, Government Medical College, Bhavnagar, Gujarat, India

Date of Web Publication2-May-2018

Correspondence Address:
Dr. Vikas Sinha
Department of ENT, Government Medical College, Sir T. Hospital Campus, Bhavnagar - 364 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_132_16

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  Abstract 


Background: The diagnosis of Chronic Suppurative otitis media (CSOM) implies a permanent abnormality of the pars tensa or flaccida, most likely a result of earlier acute otitis media or negative middle ear pressure. Changes in the microbiological flora following the advent of sophisticated synthetic antibiotics increase the relevance of antibiotic sensitivity to plan a general outline of treatment for a patient with a chronically discharging ear. Aim: To evaluate the bacteriological causes of CSOM. To know their antibiotic sensitivity pattern to commonly used antibiotics. Study Design: Prospective Observational Study. Materials and Methods: Sixty patients of Suppurative otitis media both unilateral and bilateral who present with active purulent discharge for to Ear, Nose and Throat (ENT) Department will be prospectively studied. Patients were of all age group, both sexes and had symptoms of active ear discharge for more than 6 weeks. Patients suffering from SOM who are on systemic antibiotics and on topical medications to the ear were not included in the study. Results: Of the 60 patients 64% were males with maximum incidence in 26-50 y age group.55% of patients were from lower Socio Economic Status.Of the organisms isolated Staph. Aureus(35%) was most predominant followed by Pseudomonas(31%).All gram positive organisms were susceptible to Co-trimoxazole, Vancomycin , Gentamycin and all Gram negative to Meropenam, Aztreonam, Piperacillin. Conclusion: The patients should also be advised to take the drugs for the complete prescribed duration. This will not only help in minimizing the complications, but also help in preventing the emergence of resistant strains.

Keywords: Antibiotic sensitivity, CSOM, resistant strains


How to cite this article:
Samanth T U, Jha SG, Sinha V, Dadhich S. Bacteriology and drug susceptibility in chronic suppurative otitis media in Ear, Nose, and Throat outpatient and inpatient department of tertiary care Hospital, Bhavnagar. Indian J Otol 2017;23:252-5

How to cite this URL:
Samanth T U, Jha SG, Sinha V, Dadhich S. Bacteriology and drug susceptibility in chronic suppurative otitis media in Ear, Nose, and Throat outpatient and inpatient department of tertiary care Hospital, Bhavnagar. Indian J Otol [serial online] 2017 [cited 2019 Sep 21];23:252-5. Available from: http://www.indianjotol.org/text.asp?2017/23/4/252/231640




  Introduction Top


The diagnosis of chronic suppurative otitis media (CSOM) implies a permanent abnormality of the pars tensa or flaccida, most likely a result of earlier acute otitis media, negative middle ear pressure, or otitis media with effusion.[1] Chronic otitis media (COM) equates with the classic term chronic “suppurative” otitis media that is no longer advocated as COM is not necessarily a result of “the gathering of pus.” The prevalence amounts to about 72/1000 people.[2] The disease usually occurs after upper respiratory viral infections followed by invasion of pyogenic organisms.[2] Many studies have showed that the common organisms isolated from cases of CSOM are found to be Pseudomonas spp, Staphylococcus aureus, Klebsiella pneumoniae, and Proteus spp. It is calculated that about 13.8%–36.2% of the people have hearing impairment due to CSOM.[3] The classic type of hearing loss described for this condition is conductive. However, several investigators have reported sensorineural hearing loss do occur concomitantly or as sequelae of CSOM.[4]

The widespread use of antibiotics has precipitated the emergence of multiple resistant strains of bacteria which can produce both primary and postoperative infections. The indiscriminate, haphazard, and half-hearted use of antibiotics and poor follow-up of patients have resulted in persistence of low-grade infections. Changes in the microbiological flora following the advent of sophisticated synthetic antibiotics increase the relevance of reappraisal of modern-day flora in CSOM, and their in vitro antibiotic sensitivity pattern is very important for the clinician to plan a general outline of treatment for a patient with a chronically discharging ear.

Aims and objectives

To evaluate the bacteriological causes of SOM. To know their antibiotic sensitivity pattern to commonly used antibiotics. To provide a guideline for making a protocol for empirical antibiotic therapy where culture facilities are not available. To know the distribution of SOM cases with respect to age, sex, and socioeconomic status.

Review of literature

In general, patients with tympanic membrane perforations which continue to discharge mucoid material for periods from 6 weeks to 3 months, despite medical treatment, are recognized as CSOM cases.[4] The WHO definition requires only 2 weeks of otorrhea,[5] but otolaryngologists tend to adopt a longer duration, for example, more than 3 months of active disease.[6] CSOM is a global problem and affects all ages but especially prevalent in children younger than 7 years due to horizontal, wider, and short  Eustachian tube More Details.[7] The disease is prevalent in developing countries and is a disease of the poverty.[8] The most probable risk factors included are untreated sore throat, low socioeconomic status, age, poor hygiene, upper respiratory tract infection, immunocompromised, environmental factors, nutritional factors, and facial anomalies.[7],[9] India belongs to high prevalence rate group of CSOM.[10] In CSOM, the most frequently isolated bacteria are Pseudomonas aeruginosa, S. aureus, Proteus spp,  Escherichia More Details coli, and Klebsiella spp. It may often be accompanied by complications including septicemia, meningitis, brain abscess, facial paralysis, and mental retardation and it is believed to be responsible for more than two-thirds of deafness in children.[11]

Divya Vaishnavi (2015) studied one hundred clinically diagnosed cases of CSOM admitted in Ear, Nose, and Throat (ENT) wards in Kamineni Institute of Medical Sciences, Nalgonda, with chronic ear discharge with no prior antibiotic consumption were considered, whose ear swabs were collected and cultured for bacteria. Standard methods of isolation and identification were done followed by antibiotic susceptibility testing by Kirby-Bauer disc diffusion method. S. aureus was the most dominant including isolates of Methicillin-resistant S. aureus, followed by P. aeruginosa. Antibiotic sensitivity pattern shows ciprofloxacin to be the most effective drug, followed by gentamicin and amikacin.

Asima Banu (2016) studied 50 patients of CSOM with cholesteatoma in BMCRI, Bangalore. In this study, 40 (80%) out of 50 of the cultures were positive, of which 32 (64%) were aerobes, 7 (14%) were anaerobes, and 1 (2%) was fungus. The predominant aerobic bacteria was S. aureus.[12]


  Materials and Methods Top


This study was carried out in the Department of ENT, Government Medical College and Sir T. Hospital, Bhavnagar. Sixty patients of SOM both unilateral and bilateral who present with active purulent discharge for to ENT Department will be prospectively studied. Patients were of all age group, both sexes, and had symptoms of active ear discharge for more than 6 weeks. Patients suffering from SOM who are on systemic antibiotics and on topical medications to the ear were not included in the study. The ear discharge is collected using sterile cotton wool swabs under aseptic precautions with the aid of an aural speculum, before instillation of any topical medication. Swabs are then transported to the laboratory.

Gram's stain: The first swab is used to make a smear on a glass slide for direct smear examination by Gram's stain. Aerobic culture: The second swab will be processed for the isolation of aerobic bacteria. The swab on reaching laboratory will be inoculated on the following culture media: MacConkey agar and Blood agar. Antibiotic sensitivity testing is performed by Kirby-Bauer disc diffusion method according to CLSI guidelines.

Observation

The number of males was more than number of females. There were 38 (63%) males and 22 (37%) females in the study. Age range of the patient studied was 1–100 years, with maximum number of patients – 32 (52.3%) – were in 18–30 years age group. The various clinical symptoms in SOM patients are pain (95%), purulent ear discharge (90%), itching (35%), hearing loss (25%), bloody ear discharge (10%), and dizziness (5%). The patients of different socioeconomic status are low (55%), middle (40%), and upper (5%) [Figure 1], [Figure 2], [Figure 3].
Figure 1: Organisms isolated from middle ear infection

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Figure 2: Antibiotic susceptibility pattern in Staphylococcus aureus

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Figure 3: Antibiotic susceptibility pattern in Pseudomonas

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  Results Top


Out of 60 cases studied, unilateral infection was seen in 53 (88.44%) patients and bilateral in 7 (11.66%). Of the cases studied, 38 (63.33%) were males and 22 (36.67%) females. Similarly, higher incidence of CSOM was seen in 26–50 years of age group and it decreases as the age increases. The main clinical symptoms seen in 90%–95% patients were pain and purulent discharge. Other important factors associated were poor hygiene (60%) and URTI (40%). Most of the patients were from lower SES (55%). About 50% patients had left side SOM and 12% had bilateral SOM.

Among the 60 patients, no growth was seen in 5 patients. Of the 60 samples collected, 55 showed microbial growth and 5 (9%) showed no growth. A total of five different microorganisms were isolated in this study, Gram-positive bacteria predominated; S. aureus (35%) being the most predominated one followed by Gram negative and that being Pseudomonas (31%), Klebsiella (17%), E. coli (7%), and Proteus mirabilis (1%). Out of the Gram-positive bacteria isolated, all (100%) were sensitive to cotrimoxazole, vancomycin, gentamycin, and 85%–95% were sensitive to cefotaxime, ciprofloxacin, roxithromycin, and linezolid. Gram-positive bacteria showed resistance against penicillin (100%) and to azithromycin (48%) and erythromycin (38%). Antibiotic susceptibility testing done for Gram-negative bacteria like Pseudomonas showed higher susceptibility toward meropenem (100%), aztreonam (95%), piperacillin (90%), and levofloxacin (79%). Around 50% sensitive to ciprofloxacin, amikacin, gentamycin, cefotaxime, and ceftriaxone. Highly resistant to ampicillin, amoxycillin (95%), and cefixime (100%). Klebsiella was sensitive to ciprofloxacin, meropenem, gentamycin, amikacin, cefotaxime, levofloxacin (80%–100%), and resistant to ampicillin, cefixime (100%), and amoxycillin (70%). E. coli was sensitive to ciprofloxacin, gentamycin, piperacillin, cefotaxime, levofloxacin (75%–100%), and resistant to ampicillin, amoxycillin, and cefixime (100%). Proteus was resistant to ampicillin, ceftazidime, cefixime, and sensitive to all others.

In our study, males were more commonly affected than females and which is in concordance with findings of Ahmed et al.[13] in which males were 57.3% and females were 42.7%.[14],[15] This observation was in contrast with the findings of few authors [12],[16] and in parallel with other researchers.[17] All samples in the present study yielded single type of organism. Kumar et al.[17] and Fatma et al.[18] also reported 93.1 and 94% of monobacterial growth in their studies, respectively, while Vijaya (2000)[19] reported only in 51% of samples. In the present study, bacterial growth rate was lower compared to previously studies done in Ethiopia, the Philippines, Nigeria, Kenya, and India,[20] respectively. The relatively low culture-positive rate in this study could be due to prior use of antibiotics and inability to perform anaerobic culture.


  Conclusion Top


There can be a variation in the organisms infecting and their susceptibility pattern in ear infection. In our study, S. aureus, Pseudomonas, Klebsiella, E. coli, and Proteus were the most frequently isolated organisms in ear infection. For Gram-negative bacteria, levofloxacin, ciprofloxacin, and piperacillin appear to be the first-line antibiotic to treat SOM. Similarly, for Gram-positive bacteria, cotrimoxazole, ciprofloxacin, linezolid, and gentamycin appear to be the first-line antibiotic to treat SOM. The patients should also be advised to take the drugs for the complete prescribed duration. This will not only help in minimizing the complications but also help in preventing the emergence of resistant strains. The antibiotic susceptibility patterns must be continuously and periodically evaluated to decrease the risk of resistant strains. Continuous and periodic evaluation of microbial pattern and antibiotic sensitivity of SOM help to decrease the potential risk of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ahmed A, Usman J, Hashim R. Isolates from chronicsuppurative otitis media and their antimicrobialsensitivity. Pak Armed Forces Med J 1999;49:82-5.  Back to cited text no. 13
    
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  [Figure 1], [Figure 2], [Figure 3]



 

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