|Year : 2018 | Volume
| Issue : 4 | Page : 214-218
Bacteriology and antibiotic sensitivity of chronic suppurative otitis media in a government hospital
Ashok Sharma, Madhurima Banerjee, Meenakshi Mehra, Pulkit Khandelwal, Vivek Taneja
Department of ENT, Sanjay Gandhi Memorial Hospital, Delhi, India
|Date of Web Publication||15-Mar-2019|
Dr. Madhurima Banerjee
Department of ENT, Sanjay Gandhi Memorial Hospital, Room No. 25, ENT OPD, Mangolpuri, Delhi - 110 083
Source of Support: None, Conflict of Interest: None
Background: Chronic Suppurative Otitis Media (CSOM) is a disease well known for its persistence and recurrence, inspite of giving treatment. The microbiology cultures show the growth of a lot of organisms, frequently multiple and these differ based on patient population, climate, and whether or not antibiotics have been recently used. Objectives: To identify the commonest causative organism of CSOM in a government hospital of northern India and identify the sensitivity to antibiotics so as to achieve early dry ear for surgical intervention. Methodology: This study was done, from March 2018 to September 2018 on 100 patients with complaints of ear discharge. Pus samples were collected from the discharging ears, subjected to culture and sensitivity and the organisms isolated were identified by morphological, cultural and biochemical characteristics. Results: Most common organism causing CSOM in our study Staphylococcus aureus, followed by Pseudomonas aeruginosa. Most patients with Staphylococcus infection were sensitive to Vancomycin followed by Linezolid and Gentamycin whereas patients with Pseudomonas aeruginosa were sensitive to Amikacin and Ciprofloxacin. Conclusion: Early and effective intervention using appropriate topical as well as systemic antibiotics can decrease the chronicity of CSOM and prevent long term complications.
Keywords: Bacteriology, chronic suppurative otitis media, CSOM, culture sensitivity of CSOM
|How to cite this article:|
Sharma A, Banerjee M, Mehra M, Khandelwal P, Taneja V. Bacteriology and antibiotic sensitivity of chronic suppurative otitis media in a government hospital. Indian J Otol 2018;24:214-8
|How to cite this URL:|
Sharma A, Banerjee M, Mehra M, Khandelwal P, Taneja V. Bacteriology and antibiotic sensitivity of chronic suppurative otitis media in a government hospital. Indian J Otol [serial online] 2018 [cited 2019 Mar 21];24:214-8. Available from: http://www.indianjotol.org/text.asp?2018/24/4/214/254224
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a chronic and long-standing infection of the middle ear cleft which presents as a discharging ear and variable degree of hearing loss. CSOM is a disease with a variety of etiology and is well known for its recurrent nature, in spite of giving treatment. A destructive disease with grave and irreversible sequelae, it can lead to serious intra- and/or extracranial complications., It is one of the most common diseases encountered in an ear, nose, and throat (ENT) outpatient department on a daily basis, and hence, in-depth knowledge of every aspect of this disease is of utmost benefit to an ENT surgeon.
While the incidence of complications is low, untreated cases of CSOM can lead to a wide range of problems such as persistent otorrhea, labyrinthitis, mastoiditis, and paralysis of the facial nerve to more serious complications, so the knowledge of the local pattern of infection is essential to enable efficacious treatment of this disorder.
This study was carried out to evaluate the microorganisms involved in causing CSOM along with their antibiotic sensitivity and to provide a guideline for empirical antibiotic therapy.
| Materials and Methods|| |
This was a prospective study done in the ENT department of a government hospital from March 2018 to September 2018 on 100 patients who presented to our outpatient department with complaints of ear discharge. The study was done in accordance with the ethical standards of the responsible committee on human experimentation.
Patients of all ages and either gender suffering from CSOM, as determined by otoscopic examination, who had not received antibiotic therapy (topical or systemic) for previous 10 days, were enrolled through convenience sampling.
The patients with active aural discharge and with a visible tympanic membrane perforation, belonging to different age, sex, religion, and different classes, were included in the study.
The patients with aural discharge due to any cause other than CSOM (foreign body ear, otomycosis, furuncle in the ear, etc.) were excluded from the study. Also excluded were patients with a history of recent trauma to the ear.
An informed consent was obtained from all the patients, but ethical approval was not necessary in this observational study. Pus samples were collected from the discharging ears using an aural speculum with the use of sterile swab sticks. The specimens so collected were subjected to culture and sensitivity in the department of microbiology. The organisms isolated were identified by morphological, cultural, and biochemical characteristics. All organisms isolated were identified according to the standard microbiological methods.
| Results|| |
In this study, as shown in [Table 1], majority of the patients were of 6–10 years of age (41%), followed by 23% in 11–20 years' age group and 18% patients in the 20–30 years' age range. Minimum patients were in the age range of 71–80 years.
Female patients constituted the majority (55%) in the study as given in [Table 2].
Seventynine percent of the isolates showed pure growth, whereas 16% were mixed growths and no growth was seen in 5% patients which is depicted in [Table 3].
Staphylococcus aureus (32, 40.52%) and Pseudomonas aeruginosa (29, 36.7%) were identified to be the most common causative bacteria as pure growth. Methicillin-sensitive S. aureus (MSSA) isolates were more in number than methicillin-resistant S. aureus (MRSA) or coagulase-negative S. aureus (CONS). The remaining 18 isolates were growing the other bacteria (Klebsiella spp., Escherichia More Details coli spp., Proteus spp., Enterobacter spp., and Citrobacter sp.) [Table 4].
In [Table 5], S. aureus (31.25%) and P. aeruginosa (31.25%) were identified to be the most common causative bacteria as mixed growth. MSSA isolates were more in number than MRSA. Other organisms grown were Klebsiella species (6.25%), E. coli (6.25%), and Proteus species (25%).
MSSA was mainly sensitive to amikacin (76.2%), cefuroxime (76.2%), clindamycin (81%), gentamicin (90%), linezolid (90%), and vancomycin (95%) in the ascending order.
MRSA showed maximum sensitivity to amikacin (66.7%), clindamycin (83%), linezolid (83%), gentamicin (100%), and vancomycin (100%). It was resistant to amoxyclav completely.
Pseudomonas showed maximum sensitivity to amikacin (82.3%) and ciprofloxacin (76.5%). Maximum resistance was to azithromycin (85.3%) and clindamycin (79%) [Table 6].
| Discussion|| |
CSOM is a condition of the middle ear that is characterized by persistent or recurrent discharge through a permanent perforation of the tympanic membrane. Infection can spread from middle ear to vital structures such as facial nerve, mastoid, labyrinth, lateral sinus, brain and meninges leading to mastoid abscess, facial nerve paralysis, deafness, lateral sinus thrombosis, meningitis, and intracranial abscess. Although the incidence of such complications is low, they need to be borne in mind when faced by a patient with active CSOM. Of all the complications, hearing loss associated with chronic ear discharge is nearly always significant, reported in 50% of cases and tending to be more severe than those reported in other types of otitis media. Early bacteriological diagnosis of all cases can assure appropriate and effective therapy. Selection of the antibiotic is influenced by its efficacy and resistance of bacteria, safety, risk of toxicity, and costs.
The microbiology pus cultures of ear discharge are influenced by patient population, climate, and whether or not antibiotics have been recently used.
Many studies done about CSOM have found the predominance of Gram-negative bacteria in the ear discharge, with Pseudomonas and Proteus species as the most commonly identified aerobic organisms, while Bacteroides and Peptococcus/Peptostreptococcus spp. are the most commonly found anaerobes. Gram positives (S. aureus, MRSA) are also found but are less common. There have been reports of unusual organisms such as Mycobacterium tuberculosis, M. chelonae, M. avium complex, Actinomyces species, and Candida species as well.
These days, it is somewhat rare for an ENT surgeon, to see ears with discharge that have not already had the bacterial flora modified due to prior antibiotic treatment, since most patients attend the hospital very late when pus cultures are rendered sterile and hence not of any value. This may be attributed to the resistance of the bacteria to these antibiotics, thereby suggesting their failure, leading to continuous purulent discharge from the ear.
Effective antibiotic therapy depends on the extent of knowledge of the nature of infecting organisms. Various methods have been employed for culturing the organisms producing the disease. These include using sterile cotton swab, collection of discharge from external auditory canal in sterile containers, needle aspiration of the middle ear, namely tympanocentesis, and aspiration of a sample of the discharge from the middle ear through the tympanic membrane perforation which was used in our study. Although the method needle aspiration (tympanocentesis) increases the specificity of the culture, it is useless once the tympanic membrane gets ruptured and the discharge from the middle ear comes into the external auditory canal. The discharge here gets mixed with the preexisting flora in the external auditory canal, and the identification of causative organisms is lost.,
High prevalence of CSOM in this study was in the age group of 6–10 years (41%) followed by 11–20 years (23%). Similar results were seen in studies by Patigaroo et al., Saini et al., and Nazir and Kadri. The high prevalence of otitis media in early age group may be attributed to the fact that they are usually more prone to develop upper respiratory tract infections (URTIs). Furthermore, cold weather predisposes children to URTI.
Analysis of the gender distribution in this study revealed that CSOM was found to be more common in females (55%) than in males (45%) consistent with study done by Nazir and Kadri, Moshi et al., and Loy et al., while a study by Patigaroo et al. and Moshi et al. showed a higher incidence in male population as compared to females.
Five percent of the patients in our study had no growth in culture, while 79% had pure growth and 16% had mixed growth. Similar results noted in studies by Malkappa et al., Patigaroo et al., and Sharma et al. where incidence of sterile growth was least while incidence of pure growth had shown the highest trends.
Unlike studies done by Fliss et al., Maji et al., Malkappa et al., and Indudharan et al. where the most common causative agent is P. aeruginosa, our study showed the most common causative agent was S. aureus (40.52% in pure growth and 31.25% in mixed growth), while P. aeruginosa had the 2nd most common incidence (36.7% in pure growth and 31.25% in mixed growth).
MSSA in our study was mainly sensitive to amikacin (76.2%), cefuroxime (76.2%), clindamycin (81%), gentamicin (90%), linezolid (90%), and vancomycin (95%) in the ascending order, whereas in the study done by Patigaroo et al., MSSA was sensitive to linezolid (92.5%), amoxiclav (90%), vancomycin (90%), cefuroxime (80%), and amikacin (45%). In a study by Sanjana et al., S. aureus (other than MRSA), 95.2% were sensitive to cloxacillin, 83.3% to gentamicin, and only 26.1% of the isolates showed sensitivity to ciprofloxacin.
MRSA showed maximum sensitivity to amikacin (66.7%), clindamycin (83%), linezolid (83%), gentamicin (100%), and vancomycin (100%). It was resistant to amoxyclav completely. In the study done by Patigaroo et al., all the MRSA isolates were sensitive to vancomycin, linezolid, tetracycline, and doxycycline, 33% isolates to gentamicin, ciprofloxacin, clindamycin, and co-trimoxazole, and 17% isolates to erythromycin.
Pseudomonas in our study showed maximum sensitivity to amikacin (82.3%) and ciprofloxacin (76.5%). Maximum resistance was to azithromycin (85.3%) and clindamycin (79%), which was similar in the study by Patigaroo et al., wherein most of the Pseudomonas spp. were sensitive to amikacin (87%) and ciprofloxacin (75%), while most of them were resistant to amoxyclav, linezolid, vancomycin, and azithromycin. In a study done by Loy et al., P. aeruginosa was shown to be sensitive to ceftazidime, ciprofloxacin, piperacillin, and amikacin.
In the study by Nazir and Kadri, the most effective antibiotic against P. aeruginosa was amikacin (92.30%), followed by piperacillin (79.48%), imipenem, piperacillin plus tazobactam, levofloxacin, and ceftazidime. This finding was corroborated by studies of numerous other authors including Mansoor et al.
Ninety percent of isolates showed resistance to amoxicillin in a study done by Malkappa et al. A study carried out in Turkey in 1996 revealed only 6% of P. aeruginosa isolates to be resistant to ciprofloxacin; whereas, in South Korea in a study carried out in 2004, ciprofloxacin resistance was noted in 100% of isolates.
Hence, we found in our study, that S. aureus is the most common reason for CSOM in the patients among which MSSA and MRSA are almost equally responsible, and Gramnegatives are not commonly involved. Hence we would like to believe that empirical antibiotics if prescribed to patients should certainly cover Grampositives (S. aureus) and especially if possible, they should cover MRSA. In our set of patients, we now believe that amikacin, linezolid, gentamicin, vancomycin, and clindamycin are the drugs of choice replacing the traditional drugs such as ciprofloxacin and third-generation cephalosporin.
| Conclusion|| |
CSOM is predominantly a disease of childhood to early adulthood with ear discharge as an early and frequent symptom along with deafness. Maximum number of cultures obtained are monomicrobial and mixed infections are comparatively less common. S. aureus is the most common causative organism isolated from most ears, followed by P. aeruginosa and is sensitive to a number of antibiotics. Early and effective intervention using appropriate topical as well as systemic antibiotics can decrease the chronicity of CSOM and prevent long-term complications.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Maji PK, Chatterjee TK, Chatterjee S, Chakrabarty J, Mukhopadhyay BB. The investigation of bacteriology of chronic suppurative otitis media in patients attending a tertiary care hospital with special emphasis on seasonal variation. Indian J Otolaryngol Head Neck Surg 2007;59:128-31.
Poorey VK, Lyer A. Study of bacterial flora in csom and its clinical significance. Indian J Otolaryngol Head Neck Surg 2002; 54:91-5.
Malkappa S, Kondapaneni S, Surpam R, Chakraverti T. Study of aerobic bacterial isolates and their antibiotic susceptibility pattern in chronic suppurative otitis media. Indian J Otol 2012;18:136. Available from: http://www.indianjotol.org/text.asp?2012/18/3/136/103440
. [Last acessed on 2018 Sep 29].
Loy AH, Tan AL, Lu PK. Microbiology of chronic suppurative otitis media in Singapore. Singapore Med J 2002;43:296-9.
Sharma K, Aggarwal A, Khurana PM. Comparison of bacteriology in bilaterally discharging ears in chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg 2010;62:153-7.
Patigaroo SA, Wani SM, Anjum N, Islam M, Sumbrai D, Ahmad R. Drift in the bacteriology of chronic suppurative otitis media and methicillin-resistant Staphylococcus aureus
as an emerging pathogen: an experience. Int J Med Sci Public Health 2016;5:671-7. Avaialble from: https://www.ejmanager.com/mnstemps/67/671437023413.pdf
. [Last accessed on 2018 Sep 29].
Saini S, Gupta N, Aparna, Seema, Sachdeva OP. Bacteriological study of paediatric and adult chronic suppurative otitis media. Indian J Pathol Microbiol 2005;48:4136.
Moshi NH, Minja BM, Ole-Lengine L, Mwakagile DS. Bacteriology of chronic otitis media in Dar es Salaam, Tanzania. East Afr Med J 2000;77:20-2.
Fliss DM, Dagan R, Meidan N, Leiberman A. Aerobic bacteriology of chronic suppurative otitis media without cholesteatoma in children. Ann Otol Rhinol Laryngol 1992;101:866-9.
Indudharan R, Haq JA, Aiyar S. Antibiotics in chronic suppurative otitis media: A bacteriologic study. Ann Otol Rhinol Laryngol 1999;108:440-5.
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 2009;21:120-3. Available from: http://www.ayubmed.edu.pk/JAMC/PAST/21-2/Tahira.pdf
Jang CH, Park SY. Emergence of ciprofloxacin-resistant Pseudomonas
in chronic suppurative otitis media. Clin Otolaryngol Allied Sci 2004;29:321-3.
Altuntas A, Aslan A, Eren N, Unal A, Nalca Y. Susceptibility of microorganisms isolated from chronic suppurative otitis media to ciprofloxacin. Eur Arch Otorhinolaryngol 1996;253:364-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]