International Journal of Current Medical And Applied Sciences, vol.6. Issue 3, May: 2015. PP: 177-183.
Risk Factors and Microbiology of Chronic Suppurative Otitis Media and its Clinical Significance in a Tartiary Care Setup in Western Uttar Pradesh, India. Arun Ghosh*, Amit Rana** & Surendra Prasad*** *Associate Professor, Department of Microbiology,**Post-Graduate Student , ***Professor, Department of Otorhinolaryngology and Head & Neck Surgery, Rohilkhand Medical College and Hospital, Pilibhit Bye Pass Road, Bareilly, [U.P.], India. Corresponding Email
[email protected] Research Article Subject: Microbiology ---------------------------------------------------------------------------------------------------------------------------Keywords: CSOM, Risk factors, Lower socioeconomic Abstract: Background: Chronic suppurative otitis media (CSOM) is a notorious infection prevalent mostly in developing countries causing chronic inflammation of middle ear cavity leading to dangerous complications in absence of timely management. Microbial isolation and its antibiotic sensitivity help in appropriate management and planning of treatment protocol. Aim: To identify risk factors, bacterial isolates causing CSOM and to study the antimicrobial susceptibility patterns of aerobic isolates. Material and methods: A total of 135 patients clinically diagnosed as CSOM were enrolled in study and samples obtained using sterile swabs were taken and processed. Aerobic bacterial isolates were identified and drug susceptibility testing was conducted using Kirby –Bauer disc diffusion method. Results: Pseudomonas aeruginosa (40.76%) was the most predominant isolate followed by Staphylococcus aureus (28.46%) amongst the 130 culture positive aerobic isolates. Antimicrobial profile of aerobic isolates revealed maximum sensitivity to Amikacin (80.76%), Cefixime (70 %), Gentamicin (68.46%), Ceftriaxone / Tazobactam (66.92%), Imipenem, cefotaxime, ceftriaxone, cefotaxime are all closely associated with (64%) respectively. Conclusion: Knowing the risk factors and etiological agents of CSOM and their antibiogram is important for effective treatment and prevention of complications and antibiotic resistance. These vary for geographical regions and needs constant research.
group, Pseudomonasaeruginosa, Antibiotic susceptibility. -----------------------------------------------------------------------
Introduction: Chronic Suppurative otitis media (CSOM) is a disease of multiple etiology and well known for its persistence and recurrence. Chronic suppurative otitis media is chronic inflammation of middle ear cavity affecting mucoperiosteal lining of middle ear and mastoid cavity which presents with recurrent ear discharge through a tympanic membrane perforation, with hearing impairment and may be associated with other complications. The wide spread, irregular, irrational and haphazard treatment of antibiotics has precipitated the emergence of multiple resistant strains of bacteria which can produce both primary and postoperative infection. The indiscriminate use of antibiotics and poor follow up of patients has resulted in persistence low grade infections. In vitro antibiotic sensitivity becomes important for the clinician to make a protocol for a patient of discharging ear. India belongs to high prevalence rate group of CSOM [1]. The disease usually begins in childhood as a spontaneous tympanic perforation due to acute infection of the middle ear, known as acute otitis media(AOM) or a sequel of less severe forms of otitis media (e.g. secretory OM). The infection may occur during any group, with a peak around 2 years. Generally patients with tympanic perforations which continue to discharge for periods from 6 week to 3 months are recognized as CSOM cases [2]. Chronic suppurative otitis media is seen more frequently in the developing world with an prevalence
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Arun Ghosh, Amit Rana & Surendra Prasad ranging from 6 -46% in different Geographical areas and populations [3]. Clinically otitis media classified as acute and chronic suppurative otitis media leading to dangerous complication, subdural abscess and meningitis in absence of timely management. Since introduction of antibiotics, complications have become less common. Microbial culture and sensitivity helps appropriate management of chronic suppurative otitis media. [4]. Incidence of Chronic otitis media is higher in developing countries especially among low socioeconomic society due to malnutrition, overcrowding, poor hygiene, inadequate health care and recurrent upper respiratory tract infection. [5] Chronic suppurative otitis media is one of the most common infection which is more reported from rural populations where they belongs to low economic group. The urban to rural ratio 1:2 [5, 6, 7. 8] and poorer rural communities have highest prevalence. [5,6]. Out of all total complications hearing loss associated with chronic ear discharge is nearly always significant, reported in 50% of cases and tending to be more severe than other types of otitis media.[9]The episodes of otorrhoea are often provoked by upper respiratory infections. This is particularly common in children. Infection of the middle ear from swimming or bathing in dirty water may also lead to the disease [10].Chronic suppurative otitis media affect diverse cultural and racial groups that are distributed in both developing and developed countries. Risk factors, gender, low socio economic status, overcrowding, unawareness about the disease, day care center attendance, slum area, poor hygiene, bathing in pond/river water, smoking parent, foreign body in ear, supine bottle feed etc. are important predisposing factors which causes chronic suppurative otitis media. Presence of associated conditions like deviated nasal septum, tuberculosis, chronic tonsillitis, recurrent upper respiratory tract infection, adenoid enlargement, immunization with pneumococcal vaccine, Hib or measles vaccines, are also cited as risk factor by different author [11, 12]. CSOM is commonly caused by dysfunction of Eustachian tube and microbial infections, it is important to control the acute infection before the operations for good surgical outcome. But infection and inflammation could still exist due to the alterations of bacterial flora and their antibiotic sensitivities, nosocomial infections, descending
infection from mastoid or external auditory canal and ascending infection from nasal cavity and nasopharynx. There have been reports describing bacteriologic distributions of middle ear, mastoid and EAC in normal and chronic suppurative otitis media patients and have acknowledged the value of nasopharyngeal bacterial reservoir as the etiology of otitis media.[13].
Material and Methods: This hospital based Prospective study was carried out for a period of six months ( July 2014 to December 2014) in a tertiary care hospital of Western U.P. Total 135 patients clinically diagnosed chronic suppurative otitis media with discharging ears who are not under cover of local and systemic antibiotics for last 7 days were enrolled for the study. Two sterile cotton swab samples with help of aural speculum were collected from each patient and processed in the Microbiology lab. First swab was used for direct gram stain for Microscopy and to see the morphology under oil immersion. Second swab was inoculated to culture media. Cultures were done on blood agar, nutrient agar, Mac-conkey agar, chocolate agar, and incubated at 37ºc for 24 to 48 hrs. Organisms were identified on culture media by colony morphology, alpha/beta hemolysis etc. as per standard procedure. Pathogenic and non pathogenic staphylococcus were identified by slide coagulase test in according to Williams and Herper (1946) method and tube test was done by Gillespies method [14].The gram negative bacilli were tested by motility hanging drop, oxidase /catalase test, production of pigments, Cultural characteristics, sugar fermentation reaction and biochemical tests like indole, methyl red, VP, citrate, urease were done [15]. Antibiotic susceptibility tests were done by modified Kirby-Bauer method in mullerhilton agar. The plates were read after overnight incubation at 37°C by measuring the zone of inhibition around the antibiotic discs as per CLSI (clinical laboratory standards Institute) guidelines. Antibiotics used for testing are ampicillin, Amikacin, Gentamycin, Imipenem, Amoxyclav, Amoxycillin, Erythromycin, Tetracycline, Cefixime, ceftriaxone, ciprofloxacin, Azetronam, Norfloxacin, Cefotaxime, Ofloxacin, and Ceftriaxone [16].
Results: Table 1 : Sex Distribution of Cases Sex Male Female
No. of Cases 86 49
Percentage 63.70 36.20
Ratio 1.7 :1
Gender distribution of the patients were 86(63.70%) males and 49 (37.69%) females (Table 1).
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Logic Publications @ 2015, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327. Table 2 ; Showing age distribution Age in Years < 1 1-10 11 - 20 21 - 30 31- 40 41 - 50 51 - 60 61 - 70
Number of cases 02 60 32 09 11 07 09 05
Percentage 1.4 44.44 23.70 6.66 8.14 5.18 6.66 3.70
94(72.30%) patients were below 20 years age and 36 (27.69%) were from above 20yrs (Table-2). Table 3 ; Other factors Associated with C.S.O.M: Associated Factors URTI Nasal allergy T.B D.N.S Chr.Tonsillitis Adenoids Slum area Pond/river Water bath Poor hygeine Immunization Positive Supine bottle feed Parent smoking Foreign body ear Day care attendance
No of cases
% Socioeconomic Groups Lower Lower Upper middle middle 20 11 8 08 03 06 02 01 11 09 06 10 09 05 01 02 01 58 04 28 15 04
High
42 18 03 29 26 04 62 48
31.11 13.33 2.22 21.46 19.25 2.96 45.92 35.55
3 01 03 02 01
76
56.29
56
10
06
04
96 32 48 30 28
71.11 23.70 35.55 22.22 20.74
18 04 18 16 02
12 06 16 08 06
10 10 12 04 12
46 12 2 02 08
The risk factor associated with 130 cases of chronic suppurative otitis media were Poor hygiene 76(56.29%), Immunization positive 96(71.11%), Slum dweller 62(45.92%), Smoking parent 48(35.55%), Foreign body 30(22.22%),Day care center 28(20.74%). Diseases associated with chronic suppurative otitis media were Upper respiratory tract infection 42(31.11%),Deviated nasal septum 29(21.46%), Chronic tonsillitis 26(19.25%),Adenoids 4(2.96%), and Tuberculosis 3(2.22%) respectively (Table -3) Table 4 : Predominant side of Chronic Suppurative otitis Media Ear Discharge Number Percentage Right Ear 90 66.66 Left Ear 40 29.62 Both Ear 05 3.70 The predominant side of ear discharges are from right ear 90(66.66%) and left ear 40(29.62%) and both ear 5(370%) respectively (table-4). Table 5: Result of Direct Smear and Culture Specimen Number Percent Smear Positive-& Culture Positive 130 96.29 Smear Negative and Culture Negative 05 3.70 130 (96.29%) samples are direct gram smear and culture positive where 5 patients (10sample) were direct gram stain and culture negative (Table 5). International Journal of Current Medical And Applied Sciences [IJCMAAS], volume.6. Issue 3.
Arun Ghosh, Amit Rana & Surendra Prasad Table 6: Microbiological profile of Aerobic Bacteria isolated in Chronic otitis Media (CSOM) Type of Organism 1.Gram (+) Bacteria Staph.aureus(Coagulase +ve) Staph epidermis( Coagulase –ve) Streptococcus pneumoniae Beta -Hemolytic streptococci Total 2. Gram ( - ) Bacteria Pseudomonas aeruginosa Klebsiella Pneumoniae Proteus spp. Citrobacter spp. E. Coli Micrococcus Total No Growth
No of Isolates n- 130
Percent (%)
37 05 03 04 49
28.46 03.84 02.30 03.07 37.69
53 10 07 02 08 01 71 05
40.76 07.69 05.38 01.53 06.15 00.76 54.61
Out of total 140 ear swabs processed, aerobic bacterial growth was seen in 130(92.85%) and 81(62.30%) were gram negative bacteria(Table 6). The most common bacteria were Pseudomonas aeruginosa 53(40.76%), followed by Staphylococcus aureus 37(28.46%). The gram positive bacteria were isolated in order to predominance were Staphylococcus epidermis 5(3.84%),Beta hemolytic streptococci 4(3.07%), Streptococcus pneumoniae 3(2.30%)(Table-6). The gram negative isolates were isolated after Pseudomonasare Klebsiella pneumonia 10(7.69%), Proteus spp. 7(5,38%),E.coli 8(6.15%), Citrobacter 2(1.53%) and Micrococcus 1(1%) respectively among the total 130 isolates (Table-6). Out of 53 Pseudomonas isolated 45(84.90%) shows highest sensitivity to Amikacin. At the same time out of total 130 isolates 105(80.76%) are sensitive toAmikacin,91(70%) to Cefixime, 89(68.46%) to Gentamycin, 87(66.92%) to Ceftriaxone, 83(64%) to Imipenem,cefotaxime,ceftriaxone and cefotaxime respectively (Table 6). Table 7 : Showing Microorganism isolated and their Antibiotic Sensitivity. Organism Isolated
AK
GE N
IC
AMC
AM X
E
TE
CF M
CIT
CI P
AT
NX
CTx
Pseudomonas spp. (53)
45
34
36
13
-
-
3
29
31
12
33
17
7 5 2 7 1
7 5 2 6 1
6 2 7 1
9 3 1 3 1
5 3 1
2 2 -
3 2 1
8 6 2 5 1
8 6 2 5 1
6 4 1 4 1
5 5 2 6 1
30
27
24
32
30
25
23
27
26
23
3 2
2 2
2 3
4 3
3 3
4 3
4 3
5 2
3 2
3
3
3
4
3
4
3
3
3
Klebsiella pneumoniae(10) Proteus spp. (7) Citrobacter (2) E.Coli(8) Micro-coccus (1) Coagulase (+) staph. aureus (37) Coagulase(-) Staph .epidermis(5) Strep. Pneumonia (3) Beta-Hemolytic Streptococci (4)
OF
CTR
23
A M P -
15
13
3 3 2 4 1
8 5 2 6 1
0 0 1 0 1
15 4 2 6 1
11 6 2 7 1
22
17
31
1 1
17
31
3 2
2 3
2 2
3 2
1 2
6 2
5 3
2
3
3
2
2
4
4
AK Amikacin, GEN Gentamicin, IC Imipenem, AMC Amoxyclav, AMX Amoxycilli, E Erythromycin, TE Tetracycline, CFM Cifixime, CIT ceftriaxone/Tazobactum, CIP Ciprofloxacin, ATAzetreonam, NX Norfloxacin, CTX Cefotaxime, AMP Ampicillin. OF Ofloxacin, CTR Ceftriaxozone.
Discussion: Out of 135 cases of chronic suppurative otitis media males and females were 86(63.70%) and 49 (36.20%)
respectively having ratio 1:7:1. This observation was similar with the observation of few authors [17, 18, 19] in contrast with other authors [20,21]. The cause of
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Logic Publications @ 2015, IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327. predominance of male patients over female is unknown. Chronic suppurative otitis media were more prevalent in pediatric age groups in this study.Among 135 cases of chronic suppurative otitis media studied, high incidence 92(68.14%) were observed in 0 -20 yr age group, out of that mostly 60(44.44%) belongs t3o pediatric (below 10 yrs) age groups. This finding corresponds with the work published by Gulati et al, Baroah et al, Singh Nandan and Radha Baskar, A Nandy, S Mallya and Shivrajan et al, Nelson text book of pediatrics, M.N. Moshi et al, reported high incidence of chronic suppurative otitis media in the first decade of life. [21, 22, 23, 24, 25].Where as Nandan and Baskar, Laxminaidu, Arya and Mohapatra, reported highest incidence among 11-20 years of age [ 14, 28,29]. High incidence of CSOM among pediatric age groups was associated with risk factors as shown in (table 3). Poor hygienic care were associated with maximum patients 76( 56.29%) [21, 26.27]. 62(45.92%) cases were from slum population and mostly belongs to lower socioeconomic groups it is in agreement with Kamal et aland, Anfasi et al [7,30]. Other risk factors like upper respiratory tract infection 42(31.11%), Deviated nasal septum 29(21.46%), chronic tonsillitis 26(19.36%), Day care attendance 28(20.74%), Immunization positive 96(71.11%), were also associated factor in this study. These findings were closely supported by different workers [10,12,27]. The overall results of bacteriological investigation revealed that out of 135 cases of chronic suppurative otitis media studied , 130(96.29%) yielded smear and culture positive and 5(3.70%) cases were shown smear and culture negative. R. Shymala et al demonstrated smear and culture positive 93% cases of CSOM ,Thceis study is close with our findings [18]. and 5 samples (3.70%) showed no growth . This is in accordance with the study of Vijoya et al [31]. whereas Fatma et al 16.9% and Chakraborty et al 12.6% found higher percentage of culture negative samples in their studies [32, 33]. The Bacteriological study of otitis media, gram negative bacteria were isolated in 81(54.61%) and gram positive bacteria in 49(37.69%) cases. In contrast Malkappa SK et al observed higher incidence of gram negative bacteria mostly bacilli in their studies [36]. Pseudomonas aeruginosa is the most prevalent microorganism being isolated in 53(40.76%) cases and followed by Staphylococcus aureus 37(28.46%), Klebsiella pneumoniae 10(7.69%), and E.coli 8 (6.5%) cases. This finding of the present study was similar with many National and International studies. Deb T et al (37%), Shymala R et al (40%), Tahira Mansaur et al (40.0%), A. Altunas et al (40.7%), Anoopshetty et al (37.5%), [17, 18, 20, 35,37] found that Pseudomonas aeruginosa is the dominant pathogen in chronic otitis
media. In Contrast Prakash et al (41.25%), Rao M.V et al (41.25%) , Rao B.N. et al (42.5%) , Tanija M et al (33.3%), Rajat prakash et al (48.69%), Singh et al (36%) found staphylococcus aureus is the dominant pathogen in their studies.[21,38, 39,40, 41]. Coagulase Positive staphylococcus is predominant pathogen in 37(28.46%) cases next to Pseudomonas. This is due to changing micro flora in different seasons. The findings are similar with T.Deb et al (17.0 %), Shymala Reddy et al (31.0%), Tahira Mansoor et al (30.9%)[ 17, 18,19]. Gram negative bacteria next to staphylococci are Klebsiella pneumoniae 10 cases (7.69%) followed E.coli 8(6.15%) and proteus spp. 7(5.38%). It correlates with loy et al [42]. Coagulase negative staphylococcus are isolated in 5(3.85%) and beta hemolytic streptococci in 4(3.07%) and streptococcus pneumoniae in 3(2.3%) cases. It is usually considered as commensal organisms of the skin, but rarely can become as opportunistic pathogen [42]. In the present study Amikacin proved the most effective drug in maximum number(105) of strains, followed by gentamycin in 89 strains ,ceftriaxone in 87 strains, and cefotaxime in 83 strains respectively [18,19,20]. Different workers showed the different sensitivity pattern to Amikacin. But the sensitivity pattern of pseudomonas to Amikacin is supported by Shymala Reddy et al and Tahira Mansoor et al [18,20].
Conclusion: Chronic suppurative otitis media has become public health importance in the present days in developing countries like India. It is well known disease of multiple etiology and its recurrence and persistence. Irregular, haphazard and indiscriminate use of antibiotics has precipitated the emergence of multi resistant bacteria. Recurrent upper respiratory infection. Slum and rural dwellers, uneducation, ignorance of parents about the disease, bathing in contaminated dirty water, foreign body, and socioeconomic status are contributing factors for developing CSOM in the present era. Therefore periodical culture, mass education, with definite strategy /policy will reduce the disease occurrence and recurrence.
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International Journal of Current Medical And Applied Sciences [IJCMAAS], volume.6. Issue 3.
