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ISOLATION OF MICROFLORA INVOLVED IN CHRONIC SUPPURATIVE OTITIS MEDIA AND FINDING ANTIBIOTIC SENSITIVITY IN KHARIAN.

Byline: Muhammad Ahmed Khan, Sumera Akram and Shahid Bin Faiz

ABSTRACT

Objective: The objective of the study is to find out the microorganisms implicated in chronic suppurative otitis media (CSOM) and to know the sensitivity pattern of these microorganisms to commonly used antibiotics in Kharian.

Study Design: Cross-sectional descriptive study.

Place and Duration of Study: The study was conducted in Combined Military Hospital (CMH) Kharian from January 2013 to Dec 2013.

Patients and Methods: One hundred and twenty (120) cases of clinically diagnosed CSOM were included in this study. Ear swabs were taken using commercially available sterile swab sticks and the samples were sent to the pathology lab under strict aseptic conditions to culture the microorganisms and find sensitivity pattern.

Results: Out of 120 cases included in the study, there were 56 (47%) females and 64 (53%) males with slight male dominance. The patients' age range was from 2 years to 63 years. Highest frequency was of. Pseudomonas aeruginosa found in 51 (42.5%) cases followed by Staphylococcus aureus in 28 (23.4 %) cases, MRSA (Methicillin Resistant Staphylococcus aureus) in 7(5.8%) cases, Proteus in 6 (9.2%) cases, Klebsiella in 8 (6.7%) cases and E-Coli in 6 (5%) case. Pseudomonas aeruginasa was highly sensitive to Ciprofloxacin, Amikacin and Sulbactum-cefoperazone. Staphylococcus aureus had high sensitivity to Amoxi-clav, Amikacin etc. MRSA (Methicillin Resistant Staphylococcus aureus) was 100% sensitive to Vancomycin.

Conclusion: Pseudomonas aeruginosa and Staphylococci are the commonest organisms involved in CSOM and they show good sensitivity to the fluoroquinolones and aminoglycosides which are available in local preparations. The knowledge of microbiological flora and its sensitivity to commonly used antibiotics is important for rationale use of the antibiotics and to avoid development of resistance.

Keywords: Antibiotic sensitivity, Chronic suppurative otitis media, Methicillin resistant Staphylococcus aureus (MRSA).

INTRODUCTION

Chronic suppurative otitis media (CSOM) is one of the common diseases in the community. It is defined as persistent or intermittent pus discharge through a chronic tympanic membrane perforation. The perforation is deemed to be chronic if present for more than three months. Most of the time, chronic suppurative otitis media develops as a result of acute otitis media causing perforation of the tympanic membrane which does not heal resulting in persistence of perforation. Previously (CSOM) was classically divided into two varieties i.e. tubotympanic and atticoantral. Tubotympanic chronic otitis media is also called safe type, it affects the anteroinferior part of tympanic membrane. Atticoantral type is termed unsafe type and in this variety there is posterosuperior defect of the tympanic membrane and is also often associated with cholesteatoma which is a bone eroding process.

Cholesteatoma is dangerous as it may cause various life threatening complications like extradural abscess, subdural abscess, dural sinus thrombosis and meningitis. Recently chronic suppurative otitis media has been classified into the following types; active mucosal, inactive mucosal, active squamous, inactive squamous and healed (dimeric, tympanosclerosis etc).

The prevalence of CSOM has been quite extensively studied. According to World Health Organization (WHO) prevalence of CSOM in South East Asia is 1.4%1. The prevalence varies a lot among different regions and countries. Prevalence rate of 1-2% has been recognized as low and 3-6% as high prevalence rates of chronic otitis media by WHO2. The commonly isolated bacteria in the culture of pus in cases of chronic otitis media include Pseudomona aeruginosa, Staphylococcus aureus, Proteus, Klebsiella. Anaerobes and fungi are also less commonly involved. There are different studies, in few Pseudomonas was the most common isolated microorganism involved while in others Staphylococcus was the most common3.

The choice of antibiotics for chronic otitis media depends upon their efficacy, safety, availability and cost. Local antibiotic preparations in the form of drops are the mainstay of treatment and also cost effective, but owing to the emerging resistance it is important to review and revise the microbiological profile of implicated organisms and finding their efficacy. The purpose of this study was to isolate the commonly involved microorganisms in CSOM and to also to check the antibiotic sensitivity and resistance in the region.

PATIENTS AND METHODS

This cross sectional descriptive study was carried out in Combined Military Hospital (CMH) Kharian from January 2013 to December 2013. Study population was all the serving and retired army personnel alongwith their families and civilians not entitled patients who reported to the hospital. Clinically diagnosed cases of CSOM i.e. pus discharge of at least more than 6 weeks duration (intermittent or persistent) through a chronic perforation of tympanic membrane and patients with active discharge or pus in external auditory meatus were included in the study. While any immunocompromised patient, patients having history of any recent surgery of ear or mastoid, or use of topical or oral antibiotics during previous 15 days, were excluded from the study.

Table-1: Sensitivity of microorganism to common antibiotics.

Antibiotics###Pseudomona###Staphylococcus###MRSA###Proteus###Klebsiella###E. coli

###aeruginosa###aureus

Amoxycillin###-###0%###0%###-###-###-

Co-trimoxizole###-###17.2%###0%###-###-###-

Gentamycin###65.5%###78.6%###-###66.7%###43.5%###65%

Ciprofloxacin###93.8%###85.7%###10%###83.3%###56%###43.5%

Doxycycline###-###63.75###10%###10%###43.5%###16.6%

Amikacin###93.8%###88.5%###60%###100%###100%###100%

Amoxi-clav###-###92.3%###-###43.5%###-###-

Sulbectum-###93.8%###-###-###100%###92.5%###100%

cefoperazone

Vancomycin###-###100%###100%###-###-###-

One hundred and twenty clinically diagnosed CSOM patients were selected by ENT specialists in the outpatient department. The cases belonged to all age groups and both genders. All the cases i.e selected patients consented for the subject research. Ethical committee certificate was obtained. Ear swabs were taken using commercially available sterile swab sticks and the samples were immediately sent to the pathology laboratory of CMH Kharian under strict aseptic conditions to culture the microorganism and find its sensitivity pattern. All the patients were followed up fortnightly alongwith culture sensitivity reports. In cases of resistant strains (where culture sensitivity report dictated) the treatments were changed accordingly. The data thus collected was analyzed with the help of statistical package for social sciences (SPSS) version 16.

RESULTS

Total 120 cases were included in the study; there were 56 (47%) females and 64 (53%) males with slight male dominance. The patient's age range was from 2 years to 63 years. Most of the patients were in age range of 2 to 7 years.

Distribution of microorganism cultured is described in fig. Most frequent organism cultured was Pseudomonas aeruginosa found in 51 (42.5%) cases followed by Staphylococcus aureus in 28 (23.4 %) cases, MRSA (Methicillin Resistant Staphylococcus aureus) in 7(5.8%) cases, Proteus in 6 (9.2%) cases, Klebsiella in 8 (6.7%) cases and E-Coli in 6 (5%) case. No organism was cultured in 9 (7.5%) cases. Pseudomonas aeruginosa was highly sensitive to Ciprofloxacin, Amikacin and Sulbactum-cefoperazone. Staphylococcus aureus had high sensitivity to Amoxi-clav, Amikacin etc. MRSA (Methicillin Resistant Staphylococcus aureus) was 100% sensitive to Vancomycin. Proteus spp was completely sensitive to Amikacin and Sulbactum-cefoperazone that is 100% and 83.3% sensitive to ciprofloxacin. Klebsiella was again 100% sensitive to Amikacin. E.coli was also cent percent sensitive to Amikacin and Sulbactum-cefoperazone (table-1).

DISCUSSION

CSOM is quite common in the developing countries. It is more prevalent in the poor socioeconomic environments and rural areas4. The highest rate of perforation of tymapanic membrane and subsequent CSOM is seen in 2 to 4 years age range and it is roughly seen three times more common than in adults. The most frequent microorganism found in this study is Pseudomonas aeruginosa which is seen in 42.5% of the cases, followed by Staphylococcus aureus seen in 23.4% of cases. Pseudomona aeruginosa is the most frequent microorganism as shown in many studies5,6. Sharma et al carried out a study and they reported Pseudomona aeruginosa to be found in 36% of cases followed by Staphylococcus aureus in 30 % of cases7. However Staphylococcus aureus was shown to be the commonest microorganism in many studies8,9. MRSA (Methicillin Resistant Staphylococcus aureus) was seen 7(5.8%) cases which is similar to that shown in study of Iqbal et al10. These MRSA cases were community acquired as were outdoor cases.

Sensitivity of Pseudomona aeruginosa to Ciprofloxacin, Amikacin and Sulbactum-cefoperazone was found to be high i.e 93.8%. It was followed by sensitivity to Gentamycin which was 65%. These findings correlate with the work of Mozafari et al, in their study the sensitivity of Pseudomona aeruginosa to Ciprofloxacin was 95% and to Gentamycin was 85%11. Staphylococcus aureus had good sensitivity to amoxi-clav and Amikacin and was 100% sensitive to vancomycin. Vancomycin was shown to be 100% sensitive for MRSA (Methicillin Resistant Staphylococcus aureus) cases. Proteus spp was completely sensitive to Amikacin and Sulbactum-cefoperazone that is 100% and 83.3% sensitive to ciprofloxacin. Klebsiella was again 100% sensitive to Amikacin. E.coli was also cent percent sensitive to Amikacin and Sulbactum-cefoperazone (table-1).

CSOM is common disease which general physicians come across almost daily. Requisite knowledge of the involved microbiological flora and their sensitivity pattern is mandatory for adequate treatment.

CONCLUSION

Pseudomona aeruginosa and Staphylococci are the commonest organisms involved in CSOM and they show good sensitivity to the fluoroquinolones and aminoglycosides which are available in local preparations. The knowledge of microbiological flora and its sensitivity to commonly used antibiotics is of utmost importance for rationale use of the antibiotics and to avoid development of resistance.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

REFERENCES

1. Chronic suppurative otitis meda. Burden of illness and management options. Child and adolescent health and development. Prevention of blindness and deafness. World Health organization Geneva, Switzerland 2004.

2. WHO/CIBA Foundation Workshop. Prevention of hearing impairment from chronic otitis media.WHO/PDH/98.4.London: CIBA Foundation, 1996.

3. Verhoeff M, Van der Veen EL, Rovers MM, Sanders EA, Schilder AG. Chronic suppurative otitis media: a review. Int J Pediatr Otorhinolaryngol. 2006;70: 1-12.

4. Ologe FE, Nwawolo CC. Chronic suppurative otitis media in school pupils in Nigeria. East Afr Med J. 2003; 80: 130-4.

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8. Prakash M, Lakshmi K, Anuradha S, Swathi GN. Bacteriological profile and their antibiotic sensitivity pattern in cases of chronic suppurative otitis media. Asian J Pharm Clin Res. 2013;6: 17-210-12.

9. Taj Y, Essa F, Kazi SU. Pathological analysis of 596 cases of chronic otitis media in Karachi. J Coll Physicians Surg Pak 2000;10: 33-5.

10. Iqbal k, Khan MI, satti L. Microbiology of chronic suppurative otitis media; experience at dera Ismail Khan. Gomal journal of medical sciences 2011; 9: 190-193.

11. Mozafari K, Sephri G, Khatmi H, Shakibaie M. Isolation and antimicrobial susceptibility of bacteria from chronic suppurative otitis media patients in Kerman, Iran. Iran Red Crescent Med J. 2011; 13(12): 891-94.
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Publication:Pakistan Armed Forces Medical Journal
Article Type:Report
Date:Jun 30, 2016
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