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Study of aerobes, anaerobes & fungi in CSOM in a referral hospital of bangalore rural.

INTRODUCTION: Chronic suppurative otitis media is a destructive and persistent disease with irreversible sequelae, characterized by the presence of intractable mucosal, submucosal and / or bone pathology of the middle ear cleft. (1) Chronic suppurative otitis media, whether attico-antral or a tubo--tympanic disease, is associated with mixed bacterial flora. Middle ear infection is a common condition especially in the young. Most cases of chronic suppurative otitis media are not secondary to cholesteatoma, but result from a partially treated or untreated acute suppurative otitis media. Anaerobic bacteria in polymicrobial infections may be an important factor in the failure of resolution of infection during acute phase of otitis media. (2)

Due to the development of beta lactamase producing microorganisms, drug resistant strains emerge making drug resistance a major cause of treatment failure in these patients. For selection of appropriate antimicrobial agents, the knowledge of the pathogens and its antibiotic sensitivity pattern are important. (3) with the changing pattern of antibiotic susceptibility of bacterial isolates in the present era of antibiotics, the study of antibiotic sensitivity becomes an essential part of any microbiological study.

Considering the above facts, this study was undertaken to isolate aerobes, anaerobes and fungi in chronic suppurative otitis media and study their sensitivity pattern to various antibiotics.

MATERIALS & METHODS: A total of 250 cases in the age group of 0-85years attending ENT outpatient department over a period of one year from Feb 2009-Jan 2010 constituted the study material. The specimen were studied, organisms isolated and identified by standard laboratory methods. 3-4 sets of swab were collected and processed for smear microscopy & KOH examination / Bacterial--Aerobic & Anaerobic / Fungal culture. For the isolation of aerobes: Swabs were inoculated on Blood agar and MacConkey's agar and incubated at 37[degrees]C for 18-24 hours.

The bacterial growth obtained was identified by studying colony morphology and biochemical reactions using standard techniques. Trypticase soy broth, Robertson's cooked meat medium and Thioglycolate broth were used for the culture and isolation of anaerobic organisms, and Neomycin or Gentamycin blood agar was used for antimicrobial susceptibility testing of anaerobes. Antibiotic susceptibility testing was done by Kirby--Bauer disc diffusion method. (4, 5, 6, 7)

The organisms isolated were subjected to antibiotic susceptibility test using the following antibiotics: amikacin, gentamycin, ciprofloxacin, cefotaxime, chloramphenicol, tetracycline, erythromycin, ampicillin, cloxacillin, cefuroxime, cephaloridine, co-trimoxazole, imipenam, carbenecillin, piperacillin, polymyxin & amoxycillin.

RESULTS: Among the 250 samples, 34(14%) remained sterile, 216(86%) samples yielded growth and a total of 361 organisms were isolated. Table I shows the age and sex distribution of CSOM infection. The incidence of CSOM was highest in the lower socio-economic group was shown in Table II. Table III shows the numbers and percentages of various organisms isolated in the present study. Table IV, V & Table VI shows the different types of bacteria and fungi isolated with their percentages. Single organism isolation was seen in 179(49.6%) & the incidence of mixed infections was seen in 50.4% [aerobes & anaerobes 65(18%); anaerobes & fungi 65(18%); aerobes, anaerobes & fungi 52 (14.40%)] of the total number of isolates.

The anaerobes isolated 57(18.1%) were 100% sensitive to metronidazole. The total number of fungi isolated as (single organism + mixed growth) were 64 (25.6%).

Table VII shows the percentage of sensitivity pattern of aerobic bacteria to various antibiotics. The gram positive organisms showed sensitivity to cloxacillin, ciprofloxacin, cefuroxime, cefotaxime and gentamycin & showed varying degrees of resistance to ampicillin, amoxicillin, erythromycin, pencillin, tetracycline, chloramphenicol & amikacin. Pseudomonas aeruginosa showed 100% sensitivity to higher generations of antibiotics followed by amikacin (63.16%), ciprofloxacin (57.90%), gentamycin (50.87%) and norfloxacin (47.3%) respectively. Klebsiella species was highly sensitive to ciprofloxacin (84.62%) and amikacin (73.07%) followed by norfloxacin and gentamycin (61.54%) respectively.

DISCUSSION: Maximum numbers of cases were found in the age group of 0-10yrs (24%) which is in accordance with the study of some workers. (8) The present study suggested the male preponderance which was in correlation with the observation of many authors. (9,10) Unhygienic conditions, poverty, illiteracy, overcrowding, lack of health consciousness and malnutrition have also been suggested as reasons for the wide-spread prevalence of CSOM, which is in accordance with other studies. (8,9) Invasive diseases caused by streptococcus pneumoniae are among the leading causes of morbidity and mortality both in children and the elderly (Lalitha M. K. study). (11)

Pneumococci showed 100% sensitivity to oxacillin & optochin. In the present study, Staphylococcus aureus (19.81%) was the dominant organism followed by Pseudomonas aeruginosa (17.92%), Proteus mirabilis (9.12%) and Klebsiella pneumoniae (8.18%) which in accordance with the reporters. (12) The incidence of mixed infections in the present study was 17.6% (44 out of 250 cases) as in the studies of various workers. (13,14)

In the present study, majority of gram negative organisms were found to be sensitive to gentamycin, ciprofloxacin, amikacin, cefotaxime & norfloxacin. Pseudomonas aeruginosa showed 100% sensitivity to imipenem, piperacillin, carbenicillin & polymyxin which is in correlation to these studies.

The sensitivity patterns of Klebsiella, Eschericia coli, Proteus and Pseudomonas species coincides with Esposito S. study. (15) In the present study Peptostreptococcus, Peptococcus, Bacteroides species were the commonest anaerobes isolated.

Anaerobes showed 100% sensitivity to metronidazole and 65% to gentamycin which was in correlation with the other studies. (16,17) The total fungi isolated were 25.6% which is in comparison with various workers. (2,10,18) The predominant fungi isolated was Aspergillus niger (12%) of the total cases followed by Aspergillus flavus (4%), Candida tropicalis (2.4%), Candida albicans (1.6%) & penicillium species (1.2%). Gulati et al showed the predominance of Candida species in their findings. Other findings in their work coincided with those of the present study. (19, 20)

CONCLUSION: CSOM is a common cause of auditory complications & sequelae like petrositis, facial palsy, labyrinthitis, and osseous changes resulting in hearing loss, cholesteatoma, tympanosclerosis & intra-cranial complications. With different groups of organisms as etiological agents, predominantly as mixed infections and their varying resistance to different classes of antibiotics, studying the microbiological pattern of organisms and antibiotic sensitivity testing will contribute considerably to the diagnosis & management of these infections.

DOI: 10.14260/jemds/2014/2739

REFERENCES:

(1.) Leiberman Alberto, Fliss M. Dan, and Ron Dagon. Aerobic bacteriology of CSOM without cholesteatoma in children. Ann. Otol Rhinol Laryngol. 1992; 101: 866-869.

(2.) Ibekwe AO., Alshareef Z., Benayam A. Anaerobes & Fungi in Chronic suppurative otitis media. Ann. Otol. Rhinol. Laryngol. 1997 (Aug); 106 (8):649-52.

(3.) Fairbanks DNF. Antimicrobial therapy of chronic suppurative otitis media. Ann. Otol rhinol laryngol. 1990; (suppl.84): 58-62.

(4.) Clinical Laboratory Standards Institute [CLSI] Guidelines for antibacterial susceptibility testing 2009.

(5.) Konemann, Elmer W., Allen, Stephen D., Janda, William M., Schreckenberger, Paul C., Winn, Washington C. Color Atlas & Text book of Diagnostic Microbiology. Philadelphia, Lippincott, New York, 2006; 6th Ed.

(6.) Mackie & Mac Cartney. Practical Medical Microbiology. New York, Churchill Livingstone, 1996; 14th Ed: 508.

(7.) Kwon Chung K J., & Benette J E. Medical mycology. Philadelphia. Leas Febiger, 1991.

(8.) Brook I. Chronic suppurative otitis media in children-Microbiological studies. Am. J. Dis Child. 1980 (Jun); 134 (6): 564-66.

(9.) Erkan Mustafa et al. Bacteriology of Chronic suppurative otitis media. Ann. Otol. Rhinol. Laryngol. 1994: 771-74.

(10.) Jaiswal SK. Fungal infections of the ear & its sensitivity pattern. Ind. J Otolaryngol. 1990 (Mar); Vol. No.1: 42-44.

(11.) Lalitha MK. et al. Changing trend in the susceptibility pattern of streptococcus pneumoniae to penicillin in India. Ind. J Med Res. 1999 (Nov); 110: 164-68.

(12.) Paparella M. Michael, Shumrick A., Donald & Meyerhoff L. William. Otolaryngology. Vol. II Head & Neck, Philadelphia, W.B. Saunders Company, 1980 ; 2nd Ed

(13.) Rama Rao MV., & Jayakar PA. Bacteriological study of chronic suppurative otitis media. J. Ind. Med Association. 1980; 75: 30.

(14.) Narasinga Rao B. et al: Chronic suppurative otitis media--a prospective study. I J O. 1991. (Apr): 72-76.

(15.) Silvano Esposito et al. Topical ciprofloxacin vs intramuscular gentamycin for chronic otitis media. Arch. Otolaryngol H&N surg. 1992 (Aug); 118: 842-44.

(16.) Sugita R., et al: Studies on anaerobic bacteria in chronic suppurative otitis media. Laryngoscope. 1981; 91: 816-21.

(17.) Beena Antony et al. Prevalence of anaerobes in chronic suppurative otitis media in coastal Karnataka region. Ind. J Otolaryngol. H & N Surg. 1996 (Apr); 48(2): 153-56.

(18.) Vijaya D., et al. Characterisation & antifungal susceptibility of candida species--preliminary study. J Acad. Clin. Microb. 2000 (Nov); 2: 55-57.

(19.) Gulati J, Tandon P L., et al. Study of bacterial flora in CSOM. Ind. J Otolaryngol. 1969; 21(4): 198.

(20.) Gulati J. Investigative profile in patients of chronic suppurative otitis media. I J O. 1997 (Jun); 3(2): 59-62.

AUTHORS:

[1.] Geeta S. H.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Microbiology, MVJ Medical College, Hoskote, Bangalore.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Geeta S. H, No. 54/5, Arun Nivas Apts, RMS Colony, Bhattarahalli, Old Madras Road, Bangalore-560049.

E-mail: drgeetashashikant@gmail.com

Date of Submission: 15/05/2014.

Date of Peer Review: 16/05/2014.

Date of Acceptance: 26/05/2014.

Date of Publishing: 04/06/2014.
Table I: Showing age and sex distribution of Chronic suppurative
otitis media

AGE (YEARS)   MALE (143)   FEMALE (107)   TOTAL (250)    %

0-10              37            39            76        30.4
11-20             31            29            60        24.0
21-30             30            16            46        18.4
31-40             24            14            38        15.2
41-50             07            05            12        04.8
>50               14            04            18        07.2

Table II: Socio-economic conditions in CSOM

CLASS                 A) NO. OF CASES (250)    %

Lower income group             150            60
Middle income group            70             28
Higher income group            30             12

Table III: Culture report of the 250 cases in the present study

TYPE                          NO. OF ISOLATES (361)     %

Aerobes                                163            45.15
Anaerobes                              07             1.93
Fungi                                  09             2.49
Aerobes + Anaerobes                    65             18.00
Aerobes + Anaerobes + Fungi            52             14.40
Aerobes + Fungi                        65             18.00

Table IV: Shows the total number of organisms
isolated in the present study

ORGANISMS                      B) NO. OF ISOLATES (361)     %

Staphylococcus aureus                     63              19.81
Pseudomonas aeruginosa                    57              17.92
Aspergillus niger                         31              09.75
Proteus mirabilis                         29              09.12
Klebsiella pneumoniae                     26              08.18
Aspregillus flavus                        16              05.03
Citrobacter fruendii                      14              04.40
Klebsiella oxytoca                        10              03.14
Coagulase negative staph                  09              02.83
Enterobacter aerogenes                    09              02.83
Acinetobacter spp                         07              02.20
Citrobacter koseri                        06              01.88
Candida albicans                          05              01.57
Candida tropicalis                        06              01.88
P.vulgaris                                05              01.57
Eschericia coli                           04              01.26
Pencillium species                        03              00.94
Rhizopus species                          02              00.63
Pneumococci                               02              00.63
Aspergillus fumigatus                     02              00.63
E.cloacae                                 02              00.63
Corynebacterium diphtheriae               01              00.31
Enterococcus faecalis                     01              00.31
Candida krusei                            01              00.31
Candida guillerimondi                     01              00.31
Candida stelletoidae                      01              00.31
Mucor species                             01              00.31
Aspergillus terreus                       01              00.31
Candida glagrata                          01              00.31
Peptostreptococcus                        26              08.18
Bacteroides species                       10              03.14
Clostridium species                       08              02.13
Peptococcus species                       06              01.88
Fusobacterium species                     04              01.26
Veilonella species                        03              00.94

Table V: Shows anaerobes isolated in CSOM in the present study

ORGANISMS              NO. OF ISOLATES (57)     %

Peptostreptococcus     26                     45.61
Bacteroides species    10                     17.54
Clostridium species    08                     14.03
Peptococcus species    06                     10.52
Fusobcterium species   04                     07.01
Veillonela species     03                     05.26

Table VI: Shows different fungi isolated

FUNGUS                  NO.OF ISOLATES (64)   % (for 64 cases)

Aspergillus niger               30                 46.88
Aspergillus flavus              10                 15.63
Aspergillus fumigatus           01                 01.56
Candida albicans                04                 06.25
Candida tropicalis              06                 09.38
Candida guillermondi            01                 01.56
Candida stellatoidae            01                 01.56
Candida krusei                  01                 01.56
Pencillium species              03                 04.69
Mucor species                   01                 01.56
Rhizopus                        03                 04.69
Aspergillus terreus             01                 01.56
Trichosporon species            01                 01.56
Candida glabrata                01                 01.56

Table VII. Shows sensitivity pattern of organisms to various
Antibiotics used in percentage:

ORGANISM                   A      Ak       C      Cp      Co      Cf
                                                 51.7
Staphaureus      (163)   12.70   07.54   22.20     5     09.52   26.98
                                                 03.5
P. aeruginosa    (57)    01.75   63.16   01.75     1     07.02   57.89
                                                 10.3
P. ml rabills    (29)     --     58.62   06.89     4     10.34   65.51
                                                 19.2
K. pneumoniae    (26)     --     73.07   15.38     3     15.34   84.61
K. oxytoca       (10)    20.0    70.0    50.0    20.0    40.0    80.0
                                                 25.0
Coag.neg staph   (08)    12.50   12.50   37.50     0      --     62.50
E. aerogenes     (09)     --     66.66   11.11    --     22.22   66.66
Acinetobacter    (07)     --     85.71    --      --      --     85.71
                                                 07.1
C. true ndil     (14)     --     64.28   14.28     4      --     64.28
C. koserl        (07)     --     57.14   14.28    --     14.28   42.85
P.vulgaris       (05)     --     60.0    20.0    20.0    20.0    60.0

ORGANISM                   G       T      Nx       E      Am      Ce

Staphaureus      (163)   34.32   20.64   25.39   12.69   19.05   53.97

P. aeruginosa    (57)    50.87   05.26   47.36   01.75    --      --

P. ml rabills    (29)    44.82   06.89   37.93   03.44    --     06.89

K. pneumoniae    (26)    61.53   11.53   61.53   03.84    --      --
K. oxytoca       (10)    80.0    30.0    60.0    10.0     --      --

Coag.neg staph   (08)    12.50   12.50   37.50    --     12.50   12.50
E. aerogenes     (09)    66.66    --     55.55    --      --      --
Acinetobacter    (07)    71.45   14.28   71.43    --      --     14.28

C. true ndil     (14)    57.14   7.14    35.71   07.14    --      --
C. koserl        (07)    42.85    --     28.57    --      --      --
P.vulgaris       (05)    60.0    20.0    60.0     --      --      --

ORGANISM                  Cu      Cl     1     Cb      Pc     Pb

Staphaureus      (163)   65.07   63.43   --    --      --     --

P. aeruginosa    (57)    03.51    --     100  98.25    100    100

P. ml rabills    (29)    03.44    --     --    --      --     --

K. pneumoniae    (26)     --      --     --    --      --     --
K. oxytoca       (10)     --      --     --    --      --     --

Coag.neg staph   (08)    75.00   25.0    --    --      --     --
E. aerogenes     (09)     --      --     --    --      --     --
Acinetobacter    (07)    14.28    --     --    --     14.28   --

C. true ndil     (14)     --      --     --    --      --     --
C. koserl        (07)     --      --     --    --      --     --
P.vulgaris       (05)    20.0     --     --    --      --     --

ORGANISM                   P

Staphaureus      (163)   06.35

P. aeruginosa    (57)     --

P. ml rabills    (29)     --

K. pneumoniae    (26)     --
K. oxytoca       (10)     --

Coag.neg staph   (08)     --
E. aerogenes     (09)     --
Acinetobacter    (07)     --

C. true ndil     (14)     --
C. koserl        (07)    14.28
P.vulgaris       (05)     --

A--Ampicillin
C--Chloramphenicol
Co--Cotrimoxazole
G--Gentamycin
Nx--Norfloxacin

Am--Amoxycillin
Cu--Cefuroxime
I- Imipenam
Pc--Pipericillin
P--Penicillin

Ak--Amikacin
Cp--Cephalexine
Cf--Ciprofloxacin
T--T etracycline
E--Erythromycin

Ce--Cefotaxime
Cx--Cloxacillin
Cb--Carbencellin
Pb--Polymyxins
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Title Annotation:ORIGINAL ARTICLE
Author:Geeta, S.H.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Jun 9, 2014
Words:2366
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