Bacteriological Study Of Chronic Suppurative Otitis Media

Background: Chronic suppurative otitis media is a destructive disease of middle ear cleft that can progress rapidly. Medical treatment which depend on proper antibiotic selected from culture and sensitivity were prescribed, otherwise process goes to intra or extracranial complication. Objective: Relation of certain clinical features to each isolated bacteria. The types of bacteria in chronic suppurative otitis media. Drug sensitivity for each isolated bacteria. Patients and Methods: Forty-six patients enrolled in the current study, 41 patients have unilaterally discharged ears and 5 bilaterally discharged ears. The total ears are 51 ears were taken for examination, microorganism isolation, biochemical tests and then culture and sensitivity tests. Regarding ear examination, it involved clinical picture. Regarding laboratory tests certain types of biochemical test, 4 types of media were used for isolation of bacteria and in culture and sensitivity tests. 16 types of drugs used for culture and sensitivity test. All collected data putted in a questionnaire, tables and histograms. Results: 55% of patients with profuse discharge while 45% scanty amount of ears discharge. Mucosal type of chronic suppurative otitis media were 53% while 47% of squamous type. Regarding types of bacteria, Pseudomonas aeruginosa of 41.2%, Staphylococcus aureus of 11.6% are the most common isolated bacteria. Regarding drug sensitivity, Imipenem, Meropenem of 100% sensitivity, Amikacin of 92% sensitivity while Cefixime of 62% resistance. Conclusion: There was a relation between particular suppurative chronic otitis media causing microorganisms and specific discharge.Pseudomonas


Introduction
Chronic Suppurative Otitis Media (CSOM): Is defined as a continuous and enduring inflammation and infection of middle ear cleft and mastoid air cells for more than 6 weeks [1]. The duration of otorrhea for classifying chronic suppurative otitis media has been the subject of discussion among Otorhinolaryngologists with period ranging between 3 weeks to 3 months [2] while WHO recommended the period of 2 weeks duration [3,4].
It's characterized by its destructive disease of middle ear. Symptoms and signs of illness include tympanic membrane perforation, discharge from the ear, eroding of ossicles, bony walls of tympanic cavity, and hearing impairment [5]. The most common aerobic bacteria causing chronic suppurative otitis media include Pseudomonas aeruginosa and Staphylococcus aureus. It can be caused by anaerobic bacteria like Bacteroides fragilis and Peptostreptococcus [6].

Patients and Methods
This study is a hospital-based crosssectional study carried out at the ENT outpatient clinic and the Microbiology department of Al-Yarmouk teaching hospital between February 2019 and October 2019.
After the institutional review board approval. The sample comprised of forty six patients equal or above 10 years old and both genders with unilateral or bilateral active chronic suppurative otitis media who met the inclusion criteria. All patients were evaluated through a detailed history and clinical examination after getting consent from them or their relatives. Discharge from draining ears were collected by sterilized ear swabs. The swabs were sent for microbiological analysis. Inclusion criteria: Patients equal or above 10 years old of both gender with actively draining ears for more than 3 weeks whom consented or their relative have been consented to participate in the study. We choose this age group depending on the age of the patients that visit the outpatient clinic of the hospital. as there are many symptoms and signs related to chronic suppurative otitis media we were taking the aural discharge as the main clinical feature of our current study. The aural discharge (amount, type, color and odor) of the active ear together with the results of type of bacteria and culture and sensitivity tests are collected in a questionnaire.

B-Bacterial isolation:
Aural discharge was taken from the draining ears of the patients with chronic suppurative otitis media attending the outpatient clinic. Aural discharge was collected from the discharging ear by using sterilized ear swab. Collected swabs are then send to the microbiology laboratory for microbiological analysis.
For bacterial isolation, the specimen was inoculated on blood agar, MacConkey's agar and chocolate agar. The culture plates were incubated aerobically at 37 °C for 24 to 48 hours. Loopfull from growing colonies were inoculated into Molar Agar for subsequent biochemical tests. Gram positive isolates were tests for catalase and coagulase tests. Gram negative isolates were tests for oxidase enzymes, urease production and citrate utilization. Some of these chemical tests done manually and some done by Autoanalyzer (Vitek 2) compact device.

Statistical analysis
The statistical significance level was established at a P-value ≤ 0.05.  Achromobacter     The bacterial isolates were completely sensitive (S) toward Meropenem & Imipenem (100%). The highest level of bacterial resistance (R) was against Cefixime (62%).

Discussion
The findings compared with other studies as follow: 1-Number and gender distribution: In relation to gender, we found that 23 of them were male (50%) and 23 of them were females (50%) and this is because no known anatomical or genetic differences between male and females pertaining the ear exists. In a study of patients by Shyamala, et al. [7]. 2-Age distribution: In relation to the age group, this study includes wide range of peoples from (10 to over 50 years old). The majority of cases 14 (30.4%) were within the age group (40-49 years) and the minority (10.8%) were (20-29 years) of age. In another study by Shrestha, et al. [8] with a total of 230 patients, they found that the most involved age group (21-30 years) 43 (18.7%). In a similar study by Loy AH, et al. [9]the commonest group that were involved (31-40 years). 3-Side of ear involvement: In relation to the side of the ear involvement we found that 22 of the patients were have right ear involvement (47.85%) while the left ear involved in 19 patients (41.3%).

Bacteriological Study Of Chronic Suppurative Otitis Media
Ammar Adnan Hadi patients (10.8%). In 2 out of 5 patients with bilateral ear involvement there were a difference in the type of bacteria isolated from the 2 ears as they have a right ear pathogen different from the left ear pathogen and this result was reported with a previous similar studies. In a study done by M Chirwa, et al. [10] the total patients were 104, 90 patients (86.5%) with unilateral disease and 14 patients (6.7%) with bilateral disease.
In a study by Shrestha, et al. [8] of 230 patients the right ear was involved in 114 cases (49.6%) and the left ear in 102 cases (44.3%) and bilateral (6.1%). In a study by Abraham ZS,et al. [11] unilateral involvement (97.5%) was commoner than bilaterally (2.5%). Left ear infections and bilaterally accounted for 58.3% and 2.5% of the cases respectively. 4-Clinical picture distribution: Regarding amount of aural discharge, the discharge was mostly profuse in 28 ears (55%) and the least is scanty in 23 ears (45%). Discharge was foul smell in 30 ears (59%) and odorless in 21 ears (41%). Discharge was mostly purulent in 26 ears (51%) and the least is mucopurulent in 25 ears (49%). Profuse discharge was mostly caused by Staphylococcus aureus in 6 ears (21.4%). Scanty discharge was commoner type of discharge by Pseudomonas aeruginosa in 17 ears (74%). Pseudomonas aeruginosa discharge was the foulest discharge in 15 ears (50%). In a study done by M Chirwa, et al. [10]the total number of patients were 104, discharge was profuse in 55 ears (46.6%) and scanty in 63 ears (53.4%), discharge was foul smell in 90 ears (76.25%) and odorless in 28 (23.8%). In a study by Chowdhury MA, et al. [13] aural discharge was mucopurulent in majority of cases 80% and foul-smelling scanty ear discharge was from 88% of subjects. 5-Type of Chronic otitis media distribution: Majority of cases were mucosal type 27 ears (53%) while squamous Otitis media were present within 24 ears (47%). Squamous chronic otitis media were mostly caused by Pseudomonas aeruginosa in 17 ears (71%) while Staphylococcus aureus was the most common cause of mucosal chronic otitis media in 6 ears (22.2%). In a study by Shrestha, B., et al. [14]. The results showed that, out of 200 cases, 120 (60%) were chronic otitis media-mucosal and 80 (40%) were chronic otitis mediasquamous. 6-Types of bacteria found in chronic otitis media: The total number of pathogens isolated from 46 patients (51 ears) were 13 types of bacteria. We found that Gram negative bacteria accounted for the majority of organisms in 42 ears (82.4%) while Gram positive bacteria accounted for the least 9 ears (17.6%). The most common pathogen was Pseudomonas aeruginosa in 21 ears (41.2%) followed by Staphylococcus aureus in 6 ears (11.6%). In a study by Kumar H, et al. [15], Analysis of isolated bacteria showed predominance of gram negative bactria (59.74%).
In a study of patients by Shyamala, et al. [7] the majority of cases were caused by Pseudomonas aeruginosa 40% followed by Vol In a similar study done by Mansoor T, et al. [16] with a total of 263 patients the Pseudomonas aeruginosa (40%) and Staphylococcus aureus (30.9%) were the most common pathogens found In Chronic suppurative otitis media. 7-Sensitivity of bacteria to antibiotics: We have used 16 Antibiotics in this study. The highest effective antibiotics against these 13 pathogens were Imipenem and Meropenem equally (100%) followed by Amikacin (92%). The lowest effective antibiotic was Cefixime of (62%) resistance. In a study by Jang CH, et al. [17].Pseudomonas aeruginosa were tested against 16 antibiotics. Imipenem was the most sensitive antibiotic agent of 96.5% followed by amikacin (55.6%). This study goes with our study.

Conclusions
There was a relation between particular suppurative chronic otitis media causing microorganisms and specific discharge. The most common pathogen was Pseudomonas aeruginosa followed by Staphylococcus aureus.Imipenem, Meropenem and Amikacin are highly recommended as the first line treatments in patients with chronic suppurative otitis media while the lowest effective antibiotic was Cefixime. Anaerobic media and specific tests for anaerobic bacteria isolation