|Year : 2021 | Volume
| Issue : 1 | Page : 22-25
Chronic suppurative otitis media and microbial flora: Adult versus pediatric population
Ashish Chandra Agarwal1, Anitya Srivastava1, Manodeep Sen2
1 Department of ENT, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||11-Jun-2020|
|Date of Acceptance||04-Aug-2020|
|Date of Web Publication||26-Oct-2021|
Dr. Anitya Srivastava
Department of ENT, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Context: Chronic suppurative otitis media (CSOM) is an inflammatory condition of the middle ear which manifests as recurrent episodes of ear discharge. Due to the inappropriate use of antibiotics, the microbiological profile and the drug sensitivity pattern is changing, leading to either inadequate treatment or recurrence. Hence, there is a need to study the microbial profile and its sensitivity pattern in order to initiate the appropriate treatment. Aim: The study has been done to evaluate the microbiological profile of ear discharge in patients of CSOM and also to assess any difference in the microbiology in the adult and pediatric population. Setting and Design: A cross-sectional record-based study was conducted in a tertiary care hospital in North India on patients diagnosed to have tubotympanic type of CSOM. Materials and Methods: The study duration was 12 months. Sterile swabs were collected from the study individuals. The organisms were isolated using the standard microbiological methods and antimicrobial susceptibility test was performed using diffusion method. Statistical Analysis: Descriptive statistics were used. Appropriate parametric and nonparametric tests were applied to assess the association between various variables. Results: Amongst children, the most common isolate was Staphylococcus aureus and this was followed by Proteus mirabilis and Pseudomonas aeruginosa. Among adults, the most common organism was P. aeruginosa and this was followed by S. aureus. Conclusion: Age, environmental, and geographical conditions of an individual affect the microbiological profile. Antibiotic therapy administered in accordance to the sensitivity pattern achieves best result.
Keywords: Antibiotic sensitivity, chronic suppurative otitis media, microbiological profile
|How to cite this article:|
Agarwal AC, Srivastava A, Sen M. Chronic suppurative otitis media and microbial flora: Adult versus pediatric population. Indian J Otol 2021;27:22-5
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a frequently encountered middle ear infection which manifests as ear discharge through a tympanic membrane perforation. As per the World Health Organization (WHO), 65–330 million people worldwide are affected by CSOM. The disease is common in developing countries due to malnutrition, overcrowding, poor hygiene, inadequate health care, and recurrent upper respiratory tract infections. It is a condition which can even lead to extradural and intradural complications if left untreated.
CSOM is classified into two types: tubotympanic (safe type) and atticoantral (unsafe type). Atticoantral disease is notoriously famous for causing complications. Infection spreads from the middle ear to the nearby vital structures namely facial nerve, labyrinth, lateral sinus, meninges, and the brain.
Various forms of bacteria are the usual incriminating organism and there can be a super added fungal infection. The prevalence of these organisms varies according to the geography and economic status of the area. Antibiogram of the organisms is variable due to the rampant and haphazard use of antibiotics. Hence, it is important that a periodic update of the causative organism and its antibiotic sensitivity be done to avoid improper antibiotic treatment, as this leads to increased morbidity.
Some studies on CSOM have shown that there is an inclination toward the younger age group. A prospective population-based longitudinal cohort study among the children aged 0–4 years demonstrated a cumulative incidence rate of CSOM to be 14%. The microbiological profile of children can be different from the adults and hence research is required to assess the prevalent organism and the future course of medical management. Due to increasing drug resistance, a periodic monitoring of the microbiological profile and its clinical correlation will help in reducing the disease burden.
| Materials and Methods|| |
A cross-sectional record-based study was conducted in the department of ENT and the department of microbiology of the tertiary care center of Northern India. The study duration was 12 months (January 2018–December 2019). Patients who were diagnosed with actively discharging tubotympanic type of CSOM and not on any antibiotics for the past 15 days were taken into consideration. Patients having atticoantral type of CSOM, history of ear surgery, having malignancy of the ear, having a history of radiation to the head and neck region, diagnosed cases of tuberculosis, or having a history of taking antitubercular therapy were excluded from the study. Based on the inclusion criteria, the number of samples which could be included during the study period of twenty four months was 54. The ear discharge of the patient were collected under sterile conditions and inoculated onto the culture medium (Robert Cooks Meat Media and McKonkey Agar) and then growth was studied along with the antibiotic sensitivity. Antimicrobial susceptibility tests were performed by diffusion method. The patient's data were recorded using retrospective charts review data collection method based on the articulated aims of the study. The data were analyzed using Microsoft Excel and SPSS version 20 statistical software (IBM SPSS version 22 licenced to Dr Ram Manohar Lohia Institute Of Medical Sciences, Lucknow). Descriptive statistics were used. Appropriate parametric and nonparametric tests were applied to assess the association between various variables and were expressed in percentage.
Ethical clearance was taken from the institute's ethical board [IEC No: 60/20]
| Results and Observation|| |
Based on the inclusion criteria, the number of samples which could be included during the study period was 54. Among these, 23 (42.5%) were in the pediatric age group (≤15 years age) and 31 (57.5%) were adults. The mean age of the children was 7.8 years and adults 38 years.
In terms of gender distribution, there were 28 (51.86%) males and 26 (48.14%) females. The male to female ratio was 1.07:1. On distributing the cases on the basis of age and gender, 15 cases were male and 8 were female in the pediatric age group, whereas, 13 males and 18 females in the adult age group [Table 1].
Of the 54 ear swabs, microbial growth was seen in 50 swabs (92.5%) and 4 swabs were sterile (7.5%). Of the 50 swabs having a microbial growth, 5 (10%) had polymicrobial growth and 45 (90%) showed monomicrobial growth. [Table 2] shows the distribution of the microbes in the pediatric and adult age groups. From the data of table 2, it can be deduced that the fungal growth was more common in the adult population.
Aeruginosa was the predominant organism among the adults (growth was seen in 15 swabs), whereas Staphylococcus aureus was the predominant organism in the pediatric age group (growth was seen in 9 swabs) [Table 3].
Although fungal growth was observed in both the age groups, it was more common in adults. Three swabs from the adult population showed the growth of Aspergillus [Table 4].
Antimicrobial sensitivity was carried out for all the microorganisms and it was observed that P. aeruginosa was susceptible to cefoperazone + sulbactam and piperacillin + tazobactam. S. aureus was most susceptible to amikacin followed by cefoperazone and ciprofloxacin. Coagulase-negative staphylococcus was most sensitive to amikacin. Proteus mirabilis and Escherichia More Details coli were isolated from the pediatric group and were susceptible to gentamycin.
| Discussion|| |
CSOM is one of the common health problems in India affecting pediatric and adult population. It is a chronic disease with serious complications which might even be fatal. It is a major concern in children as the hearing impairment can hamper communication and language development. It is characterized by intermittent ear discharge through a perforation of the tympanic membrane. Microorganisms gain access to the middle ear either through the perforation or from the nasopharynx through the Eustachian tube More Details.
The results of our study showed that majority of the ear swabs had a monomicrobial growth. A similar result was shown the studies conducted by Loy et al., Prakash et al., Vishwanath et al.
It has been observed that CSOM commonly affects the children as they are prone to recurrent upper respiratory tract infections and poor personal hygiene in the underdeveloped societies. In our study, 42.5% cases were children and 57.5% were adults, which were similar to result of certain studies.,, The male to female ratio was 1.07:1. A similar finding has also been reported in a few studies, done before. A slight predominance of males can be an incidental finding as there is no knowledge of any anatomical difference in the structure of ear between males and females.
In our study, S. aureus was the most common organism followed by coagulase negative staphylococcus and P. aeruginosa affecting the pediatric age group. A similar finding was reported in the study by Ahmad. In this study, it was observed that the children are equally predisposed to both Aspergillus and Candida infection and this was similar to a finding in a study by Ibekwe et al. The isolated fungus depends on the geographical area and environment affecting the cases of CSOM.
Among the adult population of our study, it was observed that P. aeruginosa was the most common isolated bacteria and this was followed by S. aureus. Similar findings have also been reported previously.,,,, Pseudomonas does not usually inhabit the upper respiratory tract and hence its presence in the middle ear should be considered as an invasion through an ear drum perforation., Among fungi; Aspergillus was the most common isolate in our study.
On comparing the adult and pediatric population of our study, the most common isolated organism was different in the two groups. In children, S. aureus can be a commensal present in the nasal cavity and nasopharynx. In adults, P. aeruginosa was the most common isolate and this is usually present in the ear canal. Hence, it can be said that the causative organism in the two age groups come from different sources. According to a report of the WHO, children are more susceptible to S. aureus where as adults are susceptible to Gram-negative organism such as P. aeruginosa.
The isolation of various aerobic, anaerobic, and fungal organisms in different studies showed that environmental and geographical conditions affect the microbiological profile and hence periodic studies are necessary to assess the current microbial profile affecting CSOM patients to administer appropriate antimicrobial therapy.
On comparing the results of our study with other studies,,,,, it can be understood that the choice of an antimicrobial agent is affected by the sensitivity of the organism which in turn keeps changing due to rampant and haphazard use of antibiotics. The growth pattern of microorganisms is affected by the geography, economic status, education standard, hygiene, and health facilities available in the area. In our study, we found that the most susceptible antimicrobial was amikacin, cefoperazone + sulbactam, piperacillin + tazobactam, and gentamycin. In countries like India where the health facilities are restricted, periodic update of the prevalence of the organism and its antibiotic sensitivity will help in designing a better protocol for the treatment of CSOM and also reduce the disease burden.
| Conclusion|| |
Microbiological profile of the patients in CSOM is influenced by the age, health awareness, sanitization, environmental and geographical conditions. Culture and sensitivity is important in administration of the appropriate antibioti cs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]