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Year : 2015 | Volume : 3 | Issue : 2 | Page : 125 - 129  


Original Articles
Bacteriology of chronic suppurative otitis media and its complications

Grishma Kulkarni1, Ajit Damle2

1Consultant Microbiologist, Max Cure Hospital, Hyderabad

2Professor, Department of Microbiology, Government Medical College, Aurangabad, Maharashtra

Corresponding Author:

Dr.Grishma Kulkarni

Email:drgrishmak@gmail.com

Abstract:

Otitis media, the infection of the middle ear, could be of acute and chronic type (CSOM) which could lead to extra and intra cranial complications. 71 cases of CSOM with the complications were studied. Intraoperative pus was collected in a sterile syringe and was stained with Gram stain and was cultured aerobically and anaerobically. Staphylococcus aureus was the most common pathogen isolated in both complications. Anaerobic culture did not grow any organism. Most of the aerobic organisms were sensitive to cefotaxime.

Key words: CSOM, complications, pus, aerobic and anaerobic culture, sensitivity.

INTRODUCTION:

 

Infection of the middle ear is known as otitis media which could be of acute or chronic type. They could lead to mastoiditis, extra and intracranial complications unless treated. 1, 2 Kangsanrk et al 3 have studied the bacteriology of the ear disease and its complication. They have found organisms isolated from the otorrhea were similar to these recovered from the sites of complications. 3

MATERIAL AND METHODS

 

This study was carried out in the department of microbiology, GMC, Aurangabad during March 1998 – Feb.1999.71 cases of CSOM with the various complications were included based on the clinical diagnosis.

In all the patients, intra operative pus was collected with the sterile syringe and needle from the site of abscess. A part of pus was inoculated in RCM and the remaining portion was poured in the plain sterile bulb. The samples were labeled and transported to the lab without delay.

In the lab, the gross examination of pus and Gram staining was done. Each sample was inoculated on blood agar (BA), chocolate agar (CA) & MacConkey agar (MAC). For every sample, streak of Staphylococcus aureus was inoculated perpendicular to the well. All media were incubated aerobically at 37o C. BA and CA were kept in candle jar for 48 hours & the plates were observed and the colony characters were noted. The smears were done from all the types of the colonies and stained with Gram stain. The findings were noted and compared with the direct smear. 4 The organisms were identified by the standard technique 4 and the antibiotic sensitivities were done by KB method.

In addition to the aerobic culture, each sample was incubated anaerobically. For this, the freshly prepared BA was inoculated from RCM. P.aeruginosa was used as a biological indicator. The plates were placed immediately in McIntosh Fildes jar and vacuum was created in the jar twice and replaced with the commercially available H2 (90%) and Co2 (10%) mixture. The jar was incubated for 48 hrs. This was followed for the first 10 samples as commercially available gas was exhausted. Hence hydrogen gas was prepared in the lab for the remaining samples as shown in fig no 15. (1st flask-ZN granules and diluteH2SO4

Fig 1

1st flask-ZN granules and diluteH2SO4

2nd flask-Lead acetate sol

3rd flask-pyrogallol sol and balloon filled with H2 gas

 

RESULTS:

 

During this study, 71 patients presented with CSOM with the various complications. The incidence of the complications was 10%, mostly affected the 10-15 years of age group as shown in table 1.

Table 1: Age and sex wise distribution of study subjects

Age (years)

Male

Female

10-15

25

12

16-20

12

08

> 20

08

06

Total

45

26

 

Table 2: Type of complication

Type of complication

No. of ears affected

Percentage

A] Extracranial

 

 

>Mastoiditis

50

70.42

>Subperiosteal abscess

2

2.80

>Bezold’s abscess

1

1.40

> Facial nerve palsy

1

1.40

B] Intracranial

 

 

> Brain abscess

16

22.53

> Lateral sinus thrombosis

1

1.4

 

Out of 71 patients, 54 (76.6%) and 17 (23.94%) had extra and intra cranial complications as shown in table no. II

Table 3: Gram stain finding

Gram stain finding

Number

Percentage

Gram positive cocci (GPC)

11

15.40

Gram negative bacilli (GNB)

19

26.7

GPC + GNB

41

57.74

               

Intra operative collected pus from the mastoid cavity was subjected to Gram stain and culture. The findings of it are shown in Table No.III.

Table 4: Bacteriology of samples

No. of samples

Sterile

Mono-bacterial

Poly-bacterial

71

30

28

01

 

Table 5: Distribution of samples showing frequency of various bacteria

Name of the bacteria

Number

A] Monobacterial

.

S.aureus

10

P.aeruginosa

7

Proteus mirabilis

4

Klebsiella pneumonia

4

Beta haemolytic streptococci

2

Alpha haemolytic streptococci

1

B] Polybacterial

 

S.aureus + P. aerugionsa

4

K.pneumoniae + P.mirabilis

4

S.aureus + E.coli

3

S.aureus + P. aerugionsa + P.mirabilis + Enterobacter sp

2

 

Out of 71 cases, 42.25% samples were sterile while 57.74% were positive aerobically. Out of these, 68.29% and 31.7% were mono and poly-bacterial respectively. Results are shown in table no IV and V.

Staphylococcus aureus was the most common pathogen isolated in extra and intra cranial complications (total 32.75%) followed by P.aeruginosa, P.mirabilis,K. pneumoniae, E.coli, Enterobacter sp, beta hemolytic streptococci and alpha hemolytic streptococci (in decreasing order) as shown in table No.VI.

Isolated organisms were subjected to the antibiotic susceptibility test. All the strains were sensitive to cefotaxime (100%) in vitro. Amikacin was 100% effective against all the strains of P.aeruginosa

Anaerobic culture did not yield any organism in any of the specimen

DISCUSSION:

Mastoiditis, extracranial and intracranial complications of CSOM are commonly encountered in the ENT practice. 3, 6, 7 In India, their incidence is still high because of poverty, ignorance and non availability of diagnostic and therapeutic measures at PHC 8 But in the western countries, they are rarely reported 8. In our study, incidence of complications was 10% (Extra-76% and intra 23.94%). As per Mumbai based study it was 42% and 58%8 and as per Thailand study, it was 0.45% and 0.24%3.

Occurrence of the complications was most common in the age group 10-15 years as per our study. African and Thailand based study3 found similar observations. In our study, the most common complication was mastoiditis (70.42%). Similar incidence was also reported by other other workers (65% 9, 62.5%10). In contrast to this, Finland study stated that the incidence decreased from 0.3% to 0.004% because of use of the effective antimicrobial therapy 9. 80% of people reported the previous episodes of acute otitis media. Other worker found the similar results.11

As per our study,49.2% of the patients were on the antibiotics such as cefotaxime and ciprofloxacin prior to admission to the hospital which may have resulted in sterility of the aerobic and anaerobic culture. Sterile cultures are reported by the workers, 3.33 %12, 8.5 % 13 and   24.8 % 9. In one study, all culture were sterile anaerobically as cefotaxime do inhibit the growth of anaerobes up to certain extent which might have resulted in the negativity14. Secondly, we incubated the plates for 48 hr. Some anaerobes do take longer time to grow 15. On the contrary; there were five cases in which culture was positive in spite of being on antibiotics. This could be cause of treatment failure, low compliance or inadequate doses .11

In one study, aerobic culture was positive in 57.7% cases. Out of these, 62.29% and 31.75 were mono & poly bacterial respectively. Similarly findings were noticed by the other workers (63.85 and 27.3%).16 In our study, Staphylococcus aureus(25%) was the most common pathogen isolated followed by P.aeruginosa (22%), P.mirabilis (18%), K. pneumoniae(14%), Enterobacter sp(4%), beta hemolytic streptococci (4%) and alpha hemolytic streptococci(2%).Other workers,8,12,13,15,16,17 also reported similar findings. All isolated organism showed varied type of susceptibility pattern which matched with the other findings10, 18 .Cefotaxime was 100% effective against all the strains tested.

CONCLUSION:

In our study, 71 people had CSOM with extra and intracranial complication. Incidence of the extracranial (76%) was high in comparison with the intracranial complication (23.94%).

Aerobic culture of pus was positive in 41 cases whereas the remaining culture were sterile. Staphylococcus aureus was the common pathogen isolated in extra and intra cranial complication. Cefotaxime was 100% effective against all isolated pathogens except P.aeruginosa against which it was not tested .Amikacin was 100% active against P. aeruginosa..

REFERENCES:

 

  1. Bhargav KB, Bhargav SK, Shah TM. A short text book of E.N.T. disease: 3rd ed. Bombay: Usha publications: 1944. P.53-99.
  2. Ranrne J. Acute suppurative otitis media and acute mastoiditis. In: Evans TN, editor. Scott Brown’s otolaryngology – paediatric Otolaryngology, 5th ed. London: Butterworth & Co; 1987. P. 185-89.
  3. Kangsanarak J, Fooanant Gnant S, Ruckphaopunt K. Extracranial and intracranial complications of suppurative otitis media – A report of 102 cases. The journal of Laryngology and Otology 1993; 107:999-1004.
  4. Cheesbrough M. Medical laboratory manual for trophical countires. 2nd ed. Cambridgeshire : ELBS & Butterworth & Co; 1987. P.124-129.
  5. Paartington JR. General and inorganic chemistry. 3rd ed London: MacMillan Co: 1961 .p.475-518.
  6. Sutter VL, Washington JA. Susceptibility testing of anerobes In: Lennette EH, editor. Manual of clinical microbiology, 3rd ed. Washington: American Society for microbiology, 1980. P.475-478.
  7. Nagoba BN, Narute JV, Bagwan NB, Kothadin SN, Jahagirdar VL. Nonsporing anaerobic bacteria in ENT infection. Indian Journal of Otolaryngology and Head, Neck Surgery 1994: 3:147-48.
  8. Grewal DS, Mistry B, Gaikwad N. Otogenic abscess – Our experience. Indian Journal of Otology & Head Neck Surgery 1995; 47:106-112.
  9. Palva T. Virtanen H. Makinen J. Acute and latent mastoiditis in children. The Journal of Laryngology & Otology 1985; 99 : 127-36.
  10. Mathews TJ. Oliver SP. Bacteriology of Mastoiditis A five year experience of Groote Sahur Hospital. The Journal of Laryngology and Otology 1988; 102:397-98.
  11. Nabal D, Herrman P,Braumann A. Acute mastoiditis – clinical microbilogical and therapeutic aspects. Eur J Paediat 1990: 149:560-64.
  12. Anatony B. Rajan R. Bairy I. Prevalance of anaerobes in chronic suppurative otitis media in coastal Karnataka region. Indian Journal of Otolaryngology & Head, Neck Surgery 1996; 48:153-56.
  13. Yaniv E. PocockR : Complications of ear disease. ClinOtolaryngol 1987; 13 : 357-61.
  14. Mandell GL. Petri WA Antimicrobial agents – Pencillins, Cephalosporins and other beta lactum antibiotics. In: Hardmen JG. Editor Goodman and Gilman’s. The Pharmacological basis of therapeutics. 9th ed. New York: McGrow Hill companies: 1996. P.1094-95.
  15. Sharref ZH, Arzt F. Anaerobes and fungi in chronic suppurative otitis media. Annal Otol Rhino Laryngol 1997; 106:649-52.
  16. Bailal M. Kishore J. Rajan R, Shivnanda PG. Chronic suppurative otitis media – A bacteriological and mycological study. Indian Journal of Otolaryngology & Head, Neck and Surgery 1992; 1:10-13.
  17. Ryan AF. New technology – Molecular biology. In : Lim DJ, editor, Recent advances of otitis media – Report of Fifth Research Conference. Annal of Otology Rhinology & Laryngology 1994. 103 Suppl 164:46-48.
  18. Damle AS, Kaundinya DV. Bacteriological profile of chronic suppurative otitis media in Ambejogai. Ind Med Gaz 1986: 20:47-49.

 

 

 

Table 6: Type of complication and bacteria involved

 

Type of complication

 

Organism and their total number/ percentage(in brackets)

   Extracranial

 

SA

PA

PM

KP

EC

ESP

BHS

AHS

-Mastoiditis

14

(28)

11

(22)

 

09

(18)

07

(14)

02

(04)

02

(04)

02

(04)

01

(02)

Subperiosteal abscess

 

01

00

00

00

00

00

00

00

Bezold’s abscess

 

01

00

00

00

00

00

00

00

Facial nerve palsy

 

00

00

00

00

00

00

00

00

Intracranial

 

 

Brain abscess

03

(18.75)

02

(12.5)

01

(6.25)

01

(6.25)

01

(6.25)

00

00

00

Lateral sinus

Thrombosis

 

00

00

00

00

00

00

00

00

 

KEY:      SA.          -S.aureus, PA            - Pseudomonas aeruginosa, PM   - Proteus mirabilis, KP       -Klebsiella pneumonia,

EC          - E. coli, ESP.                - Enterobacter species, BHS     - Beta haemolytic streptococci, AHS              - Alpha haemolytic streptococci

                                                                                                                                                 

 

 

 

 

 

 

 

 

                Table 7: Antibiotic sensitivity of organisms

 

 

Organism

 

total

 

GE

 

AMP

 

COT

 

E

 

PEN

 

TE

 

C

 

CTX

 

AK

 

CIP

 

S.aureus

 

19

 

10

(52.6%)

 

 

00

 

01

(5.26%)

 

00

 

00

 

02

(10.2%)

 

--

 

19

(100%)

 

--

 

06

(31.5%)

 

P.aeruginosa

 

13

 

05

(38.47%)

 

 

00

 

00

 

00

 

00

 

00

 

00

 

00

 

13

(100%)

 

13

(100%)

 

P.mirabilis

 

10

 

06

(60%)

 

 

00

 

05

(50%)

--

--

 

00

 

00

 

10

(100%)

--

 

02

(20%)

 

K.pnemoniae

 

08

 

03

(37.5%)

 

 

00

 

00

--

--

--

 

01

(12.5%)

 

08

(100%)

-

 

03

(37.5%)

 

E.coli

 

03

 

01

(33.3%)

 

 

00

 

00

--

-

 

00

 

00

 

03

(100%)

-

 

02

(66.6%)

 

Enterobacter sp

 

02

 

00

 

00

 

00

--

--

 

00

-

 

02

(100%)

--

 

01

(50%)

                                                                                                                                               

Note                                                                                                                                                                                                                      

  1. GE = Gentamicin, Amp = Ampicillin, COT-Cotrimoxazole, E = Erythromycin, PEN = Penicillin, TE = Tetracycline, C = Chloramphenicol, CTX - Cefotaxime, Ak = Amikacin, Cip = Ciprofloxacin.
  2. --Not tested;
  3. -00-RESISTANT
  4. Number in bracket indicate percentage




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