Frequency of Active Squamosal type of Chronic Suppurative Otitis Media and Antibiotic Susceptibility Profiles of Predominant Bacteria Isolated from
Patients, Khyber Teaching Hospital, Peshawar
Israr1, Fazal Rehman1, Siyyar Ahmad1, Mansoor Alam1, Abdul Aziz1, ArbabMohamadAkbar jan1, Aftab Ahmad1*
Department of ENT Khyber Teaching Hospital Peshawar KPK Pakistan Corresponding author: Dr Aftab ahmad
Email Id: [email protected]
Chronic suppurative otitis media (CSOM) is a persistent inflammation of the middle ear cavity offering an infected ear discharge encompassing over 3 months. The study aimed to determine the frequency of the active squamosal type of chronic suppurative otitis media (ASCOM) among patients with chronic ear discharge. In the present study, a total of 157 patients presenting chronic ear discharge with duration >3 months (without treatment), were collected from the Department of ENT, Khyber Teaching Hospital, Peshawar. Patients of varying ages and gender were included and detailed history and complete physical examination. The study was ethically approved fromthe Department of ENT, Khyber Teaching Hospital, Peshawar.Our study shows that among 157 patients’ thirty percent of patients were of age between 18-30 years, 28%, 24%, and 18% patients were in age between 31-40, 41-50, and 51-60 years, respectively. The mean age was 32 years with SD ± 12.41. Sixty-nine percent of patients were male and 31% were female. Ten percent of patients had the active squamosal type of CSOM and 90% of patients didn’t have the active squamosal type of (ACSOM). Antibiotic susceptibility assay showed that amikacin shows good activity followed by gentamycin and ciprofloxacin. This study concludes that the frequency of ASCOM was 10% among patients conferring with chronic ear discharge.
Keywords:Active squamosal type, chronic suppurative otitis media, chronic ear discharge, Antibiotic susceptibility Assay
Chronic suppurative otitis media (CSOM) is the persistent complication of the middle ear cavity(Li et al., 2015), most commonly in the overall population of South East Asia with a prevalence rate of about 5.2 % (Monasta et al., 2012).The disease is slow processing and sneaking that frequently leads to harmfulfluctuations in the middle ear mucosa, ossicles underlying bone and sometimes this proceeds to serious extracranial and intracranial complications (Yorgancılar et al., 2013). The most common bacterial isolatesinvolved in CSOM complications are Pseudomonas aeruginosa (P. aeruginosa) followed by Staphylococcus aureus
(S. aureus), Proteusspp.Klebsiella pneumoniae (K. pneumoniae), fungal isolates such as Candida albicansand Aspergillus species as well as Mycobacterium tuberculosis (Rawat, A. and Goyal, R., 2015).The occurrence of a non-intact tympanic membrane is the elementary featureassociated with all CSOM infections and classified into twocategories: tubotympanic and active squamosal, depends upon disease progression whether it wasthe outcomeof the pars tensa of the pars flaccida of the tympanic membrane(Kumar, H. and Seth, S., 2011).
The introduction of active squamosal variety is a foul-smelling aural discharge and hearing impairment. However numerous patients are uninformed of the discharge and consequentlypresent with only hearing impairment (Alabbasi et al., 2010). The active squamosal variability commonly associated with complications whenlinked to the tubotympanic assortment(Viswanatha et al., 2012) and is frequently connected with a bone erodingprocess for example cholesteatoma, granulations, or osteitis(Raj Paudel, D., 2013). The standard therapy for the attico antral type of CSOM staysmastoidectomy. It provides for unfailing and consistent eradication of disease and betterment of symptoms (Preetam et al., 2011).
CSOM burden rises not globally but disease burden is exceedingly variable from population to population. It is also revealed that ACSOM leads to more complications as compared to the tubotympanic type. Little data is available on this aspect in our local population so this study will help us regarding information about the frequency of ASCOM among patients presenting with chronic ear discharge. The current study was designed to know about the frequency of ACSOM among patients with chronic ear discharge. Moreover, the results of this study will be useful for health care professionals and the baseline for further investigation.
MATERIAL AND METHODS
The current study was performed at the Department of ENT, Khyber Teaching hospital, Peshawar. The study design was descriptive cross-sectional, from November 2019 to May 2020.
The sample size calculated was 157using World Health Organization (WHO) sample size calculation as described previously. The sampling technique was non-probability.
Inclusion and exclusion criteria
All patients presenting chronic ear discharge with greater than 3 months (without treatment).Age limits from 18 to 60 years, and of both the sexes.In exclusion criteriahistory of use of antibiotic in the last 2 week, cholesteatoma, aural polyps on otoscopic examination and mastoid surgery history was included.
The study was ethically approved bythe hospital ethical and CPSPresearch committee.
Patients with inclusion criteria were included in the current study through OPD and ENT departments. Informed and explained to all patients that the study was only for research
publication and written informed consent was obtained based on permission of patient approval.
Study patients were proceededfor comprehensive physical examination, history, otoscopic examination, and pure tone audiometry by ENT surgeon fellow of CPSP and having a minimum of 5 years experience to observe ACSOM. Patients' age, name, gender, duration of symptoms, socioeconomic status was also recorded in proforma. Strictly followexclusion criteria to control result biasness.
Bacterial isolates identification
All the isolates were initially grown on selective and differential media and their biochemical test using standard microbiological procedures.
Antibiotic Susceptibility Assay
Antibiotic susceptibility assay was performed using the Kirby Bayer disk diffusion method (Kirby, 1944). Antibiotics used in this study were following, amikacin (30µg), gentamicin (10 µg), ciprofloxacin (5 µg), cefoperazone (75 µg), cefotaxime (30 µg), and ofloxacin (5 µg) for P.
aeruginosa, ciprofloxacin (5 µg), amikacin (30µg), gentamicin (10 µg), and ofloxacin (5 µg) for Gram negative bacteria and amikacin (30µg), gentamicin (10 µg), ciprofloxacin (5 µg), cefoperazone (75 µg), cefotaxime (30 µg), and ofloxacin (5 µg) and amikacin (30µg), gentamicin (10 µg), ciprofloxacin (5 µg), cefoxitin (30 µg), and ofloxacin (5 µg) for S. aureus.
The Control strain used in this study was; S. aureus ATTCC 25923, E. coli 25922, and P.
aeruginosa 25873. Cefoxitin disk was used to screen out methicillin-resistant S. aureus (MRSA).
Data analysis was done using SPSS version 22. Mean ± SD were calculated for constant variablessuch as age and symptoms duration. Percent prevalence and frequencies were intended for categorical variablesincluding gender, socio-economic status, and active squamosal type of CSOM. Active squamosal type of CSOM was stratified with age, gender, duration of symptoms, socioeconomic status to see effect modification. Using the chi-square test of P-value < 0.05 was considered statistically significant.
Among 157 patients, 47(30%), 44(28%), 38(24%) and 28(18%) patients were with age range between 18-30,31-40, 41-50 and 51-60 years, respectively. 32 years was the Mean age with SD ± 12.41. According to gender distribution, 108(69%) patients were male and 49(31%) patients were female. Concerning time duration, 58(37%) and99(63%) patients had a duration of disease
≤6 months, and greater than 6 months, respectively. The mean duration of disease was 6 months with SD ± 4.21. According to socio-economic status, 66(42%) patients were poor, 71(45%) patients were middle class and 20 (13%) patients were rich, Table 1. More than 16(10%) patients had active squamosal type of CSOM and 141(90%) patients didn’t have active
squamosal type of CSOM, Table 2. Stratification of active squamosal type of CSOM concerning age, gender, duration of symptoms, and socio-economic status is given in Tables No 3, 4, 5, 6.
TABLE NO 1. SOCIO ECONOMIC STATUS (n= 157)
SES FREQUENCY PERCENTAGE
Poor 66 42%
Middle class 71 45%
Rich 20 13%
Total 157 100%
TABLE NO 2. ACTIVE SQUMOSAL TYPE OF CSOM (n= 157)
TYPE OF CSOM FREQUENCY PERCENTAGE
Yes 16 10%
No 141 90%
Total 157 100%
TABLE NO 3. STRATIFICATION OF ACTIVE SQUMOSAL TYPE OF CSOM WITH RESPECT TO AGE
(n= 157) ACTIVE
SQUMOSAL TYPE OF CSOM
years Total p
Yes 5 4 4 3 16 0.9939
No 42 40 34 25 141
Total 47 44 38 28 157
TABLE NO 4. STRATIFICATION OF ACTIVE SQUAMOSAL TYPE OF CSOM CONCERNING GENDER
SQUAMOSAL TYPE OF CSOM
Male Female Total p
Yes 11 5 16
No 97 44 141
Total 108 49 157
TABLE NO 5. STRATIFICATION OF ACTIVE SQUMOSAL TYPE OF CSOM WITH RESPECT TO DURATION OF DISEASE
SQUMOSAL TYPE OF CSOM
≤6 months >6 months Total P-value
Yes 6 10 16
No 52 89 141
Total 58 99 157
TABLE NO 6. STRATIFICATION OF ACTIVE SQUAMOSAL TYPE OF CSOM FOR SOCIO-ECONOMIC STATUS
SQUMOSAL Poor Middle
class Rich Total P-value
TYPE OF CSOM
Yes 7 7 2 16
No 59 64 18 141
Total 66 71 20 157
Antibiotic susceptibility results
All the isolates were screened for antibiotic susceptibility assay using routinely used antibiotics.Amikacin shows good activity followed by gentamycin and ciprofloxacin. The antibiotic susceptibility assay results for P. aeruginosa. S. aureus, K.aerogenes, and P. mirabilis were shown in Figure1 (A, B, C, D) respectively. Among S. aureus 35% of isolates were MRSA, and 65% were methicillin-sensitive S. aureus were (MSSA).
Figure 1: Antibiotic Susceptibility profiles of bacterial isolates, (A) P. aeruginosa (B) S. aureus (C) K.aerogenes (D) P. mirabilis
CSOM is a common health issue in children as well as in adult humans worldwide but with increased frequency in developing countries. In this study, the maximum age of the patients was 60 years, a similar finding was observed previously from Pakistan (Khalil et., 2013). In the current investigation, 69% of patients were male and 31% of patients were female patients, a similar result was observed previously from Pakistan (Khalil et al., 2013) that male was dominant according to gender distribution. In contrast to the current study, studies from India (Parakash et al., 2013), Pakistan (Mansoor et al., 2009), and Singapore (Loy Ah et al., 2002) reported that female patients were dominant as compared to male.Our study correlates with another study from our neighboring country India by Gopich et al, who reported that an active squamosal type of CSOM was observed in 9.09% of patients (Gopichand et al., 2015). In this study, P. aeruginosa was found to be the most common bacteria (40.65%), followed by S. aureus (14.63%), K. aerogenes (11.78%), and Proteus Mirabilis (10.56%). Similar results were also reported the P. aeruginosa was the dominant one (Khatoon et al., 2015, Kumar H and Seth S 2011, Shyamla R and Reddy SP 2012, Osazuwa et al., 2011, Mansoor et al., 2009, Khan et al., 2017), as the dominant bacteria werePseudomonas and this could be due to the dissimilarity in microorganisms in diverse regions and the result of climate. In contrast to current findings, other studies from Pakistan and India reported that S. aureus 65.2% and 32.65%, was the most dominant bacteria (Khalil et al., 2013, Gopichand et al., 2015), followed by P. aeruginosa (26.53%)and Klebsiella spp. (16.32%). Others studies (Hiremath et al. 2001, Loy et al., 2002) also reported the P. aeruginosa asthe most dominant one causing CSOM, which is similar to the current study. Various studies reported Gram-negative and positive organisms in CSOM as reported by (Kumar H and Seth S 2011, Shyamla R and Reddy SP 2012, Mansoor et al., 2009).
The difference in outcomes of several studies could be due to the difference in the patient population, the number of sample size, economic status of the patient, and variations in geographical locations.
In the current study, amikacin was the most effective. Amikacin susceptibility was shown in 95.48% isolates followed by gentamycin 92.36% and ciprofloxacin 91.30%, cefoperazone 86.42%, cefotaxime 74.54%, and Ofloxacin 62.68%. Similar reports were also reported (Kumar H and Seth S 2011, Mansoor et al., 2009) that amikacin was effective against COSM. Other reports from India noticed that amikacin, gentamicin,cefotaxime, and ciprofloxacin showed good activity against Gram-positive as well as negative bacteria (Prakash et al., 2013, Gopichand et al., 2015). Another study from Pakistan noticed that Ceftriaxone was the drug of choice for the treatment of CSOM, with an overall sensitivity of 89.2% of patients and was followed by Ofloxacin (82.6%) (Khalil et al., 2013).Microbiology and culture sensitivity is mandatory before starting the treatment for CSOM. The incidence of S. aureusinfections in the middle earis credited to their pervasive nature and especially the resistant strains such as MRSA presence in the external auditory canal and upper respiratory tract. Moreover,Proteus spp.andPseudomonas spp. were knownas the secondary invaders and leads to COSM complications.
1. Li MG, Hotez PJ, Vrabec JT, Donovan DT. Is chronic suppurative otitis media a neglected tropical disease?.PLoSNegl Trop Dis, 2015;9(3):e0003485.
2. Monasta L, Ronfani L, Marchetti F, Montico M, VecchiBrumatti L, Bavcar A, et al.
Burden of disease caused by otitis media: systematic review and global estimates. PLoS One 2012;7(4):e36226.
3. Yorgancılar E, Yıldırım M, Gun R, Bakır S, Tekın R, Gocmez C et al. Complications of chronic suppurative otitis media: a retrospective review. Eur Arch Otorhinolaryngol.
4. Rawat A, Goyal R. A study of bacterial profile and antibiotic susceptibility pattern of chronic suppurative otitis media (CSOM). Int J Curr Microbiol App Sci 2015;4(8):23-27.
5. Kumar H, Seth S. Bacterial and fungal study of 100 cases of chronic suppurative otitis media. J Clin Diag Res 2011;5:1224-27.
6. Alabbasi AM, Alsaimary IE, Najim JM.Prevelance and patterns of chronicsuppurative otitis media and hearingimpairment in Basrah city. J Med Sci 2010;1(4):129-33.
7. Viswanatha B, Vijayashree MS, Sumatha D. Unilateral attico antral ear disease with bilateral intracranial complications. Indian J Otolaryngol Head Neck Surg.
8. Paudel DR. Chronic suppurative otitis media atticoantral-type undergone canal wall down mastoidectomy in a peripheral Government Hospital of Nepal. J Nepal Med Ass 2013;52(192):596-9.
9. Preetam C, Verma R, Thakar A, Sikka K. Tympanomastoid obliteration for recalcitrant attico-antral chronic suppurative otitis media. Indian J Otol 2011;17:26-9.
10. Kirby, W.M., 1944. Extraction of a highly potent penicillin inactivator from penicillin resistant staphylococci. Science, 99(2579), pp.452-453
11. Khalil, Ahmed, Ahsanullah Mir, Mehtab Jan, Raja Imran, Gulab Shah, and Abdul Latif.
"Prevalence of bacteria in chronic suppurative otitis media patients and their sensitivity patterns against various antibiotics in human population of Gilgit." Pakistan Journal of Zoology 45, no. 6 (2013)
12. Prakash, Rajat, Deepak Juyal, Vikrant Negi, Shekhar Pal, ShamanthAdekhandi, Munesh Sharma, and Neelam Sharma. "Microbiology of chronic suppurative otitis media in a tertiary care setup of Uttarakhand state, India." North American journal of medical Sciences 5, no. 4 (2013): 282.
13. Mansoor, Tahira, Mohammed AyubMusani, Gulnaz Khalid, and Mustafa Kamal.
"Pseudomonas aeruginosa in chronic suppurative otitis media: sensitivity spectrum against various antibiotics in Karachi." J Ayub Med Coll Abbottabad 21, no. 2 (2009):
14. Loy, A. H. C., A. L. Tan, and P. K. S. Lu. "Microbiology of chronic suppurative otitis media in Singapore." Singapore medical journal 43, no. 6 (2002): 296-299
15. Gopichand WR, Madhusudan BV, Tukaram KV. Bacteriological profile of chronic suppurative otitis media. Int J Curr Microbiol App Sci 2015;4(6):41-7.
16. Khatoon, Abida, Meher Rizvi, Asfia Sultan, Fatima Khan, Mohit Sharma, Indu Shukla, and Haris M. Khan. "Chronic suppurative otitis media: a clinico-microbiological menace." Int J Res Med Sci 3, no. 8 (2015): 1932-6.
17. Shyamala, R., and P. Sreenivasulu Reddy. "Incidence and sensitivity pattern of Pseudomonas aeruginosa in chronic suppurative otitis media in South Indian Rural Population''." J Microbiol Biotech Res 2, no. 2 (2012): 346-50
18. Osazuwa, F., Osazuwa, E., Osime, C., Igharo, E.A., Imade, P.E., Lofor, P., Momoh, M., Omoregie, R. and Dirisu, J., 2011. Etiologic agents of otitis media in Benin city, Nigeria. North American journal of medical sciences, 3(2), p.95
19. Khan, T.Z., Aqeel, Z. and ur Raheem, D., 2017. Sensitivity of antibiotics against Pseudomonas aeruginosa and Staphylococcus aureus in chronic suppurative otitis media. Rawal Medical Journal, 42(2), pp.195-198.
20. Hiremath, S.L., Kanta, R.C., Yeshwanathrao, M. and Vasantha Kumar, C.M., 2001.
Aerobic bacterial isolates of CSOM and their antibiotic sensitivity pattern. The Indian Practitioner, 54(7), pp.486-489
21. Loy, A.H.C., Tan, A.L. and Lu, P.K.S., 2002. Microbiology of chronic suppurative otitis media in Singapore. Singapore medical journal, 43(6), pp.296-299.