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Microbiological Profile of Chronic Suppurative Otitis Media

Otitis media is an inflammation of the middle ear & mastoid process, which could be acute purulent otitis media, otitis media with effusion and chronic suppurative otitis media (CSOM) (Berman, 1997). CSOM is a condition of non-healing perforation of the tympanic membrane associated with chronic inflammatory changes of the Mucoperiosteum of the middle ear cleft resulting in mucoid or mucopurulent otorrhea of more than three months duration (Nwabuisi and Ologe, 2002; Sharma et al., 2004). CSOM is a major problem in developing countries like India. It is more common in children International Journal of Current Microbiology and Applied Sciences ISSN: 2319-7706 Volume 7 Number 10 (2018) Journal homepage: http://www.ijcmas.com

belonging to lower socioeconomic group (Lasisi et al., 2007). It is single most important cause of hearing impairment in our country (Srivastava et al., 2010).
The study of microorganisms associated CSOM and their antibiotic sensitivity pattern is most important for clinician to plan general outline of treatment of chronically discharging ear (Greval and Ram, 1996). The most common microorganisms found in CSOM are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis, Klebsiella species, Escherichia coli, Aspergillus spp, and Candida Spp, but these organisms vary in various geographical areas (Anwar-us-Salam and Abdulla, 1997).
Early and effective treatment based on the knowledge of causing microorganisms and their sensitivity results in good clinical recovery and prevents damage and complications caused by CSOM (Taneja, 1999). Antimicrobial therapy used to eradicate the bacterial agents causing otitis media but most of the microorganisms are acquiring antibiotic resistance. In developing countries, this problem is rapidly increasing due to misuse of antibiotics. The important factors associated with occurrence CSOM found to be a poor hospital hygiene, overcrowding, lack of resources for infection control and lack of personnel trained in controlling infections in hospital (Hart and Kariuki, 1998).
Pseudomonas aeruginosa is the most predominant organism among the cases of CSOM reported by several workers in India and abroad with an incidence ranging from 21% to 52.14% (Gulati et al., 1969;Ayyagari et al., 1981;Rao and Bhaskaran, 1984). Pseudomonas aeruginosa possesses an intrinsic resistance to many antibiotics and has an ability to develop resistance through mutations in different loci or through the horizontal acquisition of resistant genes, which carried on plasmids, transposons or integrons (Bannerman et al., 2007).
The changing flora of CSOM and emergence of strains resistant to the commonly employed antibiotics stimulated this study. The present work deals with the bacteriological study of CSOM to identify and categorize various organisms isolated and to evaluate their sensitivity pattern (Agrawal et al., 2013).

Materials and Methods
The present study carried out after the clearance from the ethical committee in the department of Microbiology at Tertiary care hospital.
Total 109 patients presenting with ear discharge for more than 3 months of age group varying from 1-70 years and both sexes were included in the study. Medical history were noted including ear discharge, its duration, hearing status, previous history of upper respiratory tract infection (URTI), ear surgery and ear trauma, presence of nasal allergy, chronic tonsilitis, tuberculosis etc.
Ear discharge collected under aseptic precaution in clinically diagnosed cases of CSOM with sterile cotton wool swabs. Excess discharge was mopped out from external auditory canal and it was cleaned with 70% alcohol first and was allowed to act for 30-40 seconds to achieve sterile area (Vartiainen and Vartiainen, 1996;Gopichand et al., 2015).
The specimens were cultured on blood agar, MacConkey's agar and chocolate agar for aerobic bacteria and incubated at 37 0 C overnight (18-24 hours). The reading of the plate, colony identification, Gram Stain, biochemical test was done as per standard microbiological method (Forbes et al., 2002). A plate showing no growth after 48 hours was considered as negative. The antimicrobial susceptibility was performed on Mueller Hinton Agar (MHA) by Kirby Bauer disc diffusion method as per CLSI guidelines (Biemer, 1973;Jorgensen et al., 2007).

Inclusion criteria
The patients with active aural discharge for more than 3 months belonging to different age, sex, religion and different classes were included in the study. The samples were further subjected to aerobic culture and Gram stain.

Exclusion criteria
Patients with history of using antibiotic either systemic or local in the form of ear drops for last 7 days were excluded in the study.

Results and Discussion
A total of 109 patients having CSOM were studied, different organisms are isolated and their antibiogram was done. The results were correlated with demographic data of the individuals.
Chronic suppurative otitis media (CSOM) is a condition of the middle ear characterized by persistent or recurrent discharge through a chronic perforation of the tympanic membrane. Due to the perforated tympanic membrane, bacteria can gain entry into the middle ear via the external ear canal. Infection of the middle ear mucosa subsequently results in ear discharge. Untreated cases of CSOM can result in broad range of complications that leads to spread of bacteria to structures adjacent to the ear or to local damage in the middle ear and such complications are ranges from persistent otorrhea, mastoiditis, labyrinthitis, facial nerve palsy and intracranial abscesses or thromboses. While the incidence of such complications is low, they need to be borne in mind when faced by a patient with active CSOM. Hence, early and effectively treatment required to avoid such complications (Loy et al., 2002).
In the present study maximum number of patients 47 (42%) were in the age group of 11-20 years. Studies conducted by (Poorey, 2002), (Vijaya and Nagarathnamma, 1998) and (Urmil Mohan and Jindal, 1998) have reported maximum number of patients belonging to the second decade. The higher incidence of otitis media in first two decades may be due to abundance of lymphoid tissue in children that may obstruct the eustachian tube and increased risk of respiratory infection in children may result in CSOM. The infection of CSOM was more common in males 71 (65%) than the females 38 (35%). The male predominance may be because of their more exposed way of life (Varshney and Gupta, 1999). The CSOM cases were more common in rural area 60(55%) as compared to urban area 49(45%) which is in accordance with (Gulati, 1997) and (Urmil Mohan and Jindal, 1998). Incidence of CSOM is high in rural areas because of lack of education, awareness and availability of trained specialists. The CSOM cases were more prevalent during winter season 59(54%) and during early spring 30(28%) which is correlated with Kathleen A. Daly (1991) and Charles D Bluestone (2004). Nwokoye et al., (2012) have reported increased incidence of CSOM in rainy season (May-Oct). Increased incidences in winter season are mainly attributed to repeated upper respiratory tract infection (viral, bacterial) (Paparella et al., 1991).
The factor associated with socio-economic status were also evaluated and it was observed that CSOM was more among lower socioeconomic class (59%) followed by middle class (30%) and 11% in upper class individuals. This finding correlates with studies of Gulati (1997), Urmil Mohan and Jindal (1998)

Escherichia coli (02)
Ciprofloxacin The criteria for socio-economic status was as follows-lower (<3000/month), middle (3000-14000/month) and upper class (>14000/month) (Paparella et al., 1991). It is presumed that multiple factors such as poor sanitation, unhygienic living conditions, overcrowding, malnutrition, illiteracy and lack of health consciousness in low socioeconomic status may contribute to the increased development of otitis media (Hivemath et al., 2001).
However, (Rao and Reddy, 1994) found equal incidence of mixed and pure culture. Use of topical and systemic broad-spectrum antibiotics in the period before consultation was probably responsible for the lower incidence of mixed infection (Koppad). Although in the present study patients not taken antibiotics were amongst the exclusion criteria, but as CSOM being chronic disease patients must have been taken topical or systemic antibiotics by local general practitioners and this is probably responsible for lower incidence of mixed infection (Koppad).
The next predominant organism in the present study was Staphylococcus aureus 33 (28.69%). This is in accordance with the finding reported by (Hiremath et al., 2001), (Loy et al., 2002). The frequency of Staphylococcus aureus in the middle ear infections can be attributed to their ubiquitous nature and high carriage of resistant strains in the external auditory canal and upper respiratory tract (Chole and Sudhoff, 1998).
The occurrence of P. aeruginosa as the prime offender can be attributed to various factors like minimal nutritional requirement and its armamentarium of antibacterial products, pyocyanin and bacteriocin (Mansoor et al., 2009). The Vartiainen and Vartianen postulated that Pseudomonas has the ability to carve out a niche for itself in local infection through the necrotizing activities of its extracellular enzymes. The physical characteristics of the niche, a damaged epithelium, interrupted circulation and devitalized tissue protects the organism from normal host defense mechanisms and antibiotic agents (Vartiainen and Vartiainen, 1996).
When the results of various workers compared, one fact became obvious that the bacteriology and antibiotic sensitivity pattern of CSOM has been changing from time to time. Sensitivity patterns and drug resistance vary according to the region and may give different picture as the time passes on. A carefully selected local and/or systemic antibiotic guided by culture and sensitivity is an effective treatment modality. This will prevent development of drug resistance and administration of unwanted antibiotics.

References
Agrawal A, Kumar D, Goyal A, Goyal S, Singh N, Khandelwal G. Microbiological profile and their antimicrobial sensitivity pattern in patients of otitis media with ear