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Table of Content Volume 12 Issue 2 - November 2019

 

 

 

Bacteriology of chronic suppurative otitis media and its associated risk factors in a tertiary care hospital

 

Kiran Gopal1, Jinu T Eldho2*, Mohammed Riyas3

 

{1Assistant Professor, Department of Microbiology} {2Assistant Professor, Department of Anatomy} Dr. Somervell Memorial CSI Medical College, Karakonam, Kerala, INDIA.

3Consultant in ENT, Government District Hospital, Kanhangad, Kerala, INDIA.

Email: kirangopal6@gmail.com

 

Abstract               Background: CSOM has been a source of a tremendous health predicament since time immemorial and even today it is immensely intricate both for patients and an otologist to deal with. The worldwide prevalence of CSOM is 65-330 million people; and 39-200 million (60%) suffer from clinically significant hearing impairment. India is one of the countries with highest CSOM prevalence (>6%) where urgent attention is needed. Therefore, the present study was undertaken to know the new trend of prevalence of CSOM, different bacteria causing CSOM and age, sex, seasonal variation and diabetes mellitus among the people in north Karnataka. Methods: Eighty-fourculture positive cases of CSOM were studied. Two swabs were taken from each patient, one for Gram’s staining and the other one for cultureonto blood agar and MacConkey agar. After isolation, Gram stain, and biochemical reactions were done according to the procedures and the organisms were identified based on that. Association of culture positive CSOM cases with respect to age, sex, seasonal variation, diabetes mellitus and other comorbidities were studied in detail. Results: A total number of 9 different bacterial species were isolated from 84 CSOM cases. The most common organism isolated was Pseudomonas aeruginosa (31.4%) followed by Staphylococcus aureus (28%), Klebsiella pneumoniae (12.3 %), Proteus mirablilis (9%), Escherichia coli (5.6%), Citrobacter freundi (4.4%), Acinetobacter spp (2.2%), Streptococcus pyogenes (2.2%) and CONS (4.4%). P. aeruginosa and S. aureus were the commonest organisms causing CSOM in children. The infection was most common within 20 years of age (51%) of the patients were affected. The incidence of the CSOM decreased with increase of age. Males were more commonly affected those females. Male: Female ratio was 1.5:1. CSOM was most common in winter (67.7%) followed by monsoon (19.4%) and was least during summer.The majority of the patients (85.7%) were not suffering from any other comorbidities. 10% of the patients had given a history of diabetes mellitus and 3.6% of the patients had HIV infection. About 75% of the patients above 45 years had given a history of diabetes mellitus. Hence diabetes mellitus can be a predisposing factor for old age CSOM. Conclusion: P. aeruginosa and S. aureus were the commonest organisms causing CSOM. The infection was most common within 20 years of age. Males were more commonly affected than females. CSOM was most common in winter season. Diabetes mellitus is a predisposing factor for old age CSOM.

Key Word: CSOM, Diabetes mellitus, Pseudomonas aeruginosa.

 

 

INTRODUCTION

CSOM has been a source of a tremendous health predicament since time immemorial and even today it is immensely intricate both for patients and an otologist to deal with.1 Morgagni was the first to describe suppuration in an ear as a primary lesion. The worldwide prevalence of CSOM is 65-330 million people; and 39-200 million (60%) suffer from clinically significant hearing impairment.3 India is one of the countries with highest CSOM prevalence (>6%) where urgent attention is needed.4CSOM is defined as persistent inflammation of middle ear or mastoid cavity, characterized by recurrent or persistent ear discharge (otorrhoea) over 2-6 weeks through a perforation of tympanic membrane.3,4 Risk factors for the development of CSOM include young age, high rates of nasopharyngeal colonization with potentially pathogenic bacteria, overcrowding, inadequate housing, poor hygiene, lack of breast feeding, poor nutrition, exposure to cigarette or smoke, eustachian tube dysfunction, inadequate or unavailable health care and poverty.5In children, CSOM can cause long term effects on early communication, language development, auditory processing, psychosocial and cognitive development, educational progress and achievement6. CSOM can cause serious otologic complications (hearing impairment). Extracranial complications consist of mastoiditis, facial nerve paralysis, labyrinthitis and cholesteatoma. Intracranial complications include meningitis, cerebral and epidural abscess, lateral sinus thrombosis and otitic hydrocephalus.7. So an early and accurate diagnosis may be lifesaving.8Knowledge of the local microbiological flora in CSOM is essential for initializing empirical therapy pending culture results.9

 

OBJECTIVE

  1. To study the organisms causing CSOM.
  2. To study the distribution of CSOM cases with respect to age, sex, seasonal variation and diabetes mellitus.

 

METHODS

Study settings

Department of Microbiology, S. Nijalingappa Medical College and Hanagal Shri kumareshwar Hospital and Research Centre, Bagalkot.

Study design: Prospective study

Duration Of Study

1 yea

Sampling Method: Census method of sampling

Sample size: A total of 84culture positive patient samples with CSOM of all age groups and both sexes

Inclusion Criteria

  1. Bacterial culture positive samples of clinically diagnosed CSOM cases,
  2. Aerobic bacterial growth only.

Exclusion criteria:

  1. Anaerobic bacterial and fungal culture positive patients’samples.

Statistical Analysis: Data obtained were consolidated, statistically evaluated using SPSS software version 16 and results obtained were represented using charts and tables.

METHODOLOGY

The study was conducted after approval by the human ethics committee, S. Nijalingappa Medical College and Hanagal Shri kumareshwar Hospital and Research Centre, Bagalkot.

History Taking And Examination: A proforma was filled for each patient documenting age, sex, address and clinical information, including chief complaints, duration of symptoms and predisposing factors were noted.

Direct microscopy: With one swab, a smear was made on a clean grease free glass slide and was fixed by heating. Gram’s staining was done for the smears so made and observed under oil immersion microscope. The stained smear was screened carefully for the presence of bacteria also for the presence of pus cells.

For aerobic culture: A. Inoculation on culture media:- The second swab was inoculated on to dried plates of 5% sheep blood agar and MacConkey agar. These plates were incubated aerobically at 370 C for 24 hours and looked for evidence of growth. If there was no growth, the plates were further incubated for 48 hours and reported as no growth.

After isolation, Gram stain, and biochemical reactions were done according to the procedures described in Mackie and McCartney Practical microbiology and Koneman’s text book of Diagnostic Microbiology.10,11 All culture positive samples were further analyzed on the basis of age, sex, seasonal variation, diabetes mellitus and other comorbidities.

 

RESULTS

Out of 84 patients’ samples studied, 79 (94%) were mono-bacterial and 5 (6 %) showed two types of bacterial growth.

Table 1

Growth

Frequency

Percentage (%)

Monobacterial

79

94

Two types of bacteria

5

6

Total

84

100

 Age Distribution

Table 2

AGE

Frequency

Percentage (%)

<10 Years

22

23.7

11-20 Years

26

28.0

21-30 Years

19

20.43

31-40 Years

14

15.05

41-50 Years

4

4.3

51-60Years

3

3.2

61-70 Years

4

4.3

71-80 Years

1

1.08

Total

93

100

The infection was most common within 20 years of age (51%) of the patients were affected. The incidence of the CSOM decreased with increase of age.

 

 

Pattern Of Organisms

Table 4:

ORGANISM

Frequency

Percentage (%)

1.P. aeruginosa

28

31.4

2. S. aureus

25

28

3. K.pneumoniae

11

12.3

4. P.mirabilis

8

9.0

5.. E. coli

5

5.6

6. C. freundi

4

4.4

7. S. pyogenes

2

2.2

8. Acinetobacter spp

2

2.2

9. CONS

4

4.4

Total

89

100

A total number of 10 different bacterial species were isolated from 89 isolates. The above table shows that the most common organism isolated was Pseudomonas aeruginosa (31.4%) followed by Staphylococcus aureus (28%), Klebsiella pneumoniae (12.3 %), Proteus mirablilis (9%), Escherichia coli (5.6%), Citrobacter freundi (4.4%), Acinetobacter spp(2.2%), Streptococcus pyogenes (2.2%) and CONS (4.4%),

Other Associated Diseases

Table 5:

Diseases

Frequency

Percentage (%)

Nil / No diseases

72

85.7

HIV

3

3.6

DM

9

10.7

Total

84

100

The majority of the patients (85.7%) were not suffering from any other illness. 10% of the patients had given a history of Diabetes mellitus and 3.6% of the patients had given a history HIV infection.

Diabetes Mellitus Vs Csom

Table 6:

Diabetes Mellitus

CSOM > 45 YEARS

 

Frequency

Percentage (%)

DM+

9

75

DM-

3

25

Total

12

100

There were no patients who were suffering from diabetes mellitus below 45 years. About 75% of the patients above 45 years had given a history of diabetes mellitus. So diabetes mellitus can be a predisposing factor for old age CSOM.


Age Vs Distribution of Organisms

Table 7:

Age

Acinetobacter

E. coli

P.aeruginosa

S.aureus

K.pneumoniae

P.mirabilis

CONS

C.freundi

S.pyogenes

<10

0

0

6

7

2

4

1

1

1

11-20

1

2

9

8

5

2

1

1

0

21-30

0

1

5

6

3

2

0

1

1

31-40

1

1

5

2

0

0

1

0

0

41-50

0

1

0

1

0

0

0

1

0

51-60

0

0

0

0

0

2

1

0

0

61-70

0

0

2

1

1

0

0

0

0

71-80

0

0

1

0

0

0

0

0

0

Total

2

5

28

25

11

8

4

4

2

P. aeruginosa and S. aureus were the commonest organisms causing CSOM in children.

 


DISCUSSION

In the present study, an attempt was made to know about the bacteria causing CSOM. Distribution of CSOM cases with respect to age, gender, seasonal variations, diabetes mellitus and HIV infection were also studied. The results are compared with the other studies and discussed as follows:

Age Distribution : Maximum number of patients were found between the age group 11 – 20 years (28%) followed by the group under 10 years of age (23.7%); so more than half of the total patients (51.7%) were less than 20 years of age. The incidence of CSOM decreased with increase in age.

Higher incidence of otitis media in first two decades may be due to

  • Abundance of lymphoid tissue in children may obstruct the eustachian tube
  • Increased risk of respiratory infection
  • Decreased immunocompetence.
  • Short and straight eustachian tube in infants and young children allows readyaccess of bacteria to middle ear.12,13

Shreshta et al14 in 2011 found that majority of the patients in CSOM were less than 20 years. Similar to the present study were also shown by A. Srivastava et al1, Bayeh Abera15(2011), Shazia Parveen and Janardhan Rao 16(2012). But in a study done by Asish J et al17(2013), the most prevalent age group was between 20 and 30 years. Moorthy et al in 182013 found that there is no age predisposition.

Sex Distribution: The present study shows that males are more commonly affected than females. Male – Female ratio was 1.5:1. Male predominance may be because of their more exposed way of life. Varshney Saurabh 19(1999), Ferede D et al 20(2001), Poorey V.K and AratiIyer21 (2002), Ihsan E Alsaimaryet al22(2010), Shreshta et al 14and E. Meyer et al23(2013) also found that males are more predominantly affected than females. But Moorthy et al18(2013) showed that both males and females are equally affected.

Pattern Of Organisms: The most common organism isolated in the present study was was Pseudomonas aeruginosa (31.4%) followed by Staphylococcus aureus (28%), Klebsiella pneumoniae (12.3 %), Proteus mirablilis (9%), Escherichia coli (5.6%), Citrobacter freundi (4.4%), Acinetobacter spp(2.2%), Streptococcus pyogenes (2.2%) andCONS (4.4%), Majority of the organisms were gram negative (66%). The current study showed similar results with the study done byMaji PK et al24(2007), Ihsan E Alsaimaryet al 22 (2010), R.K Sanjana et al25(2011),Asish J etal157(2013), S.K. Malkappaet al26(2014) and Arvind N 27et al (2014) . All these studies showed Paeruginosa as the commonest causative agent for CSOM.

Seasonal Variation: In the present study it was found that CSOM was most common in winter (63%) and least during summer (12.9 %). The findings are similar to the study done by Asish J et al17in 2013 in Raichur. But Maji P.K 24showed considerable aggregation of cases in months from July to September.

Age Wise Distribution: P. aeruginosa and S. aureus were the commonest organisms causing CSOM in children.

P.aeruginosa was the most common organism causing CSOM in adults. The findings correlate with the study of Haider.2

Diabetes Mellitus Vs Csom: About 75% of the patients above 45 years had given a history of diabetes mellitus. So diabetes mellitus can be a predisposing factor for old age CSOM. More studies are needed to substantiate this finding.

 

CONCLUSION

The most common organisms isolated were P. aeruginosa and Staphylococcus aureus. Majority of the patients were within 20 years of age, 11 – 20 years was the most common age group affected. The incidence of the CSOM decreased with increase of age. Males were more commonly affected than females. CSOM cases were more prevalent during winter than in monsoon and summer. Diabetes mellitus is a predisposing factor for old age CSOM.

 

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