Microbiological study and antimicrobial susceptibility pattern of ear infections in patients with Chronic Suppurative Otitis Media (CSOM) in Basrah Province

: The ear infections are highly popular disease in the world. Chronic suppurative otitis media (CSOM) is one of the prevalent hearing problems, this infection of the middle ear may extend to cranium that can cause many serious complications if not treated duly. It is famed for its return enduring infection. The causative agents of bacteria or fungi may be cause the CSOM infection. Therefore, our study is mainly aimed to identify the bacterial isolates which causing of CSOM and detect some isolates of fungi which implicated in this ear infection with performed of the antimicrobial susceptibility test. The study was executed on people whose attending the outpatients clinic of ENT in AL-Mwanee General Hospital during the period from November, 2016 to May, 2017 in Basrah governorate. Ear swab samples were collected and processed from eighty five (85) patients of CSOM by the following of standard bacteriological procedures mainly, for isolation and identification the bacterial pathogens, in addition, common diagnosis methods was used to detect of some fungal isolates. The positive microbial growth cultures were seen in 59 cases with frequent of (69.41 %) and 26 cases were negative in frequent of (30.58%). Their ages ranged from 1-60 years with high incidence of CSOM in age groups ≤ 10 and 31-50 years old in percent's of (38.82 % and 24.70 %) respectively. Polymicrobial samples from the total isolates (89) which identified in this study were (82) aerobic bacterial isolates in frequent (92.13 %) and 7 fungal isolates in frequent of (7.86 %). The most predominant bacterial isolated which causing CSOM was Pseudomonas aeruginosa in ratio (34.83 %) followed by Staphylococcus aureus , Streptococcus spp. , Klebsiella pneumonia , Escherichia coli , Proteus mirabilis and P.vulgaris in proportions: 29.21% , 10.11% , 8.98% , 6.74% , 1.12% and 1.12% . While, the most common fungal detection which causing of CSOM was Aspergillus spp. and Candida spp . with frequently: 71.42% and 28.57%. Susceptibility test was done for known the best antibiotic agents which can be used as a proper treatment to CSOM infection. In the present study the most effective antibiotics agents for most of bacterial isolates were Ciprofloxacin, Vancomycin, Amikacin, Augmentin, Amox-Clav and Gentamycin.

The ear infections are usually categorize into those which occur in the ear canal called otitis-externa and those which occur in the middle ear in small space behind the eardrum (Bojrab et al, 1996).Even though, the ear infection is a disease common in infants and young children but can occur at any age then, also affect the adults (Farhan et al, 2011).Otitis media is an inflammation of the middle ear.It's most commonly caused by the buildup of fluid behind the eardrum as a result of a blockage to the Eustachian tube.Otitis media is a common disease in people all over the world represents a major health problem.The prevalence of otitis media varies from place to place, also occurs with a high incidence and prevalence in both developed & developing countries (El-Gendy, 1998;Damoiseaux, Website: http://jsci.utq.edu.iqEmail: utjsci@utq.edu.iqVolume 6, Number 4, June 2018 990 2005;Sauver et al, 2006).The ear infection may be a cute, chronic or recurrent infections also, can be suppurative or non-suppurative as a cute suppurative otitis media.ASOM is a disease common in childhood and can be progress to chronic suppurative otitis media CSOM (Leach and Morris, 2006;Wariso and Ibe, 2006;Wasihum and Zemene, 2015).The chronic suppurative otitis is defined as infection of the middle ear cleft that lasting from two weeks to more than three months and is accompanied with otorrhea and perforation of the tympanic membrane mainly caused by bacteria (Rao and Reddy, 1994;Agrawal et al, 2013;Mesfin and Muluken, 2014).The infection in otitis media is mainly dependent on the route by which infection reaches to the middle ear and the chief route by which it occurs through the auditory tube (Healy and Teele, 1977;Daly, 1997).Also, the otitis media is related anatomically and pathologically with upper respiratory tract therefore the nasopharynx is a natural reservoir for several bacterial species (Fadon, 1997).CSOM is a destructive disease with sequential irreversible and can proceed to seriously intra or extra cranial complications (Poorey and Lyer, 2002).The causative organisms may be isolated in CSOM can be aerobic, anaerobic, mixed bacteria or fungi (Brook, 2003;Yeo et al, 2007;Tahira et al, 2009).Depending on the according reports of many studies, Staphylococcus aureus, Klebsiella pneumonia, Pseudomonas aeruginosa, Proteus mirabilis and Escherichia coli are the common bacteria which isolated from the cases of ear infection ( Abera and Kibret, 2011;Muluye et al, 2013;Seid et al, 2013).The entry of bacteria to the middle ear may gain through a chronic perforation (Acuin, 2004).The predisposing factors to the ear infection are higher in children than adults because, the anatomy of Eustachian tube in children easier permits access of the microorganisms through the nasopharynx (Anthony, 1997).The incidence of otitis media varies from place to place, in developing countries it is on the rise while it is declining in the developed world because of awareness (Adoga et al, 2010;Farhan et al, 2011).
The aim of this study mainly, is to detect the bacterial isolates and some other fungi in patients with otitis media infections also, apply their antibiotics susceptibility pattern against bacterial pathogens among patients who visited ENT Clinics in Basrah.

: Materials and Methods -2
The population under study was among people attending to the outpatients clinic of ENT in AL-Mwanee General Hospitals.A total of (85) patients with signs and symptoms of CSOM who were not on any antibiotics were included and investigated in this study, their ages ranged from 1 to 60 years, the investigation period extended from November, 2016 to March, 2017.
The specimens collected from patients with ear exudates by using three sterile cotton swabs under strict aseptic precautions and assist of aural speculum then processed immediately in the Lab. of microbiology.The first swab was used for the bacterial detection in microscopically and culturing on MacConkey agar, Blood and Chocolate agar which were then incubated for 24-72 hrs. at 37 C 0 in aerobic condition also, in CO2 incubator.Then, a Gram stain examination was made from the second swab of specimen with direct microscopy of sample in KOH for fungal detection.Also, the microbiological investigations were done which included: cultures, the identification of isolates after grown by using colonial morphology, characteristics of cultures and complete of the standard biochemical reactions (Cruickshank et al, 1975;Holt et al., 1994).Furthermore, the antibiotic sensitivity testing of the diagnosed organisms was determined by Kirby Bauer Method on Muller Hinton agar.The result of plates were read after incubation overnight at 37 C 0 by measure of the inhibition zones around the discs of antibiotics as per Clinical Laboratory Standards Institute ( CLSI, 2011).Finally, the third swab was used for mycology culture which included: inoculation on two slants of media on Saboroud Dextrose Agar (SDA) in 25 C 0 and 37 C 0 with the addition of chloramphenicol material.Later the examination and detection of slants were done.

3-Results:-
In the present study out of total 85 ear swabs samples were collected and processed from 85 patients suffering from CSOM.The microbial growth was seen in 59 (69.41 %) as positive culture while 26 (30.58 %) samples showed no growth.

4-Discussion
The most disease in frequently for patients to visit clinicians with take antibiotics is ear infection and the serious health care concern worldwide, it is the otitis media.Because of, not only the distress it the patients also their families but, it also because the imposes of the substantial economic burden on the care health system.The incidence of the otitis media in previously publications which reported its depend on the race the socioeconomic factors ( Shenoi, 1988 ;Rao and Reddy, 1994 ;El-Gendy, 1998 ;Ologe and Nwawolo, 2002 ;Leach and Morris, 2006 ;Egbe et al., 2010 ;Grevers, 2010).
CSOM is one of the most common ear diseases, it's a chronic infection of the middle ear may lead to deafness that's for causing of intracranial dreadful complications and irreversible local destruction of the middle ear structures.Also, this disease is notorious and more reported in lower socioeconomic status groups as well as in rural populations.If the CSOM disease untreated or poorly treated that's can lead to many complications as meningitis, mastoiditis and brain abscess (Anifasi and Tumushime-Buturo, 1989;Rao and Reddy, 1994;Fairbanks, 1996;Poorey and Lyer, 2002;Loy et al., 2002;Wariso and Ibe, 2006;Taneja and Taneja, 2009).
In our study among 85 discharging ear swabs were collected from 85 patients with CSOM.Microbial growth was found in 59 (69.41 %) as a positive culture, this is in accordance with Deb and Ray, 2012 ; Prayaga et al., 2013 but differ from Khanna et al., 2000;Poorey and Lyer, 2002;Agrawal et al., 2013 while 26 (30.58 %) samples showed no growth as negative cultures which is near similar to the prior studies of Chakraborty et al., 2005 andFatema et al., 1998 those found higher percentage of negatively culture samples whereas not accordance with Vijaya et al., 1998;Prakash et al.,2013 andDayasena et al., 2011 study.These negative cultures of results may be the reason of the modification in bacterial flora in ears affected by the previous empirical antibiotic therapy.
In the present research the increased prevalence of CSOM were in groups of age ≤ 10, 31-50 and 11-30 with frequent (38.82 %), (24.70 %), (21.17 %) respectively which is in agreement with the prior literature of Loy et al., 2002 ;Brook, 2003 ;Healy and Teele, 1977 ;Shyamala and Reddy, 2012 ;Oni et al., 2002 due to, these age of groups exposed to several predisposing factors for occurrence of otitis media any way, the more incidence of CSOM was in the first and second decade of life with accounted in 59 % of the cases during this study in addition to the ratio of age group 31-50 years old.
Also, in this study among the other gram negative pathogens which isolated next to Pseudomonas aeruginosa were including: Klebsiella pneumonia (8.98 %), Escherichia coli (6.74 %), Proteus mirabilis (1.12 %) and P.vulgaris (1.12 %).While, Streptococcus spp. in frequent (10.11 %) next to Staphylococcus aureus as gram positive pathogens.Wheres, the secondary invader was the fungal infections of the middle ear.The most common fungus causing of COSM in current study was Aspergillus spp. in isolation rate (5.61 %) followed by Candida spp. in frequent (2.24 %), these results are consort with observations of (Sunilkumar and Roopa, 2015; Kumar and Seth, 2011.Commonly, the wet pus in the middle ear may expedite the growth of the fungi.Diagnosis of the causative microorganisms is essential for suitable management the cases of CSOM disease.In the current study, the antibiotic susceptibility test was performed for all the isolated microorganisms, most of the microbial isolates which identified in this study were found to be susceptible to Ciprofloxacin.This is in accordance with study of (Prayaga et al., 2013).But, nearly 80 % of the microbial isolates showed resistance to Ampicillin drug, this was agreement with a report of (Seid et al., 2013).
In the present study, the Pseudomonas aeruginosa was highly resistance (87.09 %, 83.87 % and 80.64 %) to Trimethoprim, Ampicillin and Vancomycin respectively.Muluye et al., 2013 study revealed, the resistance levels of P.aeruginosa to Ampicillin and Amoxicillin / Clavulanic acid were 86-91.8% and 60-67 % , this result was somewhat in accordance with the our findings.However, the P.aeruginosa showed high levels of sensitivity (83.87 %, 77.41 %, and 70.96 %) to Ciprofloxacin, Levofloxacin and Gentamicin respectively.This was consisting with the results of other studies (Abera and Kibret, 2011;Wasihun and Zemene, 2015).
Our results revealed that, the agent of Ciprofloxacin was shown to be the most effectiveness agent against all the bacterial isolates with highest sensitivity for most the commonly isolated microorganisms as that of study performed by ( Afolabi et al., 2012 ).Furthermore, in the present study this effectiveness of Ciprofloxacin agent followed by Vancomycin , Amikacin , Augmentin , Amox-Clav and Gentamicin .In contrast to previously studies of ( Brook and Frazier, 1996 ;Ibekwe et al., 1997 ;Oni et al., 2001 andRebeca Mitchell &Noel Cranswick, 2008 ) whose recommended to Quinolone as second line treatment of microorganisms cause CSOM while the Penicillin can serve as the first line for drug treatment .Whereas, the others researchers revealed that, the Gentamicin agent represent the most sensitive.
In Conclusion: In our study, the chronic suppurative otitis media is still one of the most common infections in age group of ≤ 10 years old as a childhood problem and the commonest infectious bacterial agents which implicated in causing of CSOM were Pseudomonas aeruginosa followed by Staphylococcus aureus .While, the most common fungal infection which causing of CSOM was Aspergillus spp.
Ciprofloxacin , Vancomycin , Amikacin , Augmentin , Amox-Clav and Gentamicin were found to be most effectiveness antimicrobial agents against the most bacterial isolates including genera of gram negative and gram positive bacteria which isolated and detected in present study .While, its resistant to Trimethoprim, Ampicillin, Tetracycline, Chloramphenicol and Erythromycin.Most bacterial isolates were adapted to the common antibiotics and that leads to acquired resistance phenomena problem Therefore, a suitable antimicrobial drugs should be specified after proper and early diagnosis of the causative microorganisms with guided by the antimicrobial susceptibility testing of the isolates also, recommended to use of antibiotics in judicial manner with complete the full course of patients treatment and stopped the heavy used of antimicrobial agents in hospitals further to, practicing the good hand hygiene that ensures of effective the treatment to avoid the complications of CSOM disease.

Table 1 :
Distribution of CSOM patients according to age groups

Table 2 :
Category of isolates

Table 3 :
List of various Microorganisms (Bacteria, Fungi) isolated from cultures

Table 4 :
Antibiotics susceptibility pattern in Pseudomonas aeruginosa

Table 6 :
The number and percentage of antibiotics susceptibility pattern in Gram negative bacteria other than P. aeruginosa

Table 7 :
Antibiotics susceptibility pattern in Streptococcus spp.