INTRODUCTION:

Chronic suppurative otitis media (CSOM) is chronic inflammation in the middle ear and mastoid space characterized by repeated discharge through the tympanic membrane's perforation for more than three months¹.

This disease is divided into CSOM with cholesteatoma and without cholesteatoma^2,3. Chronic suppurative otitis media is still a significant problem worldwide because of its high morbidity and mortality⁴. The incidence of CSOM in developing countries is still high, especially in low socio-economic groups, dense living environments, poor hygiene, malnutrition, and inadequate health services⁵. The incidence of CSOM per year globally is estimated at 31 million, with 22% occurring in children aged less than five years⁶. The highest incidence of CSOM occurs in the first year of life, namely 15.4 new cases per 1,000 children per year⁶. The prevalence of CSOM varies in various countries, ranging from 4% to -33.3%^4,6. The high prevalence of CSOM (2-4%) is found in Nigeria, Korea, Thailand, Philippines, Malaysia, Vietnam, and China⁴. The prevalence of CSOM in Indonesia, in general, is 3.8% or around 6.6 million Indonesians⁷. CSOM patients constitute 25% of all patient visits to ENT polyclinics⁸.

Chronic suppurative otitis media has a significant impact on hearing loss and can cause complications if not treated appropriately⁹. The use of antibiotics has reduced the incidence of CSOM complications, but the use of antibiotics incorrectly leads to germ resistance^9,10. Therapy CSOM is a challenge in itself because the disease tends to recur easily, and the germs can quickly turn resistant. The patterns of germs and antibiotic sensitivity in CSOM patients differ from one place to another^9,11,12. Understanding germs' pattern and their antibiotic sensitivity will lead to a rational choice of antibiotics to prevent the emergence of resistance^9,10. This study aims to report the microbiological profile and antibiotic sensitivity patterns in CSOM patients.

MATERIAL AND METHOD :

This retrospective study was conducted at the Department of Otorhinolaryngology-Head and Neck Surgery in Dr Soetomo General Surabaya from September 2019 to March 2020 using a medical records database. This study used total sampling, namely all CSOM patients who underwent mastoidectomy with genetic anaesthesia who met the inclusion and exclusion criteria. Inclusion criteria were patients with complaints of ear secretions less than three months old and tympanic membrane perforation (MT). Exclusion criteria were patients with complaints of ear secretions for less than three months, intact MT, who had received systemic or local antibiotic therapy within the last week, and incomplete data. Samples were collected using two sterile swabs labelled with the patient's name and examined at the Clinical Microbiology Section. The first swab was used to make Gram stain smears, while the second swab was planted into Mac Conkey agar, blood agar, and chocolate agar for bacterial isolation, which was then incubated at 35-37˚C for 24-48 hours. Identification of pathogenic isolates was carried out microscopically by looking at colour, shape, cell structure, and colony characteristics, including colony morphology, hemolysis on blood agar, and agar media changes¹³.

The organisms of each colony were cultured onto nutrient agar and continued with biochemical tests. Gram-positive isolates were tested with catalase and coagulase tests, while gram-negative isolates were tested with oxidase, triple sugar iron (TSI), sulfur indole and motility (SIM), urease production and citrate utilization¹³. Antibiotic sensitivity tests were carried out on Muller Hinton agar¹⁴. Identification of pathogens was based on microscopy (gram stain, shape, cell arrangement) and colony characteristics (colony morphology, hemolysis on blood agar, changes in the physical appearance of the differential media). Organisms from discrete colonies were cultured into nutrient agar (Oxoid, UK) for subsequent. Biochemical tests. Gram-positive isolates were tested for catalase and coagulase tests, while biochemical tests for gram-negative isolated bacteria were tested for oxidase, Triple sugar Iron (TSI), Sulfur indole and motility (SIM), urease production and citrate utilization¹⁵. According to the clinical and Laboratory Standard Institute (CLSI), antibiotic susceptibility patterns of isolated bacteria pathogens were performed using the modified Kirby Bauer disc diffusion method. A colony suspension with a concentration equivalent to 0.5 McFarland solution was prepared for each identified isolate and inoculated into Mueller – Hinton-Agar (Oxoid, UK). The selected antibiotic discs were appropriately placed onto the media and incubated at 37°C for 24 hour¹⁶. Data analysis was done using the Statistical Package for Social Sciences (SPSS) version 21. The p-value of <0.05 was considered statistically significant.

RESULT:

The results of this study describe the distribution of patients based on the diagnosis of CSOM type, demographics (including age, sex, and place of residence), clinical symptoms, comorbidities, clinical signs of CSOM, and the mastoid X-ray image presented in tabular form. Microbiological profiles of CSOM patients and analysis of germ patterns and antibiotic sensitivity are presented in tables and graphs. There were 45 participants diagnosed with CSOM with cholesteatoma 26 (57,8%) and 19 participants with CSOM without cholesteatoma (42,2%).

The age distribution was 6 years to 66 years, with a mean age of 31.00 (SD ± 17.8). The most CSOM incidence occurred in the age group from 12 to 16 (20.0%), followed by the age group 17 to 25 years (17.8%). Approximately 37.8% were male, and 62.3% were female, making the male to female ratio 1.0: 1.7.

Table 1. Patient Characteristics

Age (Year)	Gender				Total
	Man		Woman		F.	%
	n	%	n	%	n	%
6 – 11	3	6.7%	2	4.4%	5	11.1%
12 – 16	4	8.9%	5	11.1%	9	20.0%
17 – 25	2	4.4%	6	13.3%	8	17.8%
26 – 35	3	6.7%	4	8.9%	7	15.6%
36 – 45	2	4.4%	3	6.7%	5	11.1%
46 – 55	2	4.4%	4	8.9%	6	13.3%
56 – 65	1	2.2%	2	4.4%	3	6.7%
> 65	0	0.0%	2	4.4%	2	4.4%
TOTAL	17	37,8%	28	62,2%	45	100,0%

All patients had complaints of hearing loss, and most of the patients had symptoms of otorrhea with a frequency of more than 5 times per year (68.9%). Clinical examination found that 75.6% of perforations in the tympanic membrane and central perforations were most found (35.6%). Schooler X-ray mastoid sclerotic features in 29 patients (59.2%). Bone erosion was present in 25 patients (45.5%).

Table 2. Characteristics of Sign, Symptom, Clinical Finding and Schuller's X-Ray Mastoid

Complaints and clinical signs	Frequency	Percentage
Hearing loss
Light	18	40,0%
Affects daily life	27	60,0%
Otore
Nothing	3	6,7%
<3 Times/ Year	4	8,9%
3-5 x/ Year	7	15,6%
>5 x/Year	31	68,9%
Physical examination	Frequency	Percentage
Tympanic membrane perforation
Perforation	34	75,6%
Cannot be evaluated	11	24,4%
MT Perforation Location
Central	16	35,6%
Atik/posterior superior	13	28,9%
Marginal	5	11,1%
Cannot be evaluated	11	24,4%
Schuller’s X-Ray Mastoid	Frequency	Percentage
Pneumatisasi mastoid
Pneumatik	2	4,4%
Diploik	14	28,6%
Sklerotik	29	59,2%
Bone Erosion
No	25	55,5%
Yes	20	45,5%

There was the growth of monomicrobial germs in 26 patients (57.8%), polymicrobial in 5 patients (11.1%), and no growth of germs/sterility in 14 patients (31.1%). About 68.89 % of the operating materials gave positive culture results, the remaining 31.11%. No microbial growth was found (Table 3).

Table 3. Growth patterns of monomicrobial and polymicrobial germs

Germ growth	Frequency	Percentage
Monomicrobial	26	57,8%
Polymicrobial	5	11,1%
No germ growth / sterile	14	31,1%
Total	45	100%

In this study, a total of 24 isolates (70.58%) were identified as a group of gram-negative bacteria with Pseudomonas aerogenosa isolates the most being found, namely 44.11%, followed by Proteus mirabilis and Providencia struartii at 8.82%, and 5.88%. 12 isolates (29.42%) were gram-positive microbes, with the most types of isolates being Staphylococcus epidermidis and Corynebacterium amycolatum, each with 2 isolates (5.55%). 5 isolates were obtained. The growth of polymicrobial bacteria with various microbes was obtained, and the growth of E coli was obtained.

Table 4. Incidence of bacterial isolates

Positive Gram

1. Enterococcus avium

2. Staphylococcus epidermidis

3. Streptococcus pygenes

4. Staphylococcus hominis

5. Corynebacterium amycolatum

6. Staphlococcus aureus

7. Streptococcus constellatus

8. Staphylococcus coagulase

9. Staphylococcus epidermidis

10. Clostridium subterminale

Total

Frequency

Percentage

31, 25 %

Negative Gram

1. Pseudomonas aeruginosa

2. Citrobacter koseri

3. Providencia struartii

4. Providencia alcalifaciens

5. Proteus mirabillis

6. Proteus vulgaris

7. Escherichia coli

Total

Frequency

Percentage

67,75 %

No Growth

Table 5. Incidence of Polymicrobial combination of isolates

Negative Gram

1. Ps. aeruginosa and Stap pyogenes

2. Citrobacter K and Stap hominis

3. E colli and Corynebacterium amycolatum

4. Ps.aeruginosa and Clostridium subterminale

5. Providencia alcalifaciens and Proteus mirabillis

Total

Freq

uency

Pseudomonas aeruginosa showed 93.33% sensitivity with Meropenam, Amikacin, Piperacillin-Tazobactam, Ceftasidim and Cefoperazone-Sulbactam. Meanwhile, showing very low sensitivity with Imipenem (6.66%), gentamicin (33.33%), with Cefotaxime and Ceftriaxone (13.33%) among the fluoroquinolones, ciprofloxacin showed a lower sensitivity of 33.33% and levofloxacin 40 %. Proteus mirabilis showed 100% sensitivity with Meronem, Amikacin, Piperacillin-Tazobactam, Ceftasidim and Cefoperazone-Sulbactam. Meanwhile, it showed very low sensitivity with Colistin and Ampicillin (33.33%). One E coli isolate was obtained, which showed 100% sensitivity of Meronem, Imipenem, Amikacin, Aztreonam, Ceftasidim, and Cefoperazone-Sulbactam. Meanwhile, it is resistant to Gentamycin, Amoxycillin, Ampicillin, Ampicillin-Sulbactam, Ceftriaxone, Cotrimoxazole, Chloramphenicol and all fluoroquinolones.

Table 6. Antibiotic susceptibility pattern

Antibiotik	Ps Aeruginosa (15)	Proteus Mirabilis (3)	Prudentia Struatii (2)	E Coli (1)	Corynebacterium Amilacatum (2)
Meropenem	14 (93,33%)	3 (100 %)	2 (100%)	1 (100%)	2 (100%)
Amikacin	14 (93,33%)	3 (100 %)	2 (100%)	1 (100%)	-
Gentamycin	5 (33,33 %)	3 (100 %)	0 (0%)	0	2 (100%)
Astreonam	3 (20 %)	2 (66,66 %)	2 (100%)	1 (100%)	-
Amoixcillin-Clavulanic Acid	1 (6,66 %)	2 (66,66 %)	0 (0%)	0 (0%)	1 (50%)
Ampicilin	1 (6,66 %)	1 (33,33%)	0 (0%)	0 (0%)	-
Ampicillin-Sulbactam	1 (6,66 %)	3 (100 %)	1 (50%)	0 (0%)	-
Piperacillin	80 %	2 (66,66 %)	1 (50%)	0 (0%)	-
Piperacillin-Tazobactam	14 (93,33%)	3 (100 %)	2 (100%)	-	-
Cephazolin	1 (6,66 %)	3 (100 %)	0 (0%)	-	-
Cotrimoxazol	-	2 (66,66 %)	2 (100%)	0 (0%)	0 (0%)
Ceftazidimie	14 (93,33%)	3 (100 %)	2 (100%)	1 (100%)	-
Cefotaxime	2 (13,33 %)	2 (66,66 %)	1 (50%)	1 (100%)	2 (100%)
Ceftriaxone	2 (13,33 %)	3 (100 %)	2 (100%)	0 (0%)	-
Cefoperazone-Sulbactam	14 (93,33%)	3 (100 %)	1 (50%)	1 (100%)	-
Tetracyclin	1 (6,66 %)	3 (100 %)	0 (0%)	1 (100%)	-
Tigecyline	4 (26,66 %)	3 (100 %)	1 (50%)	1 (100%)	-
Chloramphenicol	1 (6,66 %)	2 (66,66 %)	0 (0%)	0 (0%)	0 (0%)
Ciprofloxacin	5 (33,33 %)	3 (100 %)	1 (50%)	0 (0%)	-
Levofloxacin	6 (40 %)	-	1 (50%)	0 (0%)	0 (0%)
Moxifloxacin	-	3 (100 %)	1 (50%)	0 (0%)	-
Imipenem	1 (6,66 %)	-	-	-	-
Colistin	-	1 (33,33%)	-	-	-
Fosomycin	-	-	1 (50%)	-	-
Oxacilin	-	-	-	-	0 (0%)
Penicilin-G	-	-	-		0 (0%)
Erythromycin	-	-	-		1 (50%)
Clindamycin	-	-	-		0 (0%)

DISCUSSION:

Chronic suppurative otitis media is a chronic infectious disease that is a worldwide health problem, especially in developing countries^13,17. Chronic suppurative otitis media is an infection of the middle ear and mastoid cavity characterized by the persistent discharge from the middle ear and perforation tympanic membrane^14,17. Prompt and precise diagnosis and management are critical to prevent complications¹³. CSOM is generally divided into CSOM with cholesteatoma and without cholesteatoma^2,3. In this study, the proportion of CSOM patients with CSOM cholesteatoma more than CSOM without cholesteatoma (1.3:1). This is consistent with previous research¹⁸. This study is different from the research of Lisa and Haidar¹⁹. CSOM with cholesteatoma, which is more common in this study, may be associated with the precedence of operative action in CSOM with cholesteatoma. The patients' age in this study ranged from 6 to 66 years, with most patients in the age range 12 to 16 years (20%). The results of this study are almost the same as previous studies^1,9,20-22. Chronic suppurative otitis media is a disease that is often found in young adults, and about 50% of patients are between 11-30 years of age²³. CSOM is usually present since childhood but is mainly detected in adulthood young. Things like young patient awareness of the illness, pre-employment treatment, or accessibility to the hospital are easier for this age group.

The study found that CSOM was more common in women than in male patients with a ratio of 1.6: 1. This ratio is not entirely different from Prakash's study, which found a female to male ratio of 1.2:1²². Several researchers reported different results^13,14. The dominance of women in this study may be an incidental finding. No anatomical or genetic differences have been found related to women and men's ears to explain the differences in the incidence of CSOM in men and women¹³.

In this study, all patients had hearing loss complaints, and most of the patients had otorrhea more than 5 times per year. In this study, complaints of hearing loss were found in all patients, followed by otorrhea complaints. Several researchers reported different findings of where otorrhea was the leading complaint^19,20. Otorrhea and hearing loss are the two main symptoms of CSOM that patients often complain of hearing loss and are the most frequent sequel to CSOM, which can be conductive hearing loss or sensory neural hearing loss^5,17,20,21. Otore often causes embarrassment and inferiority in patients, while hearing loss is often an obstacle to learning and work, so they tend to seek treatment more quickly.

MT perforation was found in 75.6% of patients with the most central location of the perforation, namely 35.6%, and this is following several investigators^8,13,20. MT perforation is essential for evaluation in CSOM because it is associated with otorrhea and hearing loss complaints^17,20. In Schuller's X-ray evaluation, it was found that most pneumatization was the sclerotic type (64%) and the presence of bone erosion (44.5%). Pneumatization is defined as the process of forming air spaces in the temporal bone. Mastoid pneumatization decreases as a chronic infection of the middle ear worsen^23,24. The mastoid air cell system makes an essential contribution to middle ear ventilation^24,25. Bone erosion can occur in CSOM with and without cholesteatoma. In CSOM with cholesteatoma, the accumulation of keratin in the middle ear and mastoid cavity results in damage to the surrounding bone structures³. The growth pattern of germs in this study consisted of 57.8% monomicrobial, 11.1% polymicrobial, and no germ growth of 31.1%. The culture results found 16 kinds of germs with Pseudomonas aeruginosa as the most prominent bacteria, 35.1%, followed by Proteus mirabilis 10.8%, Staphylococcus epidermidis, Providencia stuartii, and Corynebacterium amycolatum, respectively 8.1%, and E. coli bacteria were found.

In this study, the results of polymicrobial isolates were less than polymicrobial. This is probably because topical and systemic broad-spectrum antibiotics in the period before the study may have resulted in lower polymicrobial infections¹. The discovery of polymicrobial may explain that eardrum perforation facilitates such as Escherichia coli and Pseudomonas aeruginosa associated with wet and poor hygiene of the outer ear migrates to the middle ear and reproduces¹³. Most authors elsewhere have reported Pseudomonas aeruginosa as a common isolate. This study follows Juyal, who found Pseudomonas aeruginosa 32.1% as the most bacteria in CSOM(5). Google and Harshika's research also found that the highest Pseudomonas aeruginosa was in CSOM, namely 53.91% and 33.09%^1,14. This study was different from Mofatteh, who found Staphylococci spp at 64.9%⁹. A study by VK Pooreyetal, Pseudomonas pyocyaneus in 35.2% of cases was the most frequently isolated organism, followed by Klebsiella aerogenes in 25.4% and Staphylococcus aureus in 14.7% of cases²⁶. This study was also different from Hafizah, who received the most Proteus sp^12,27. This study was different from Mofatteh, who found the most Staphylococci spp. 64.9%⁹. In a study from Agartala, Pseudomonas (37.73%) was the most isolated bacteria, followed by Escherichia coli (20.75%) and Staphylococcus aureus (20.75%) of the cases²⁸. Pseudomonas aeruginosa is the main pathogen that is often found in CSOM⁵. This pathogen is not included in the commensal germs in the upper respiratory tract, so that its presence in the middle ear cannot be attributed to invasion through the Eustachian tube^5,9. Other factors, such as poverty, hygiene, and unconventional ear drop, such as oil and honey to the middle ear, contribute to their presence in the middle ear⁵. Pseudomonas aeruginosa is difficult to treat because these bacteria can grow in various environmental or nutritional conditions and are resistant to antibiotics^5,29. These bacteria can also escape from the host's defence system by forming a shell of damaged epithelium around it, so that blood circulation to the area decreases^1,17. Organisms can damage tissues, disrupt normal body defences, and produce enzymes and damage so that antibiotics become inactive^1,5.

Pseudomonas aeruginosa growing well in the ear can cause bone necrosis and mucosal disease⁵. The next most common organism isolated was Proteus mirabilis 3 (6.09%), following Gul's findings³⁰. In this study, the Escherichia coli bacteria were also found. Isolation of Escherichia coli coliform bacteria known to be faecal bacteria, and Pseudomonas aeruginosa, which is associated with wet environmental conditions, indicates that people are at high risk of infection due to a poor hygienic environment. Patterns of antibiotics that serve as the right original electrical currents for CSOM therapy⁵. This study found that Pseudomonas aeruginosa was 90% sensitive to imipenem, ceftazidime, amikacin, and meropenem. The sensitivity of these microbes to cefoperazone-sulbactam and Piperacillin was 75%. This study follows Ghogare, who found that 89% of Pseudomonas aeruginosa is sensitive to imipenem, 70% sensitive to Piperacillin, and 67% sensitive to amikacin¹. Harshika's research found that Pseudomonas aeruginosa is sensitive to amikacin and imipenem, Piperacillin, gentamicin, tobramycin, and cefuroxime¹⁴. Juyal's research found Pseudomonas aeruginosa was sensitive to piperacillin-tazobactam, amikacin, imipenem, and cefepime⁵. This study found that 90% of Pseudomonas aeruginosa were resistant to amoxicillin-clavulanic acid, cefazolin, ceftriaxone, cotrimoxazole, and tetracyclines. These bacteria are 75% resistant to ampicillin, ampicillin-sulbactam, and cefotaxime. The resistance of Pseudomonas aeruginosa to ceftriaxone and cotrimoxazole was also found in Mofatteh's study⁹. This study was different from Juyal, who found the highest resistance of Pseudomonas aeruginosa to fluoroquinolones (48.7%), penicillin (41.7%), aminoglycosides (38.0%), and cephalosporins (29.4%)⁵. The type of bacteria and antibiotic sensitivity in CSOM varies from region to region, managed by geographic location and other factors. Increasing prevalence of antibiotic resistance for inappropriate use of antibiotics^9,12. The selection of antibiotics based on culture results and sensitivity is an effective therapeutic modality to prevent resistance^9,32.

CONCLUSION:

Pseudomonas aeruginosa is the microorganism that is most often found in this study. The pattern of sensitivity of Pseudomonas aeruginosa shows the level of resistance of this organism to the antibiotics used. This study found that 90% of Pseudomonas aeruginosa was resistant to amoxicillin-clavulanic acid, cefazolin, ceftriaxone, cotrimoxazole, and tetracyclines but sensitive to imipenem, ceftazidime, amikacin, and meropenem. The development and widespread use of antibiotics can change pathogenic microorganisms and their resistance to antibiotics. Ear secretion culture examination is helpful as a guide for the proper administration of antibiotics to prevent the emergence of resistant microbial strains. Data on germs and their sensitivity to antibiotics can formulate policies for local antibiotic use in an institution.

ETHICAL CLEARANCE:

Ethical clearance was obtained from the Research and Publications Committee of Dr Soetomo General Hospital.

CONFLICT OF INTEREST:

The authors declared there is no competing interest in the study.

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Received on 26.03.2021 Modified on 13.06.2021

Research J. Pharm.and Tech 2022; 15(4):1683-1688.

DOI: 10.52711/0974-360X.2022.00282