|Year : 2021 | Volume
| Issue : 2 | Page : 71-75
Pattern of pseudomonas aeruginosa infection among Northwestern Nigerians with chronic suppurative otitis media
Abdulrazak Ajiya1, Iliyasu Yunusa Shuaibu2, Auwal Adamu3, Hamisu Abdullahi1, Abdulazeez Omeiza Ahmed1, Shofoluwe Nurudeen Adebola2, Abdullahi Musa Kirfi3, Usman Mohammed Aminu2
1 Department of Otorhinolaryngology, Faculty of Clinical Sciences, College of Health Sciences, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
2 Department of Surgery, Division of Otorhinolaryngology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Otorhinolaryngology Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital/Abubakar Tafawa Balewa University, Bauchi, Nigeria
|Date of Submission||09-Aug-2021|
|Date of Decision||15-Nov-2021|
|Date of Acceptance||25-Dec-2021|
|Date of Web Publication||24-Feb-2022|
Dr. Iliyasu Yunusa Shuaibu
Department of Surgery, Division of Otorhinolaryngology, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: Pseudomonas aeruginosa has been particularly blamed for the deep-seated and progressive destruction of the middle ear and mastoid structure through its toxins and enzymes. Drug-resistant P. aeruginosa has been found to increase along with its frequency. Aim: This study aimed to assess the antibiotic sensitivity pattern of P. aeruginosa and the effectiveness of ciprofloxacin in chronically discharging ears. Patients and Methods: This was a retrospective review of 180 patients who were managed for chronic suppurative otitis media between January 2009 and December 2018. Results: Out of the 180 patients, majority 67 (37%) were in the age group 1–10 years, range of 1 month to 70 years with mean age of 18 years and standard deviation of ± 16.8 years and M: F of 1.5:1. Most have had ear discharge for more than 6 months and the majority 78 (43.4%) of the patients had bilateral disease. Central tympanic membrane perforation was the predominant finding, 81 (45.0%) with a complication rate of 21.1%. Abscess formation was the most common complication seen among the patients. P. aeruginosa was the most common bacterial isolate, 43 (23.9%) followed by Staphylococcus aureus, 39 (21.7%). In the pediatric population, P. aeruginosa was most sensitive to levofloxacin, as opposed to gentamicin in the adult population. Ciprofloxacin was seen to be more effective in adults than in children. Resistance to ciprofloxacin was seen more in the children than in adults. There was a significant association between gender and occurrence of the organism. Conclusion: P. aeruginosa is most sensitive to levofloxacin and gentamicin in the pediatric and adult population, respectively. Resistance to ciprofloxacin is most common among adults.
Keywords: Antibiotics, chronic suppurative otitis media, Pseudomonas aeruginosa, resistance, sensitivity
|How to cite this article:|
Ajiya A, Shuaibu IY, Adamu A, Abdullahi H, Ahmed AO, Adebola SN, Kirfi AM, Aminu UM. Pattern of pseudomonas aeruginosa infection among Northwestern Nigerians with chronic suppurative otitis media. Ann Trop Pathol 2021;12:71-5
|How to cite this URL:|
Ajiya A, Shuaibu IY, Adamu A, Abdullahi H, Ahmed AO, Adebola SN, Kirfi AM, Aminu UM. Pattern of pseudomonas aeruginosa infection among Northwestern Nigerians with chronic suppurative otitis media. Ann Trop Pathol [serial online] 2021 [cited 2022 Dec 2];12:71-5. Available from: https://www.atpjournal.org/text.asp?2021/12/2/71/338257
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a chronic inflammation (infection) of the middle ear and mastoid cavity, which presents with recurrent ear discharges or otorrhoea through a persistent tympanic membrane perforation. The disease usually begins in childhood as a spontaneous tympanic membrane perforation due to an acute infection of the middle ear, known as acute otitis media, or as sequelae of less severe forms of otitis media (e.g., secretory otitis media). In general, patients with tympanic membrane perforations that continue to discharge mucoid material for periods of 6 weeks to 3 months, despite medical treatment, are recognized as CSOM cases. However, the World Health Organization (WHO) definition requires only 2 weeks of otorrhoea.
Using the country prevalence rates as grouped based on the WHO regional classification, Nigeria is among the countries with high prevalence (2%–4%) of CSOM in the world. Moreover, otitis media is the most common ear disease in the tropics and in Nigeria in particular.,, CSOM is the most common otologic condition seen across otorhinolaryngology clinics in Nigeria.,,
In CSOM, the bacteria may be aerobic (e.g., Pseudomonas aeruginosa [P. aeruginosa], Escherichia coli, Staphylococcus aureus [S. aureus], Streptococcus pyogenes, Proteus mirabilis, Klebsiella species) or anaerobic (e.g., Bacteroides, Peptostreptococcus, Proprionibacterium).,, Among these bacteria, P. aeruginosa has been particularly blamed for the deep-seated and progressive destruction of middle ear and mastoid structures through its toxins and enzymes.
Medical management of CSOM involves appropriate use of antibiotics. P. aeruginosa is one of the common pathogenic bacteria in hospital-acquired infections and CSOM. The organism was the most frequently isolated from otorrhoea of patients, with the annual isolation rates remaining constant over time.,,,, In Nigeria, like in other findings worldwide, the leading bacterial isolates from chronically discharging ears are P. aeruginosa and S. aureus.,,,
Because of increasing bacterial resistance to antibiotics, notable changes in previously reported sensitivity pattern have been documented.,,, Thus antibiogram of bacterial isolates are not static and this creates the need for effective update of antibiogram of isolates. Drug resistance of P. aeruginosa has been found to increase along with its frequency. Ototopical ciprofloxacin has proven effectiveness against P. aeruginosa, however, recently, ciprofloxacin-resistant P. aeruginosa is on the increase. Therefore, continuous surveillance is necessary to monitor antimicrobial resistance and to guide antibacterial therapy.
This study aims to retrospectively assess the antibiotic sensitivity pattern of P. aeruginosa isolates in chronically discharging ears among patients in this environment and possibly establish trend in antibiotic resistance pattern.
| Patients and Methods|| |
This is a retrospective descriptive study of patients managed for CSOM at the department of otorhinolaryngology, Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria, over a 10-year period from January 2009 to December 2018, who had their ear discharge subjected to microscopy, culture, and sensitivity. Ethical approval was sought and obtained from the ethical review committee of AKTH, Kano, Nigeria.
All patients included had ear swab taken and sent to the laboratory for microscopy, culture, and sensitivity test. Patients that were excluded were those whose case records were either not found or do not have complete clinical or laboratory records. Patient's data were collected from the patient's case files and records of the department of microbiology, AKTH, Kano.
Information obtained from the case files included demographic characteristics such as age and sex, also clinical information such as presenting complaints, duration of symptoms, previous use of ototopical antibiotics, nature of ear discharge, presence or absence of complications, type of complications, and pattern of tympanic perforation. Antibiotic sensitivity was obtained from the laboratory result sheet.
Data were entered into a spreadsheet and analyzed using SPSS version 23 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were summarized as frequencies and percentages and presented as tables. Chi-square test was used to determine P value and to test for statistical significance, which was set at P < 0.05.
| Results|| |
Out of the 180 patients, majority 67 (37.2%) were in the age group 1–10 years, age range of 1 month to 70 years and a mean age of 18 years and standard deviation of ± 16.8 years with predominance of the male gender, 108 (60%) and M:F ratio of 1.5:1. The median age of occurrence was 14.0 years with interquatile range of 20.8 years [Table 1]. Most of the patients 113 (62.8%) presented with symptoms of more than 6-month duration, 113 (62.8%). Both right and left ears are affected equally, with the majority of the patients 78 (43.3%) having bilateral disease. Mucopurulent discharge 108 (60%) was the most commonly encountered among the patients, and most of them 125 (69.4%) had treatment with otic preparations [Table 2].
Otoscopy showed central tympanic membrane perforation in most of our patients, 81 (45%) [Table 3] and complication was seen in up to 38 (21.1%) of the patients [Figure 1].
|Figure 1: The pattern of complications among our patients with abscess formation being the most common (37%) followed by aural polyps (26%)|
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P. aeruginosa is the most common bacterial isolate 43 (23.9%) in the middle ear discharge of our patients with CSOM, followed by S. aureus, 39 (21.7%) and Proteus spp, 30 (16.7%) [Table 4].
|Table 4: Distribution bacterial isolates among patients with chronic suppurative otitis media|
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There is a statistically significant association between the gender of patients and occurrence of P. aeruginosa in CSOM with females more likely to have the infection (P < 0.05). On a similar note, a weak association was observed between age of the patients and presence of the organism in ear discharge of the assessed patients. Isolation was observed to be more likely in adults (P > 0.059) [Table 5].
|Table 5: Factors associated with occurrence of Pseudomonas aeruginosa in patients with chronic suppurative otitis media|
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Isolated P. aeruginosa is seen to be most sensitive to levofloxacin followed by azithromycin and ceftriaxone in the pediatric population. However, in adults, the organism is most sensitive to gentamicin followed by ciprofloxacin. Moreover, when the sensitivities were compared in children and adults, the organism was found to be more sensitive to ciprofloxacin in adults than in children [Figure 2].
The resistance pattern of P. aeruginosa to the tested antimicrobial agents showed that the highest resistance was to augmentin followed by tetracycline among the adults. In the pediatric population, the organism is most resistant to erythromycin followed by the trio of augmentin, ciprofloxacin, and ofloxacin. In addition, the resistance to ciprofloxacin is seen more in children than in adults [Figure 3].
| Discussion|| |
CSOM in both children and adults is a common problem, especially in resource-constrained countries. This current retrospective review showed that the majority of our patients are in the age group of 1–10 years with a mean age of 18 years. This is similar to findings from reviews in Nigeria and Ethiopia.,, However, on the contrary, data from South Korea, Japan, and china revealed a higher mean age of occurrence ranging from 32 to 51.7 years.,,, Risk factors that predispose to the occurrence of CSOM are prevalent in densely populated or resource-constrained societies who commonly have a large population of the young and low vaccination coverage.
The male gender is more commonly afflicted by the disease in our environment as is also seen in other communities.,,,,,, However, some authors reported predominance of the female gender. Long duration of symptoms beyond 6 months is common among our patients as was similarly reported by Madana et al. Bilateral affectation is a more common occurrence among our patients as was previously reported by Wasihun and Zemene Hiremath et al. However, to the contrary, Orji and Dike in Nigeria and Afolabi et al. in Nigeria reported unilateral disease as more common. This may be due to differences in sample size in the studies. In Ethiopia, Wasihun and Zemene reported that most of their patients presented with mucopurulent ear discharge in agreement with what we found in this review. Some studies in India reported tubotympanic disease as the most common form of CSOM in agreement with the findings of this study. However, in India, Madana et al. reviewed children who had mastoid surgery and found only 3% having central perforation, majority had atticoantral disease. Complications were seen in 21.1% of our subjects in contrast to 44% reported by Madana et al. in India. Although their review was among children who underwent mastoid surgery.
Occurrence of P. aeruginosa varies widely in studies across the world with prevalence ranging from 2.7% to 44%.,,,, The predominant bacterial isolate in the middle ear discharge of our patients was P. aeruginosa as similarly reported by several other authors.,,,, However, some studies revealed contrasting findings.,,, P. aeruginosa was seen in our study to be most sensitive to levofloxacin in the pediatric population, in contrast to findings by Madana et al. and Lee et al. who reported ceftazidime and cephalothin, respectively, as most active on the organism. On the other hand, gentamicin was seen among our adult patients to be most effective against P. aeruginosa isolates as similarly reported by Orji and Dike in Nigeria.
In general, ciprofloxacin that is commonly used in most otorhinolaryngological clinics across Nigeria as topical agent for the treatment of CSOM was not seen to be particularly effective against P. aeruginosa, especially in children from the findings of our study. This is comparable to the findings of other studies worldwide.,,, P. aeruginosa isolates from the ears of our patients showed high level of resistance to amoxycillin-clavulanic acid as similarly reported in some other studies.,
Our study revealed some relationship between gender and to some extent age and occurrence of P. aeruginosa in patients with CSOM. This is similar to findings by Ayaz et al. in Pakistan where they found children <10 years to be affected the most with P. aeruginosa being the predominant organism. The same study, however, found in contrast, the male gender being infected more as compared to females.
The retrospective nature of this review and the scope of the antibiotics tested for sensitivity were limitations in this study.
| Conclusion|| |
P. aeruginosa is the most common isolate in our patients with CSOM and its occurrence is statistically associated with gender and to some extent the age of patients. P. aeruginosa is most sensitive to levofloxacin and gentamicin in the pediatric and adult population, respectively. Resistance to ciprofloxacin is most common among adults.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kenna MA. Treatment of chronic suppurative otitis media. Otolaryngol Clin North Am 1994;27:457-72.
Smith AW, Hatcher J, Mackenzie IJ, Thompson S, Bal I, Macharia I, et al
. Randomised controlled trial of treatment of chronic suppurative otitis media in Kenyan schoolchildren. Lancet 1996;348:1128-33.
World Health Organization. Report of a WHO/CIBA Foundation Workshop. In: Prevention of Hearing Impairment from Chronic Suppurative Otitis Media. Geneva: World Health Organization; 1998.
Ogisi FO, Osammor JY. Bacteriology of chronic otitis media in Benin. Niger Med J 1987;12:187-90.
Brobby GW. The discharging ear in the tropics: A guide to diagnosis and management in the district hospital. Trop Doct 1992;22:10-3.
Eziyi JA, Amusa YB, Akinpelu OV. Prevalence of otolaryngological diseases in Nigerians. East Cent Afr J Surg 2010;15:85-9.
Salisu AD. Otology practice in a Nigerian tertiary health institution: A 10-year review. Ann Afr Med 2010;9:218-21.
] [Full text]
Okafor BC. Otolaryngology diseases in south eastern Nigeria: Pattern of diseases of the ear. Niger Med J 1983;13:11-9.
Adoga A, Nimkur T, Silas O. Chronic suppurative otitis media: Socio-economic implications in a tertiary hospital in Northern Nigeria. Pan Afr Med J 2010;4:3.
Brobby GW, Zadik P. Bacteriology of otitis media in Ghana. Trop Doct 1987;17:91-2.
Brook I, Frazier EH. Microbial dynamics of persistent purulent otitis media in children. J Pediatr 1996;128:237-40.
Fairbanks DN. Antimicrobial therapy for chronic suppurative otitis media. Ann Otol Rhinol Laryngol Suppl 1981;90 Suppl 84:58-62.
Aslam MA, Ahmed Z, Azim R. Microbiology and drug sensitivity patterns of chronic suppurative otitis media. J Coll Physicians Surg Pak 2004;14:459-61.
Lee SK, Lee MS, Jung SY, Byun JY, Park MS, Yeo SG. Antimicrobial resistance of Pseudomonas aeruginosa
from otorrhoea of chronic suppurative otitis media patients. Otolaryngol Head Neck Surg 2010;143:500-5.
Mansoor T, Musani MA, Khalid G, Kamal M. Pseudomonas aeruginosa
in chronic suppurative otitis media: Sensitivity spectrum against various antibiotics in Karachi. J Ayub Med Coll Abbottabad 2009;21:120-3.
Madana J, Yolmo D, Kalaiarasi R, Gopalakrishnan S, Sujatha S. Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J Pediatr Otorhinolaryngol 2011;75:1104-8.
Jang CH, Park SY. Emergence of ciprofloxacin-resistant pseudomonas in chronic suppurative otitis media. Clin Otolaryngol Allied Sci 2004;29:321-3.
Nwankwo EO, Salisu AD. Bacteriology of chronic discharging ears of patients in kano, Nigeria. J Med Lab Sci 2005;14:57-62.
Coker OA, Ijaduola GT, Odugbemi TO. Bacterial isolates from chronic discharging ears in Nigerian children. Niger Med Pract 1982;4:170-4.
Obi CL, Enweani IB, Giwa JO. Bacterial agents causing chronic suppurative otitis media. East Afr Med J 1995;72:370-2.
Orji FT, Dike BO. Observations on the current bacteriological profile of chronic suppurative otitis media in Southeastern Nigeria. Ann Med Health Sci Res 2015;5:124-8.
] [Full text]
Afolabi OA, Salaudeen G, Ologe FE, Nwabuisi C, Nwawolo CC. Pattern of bacterial isolates in the middle ear discharge of patients with chronic suppurative otitis media in a tertiary hospital in North central Nigeria. Afr Health Sci 2012;12:362-7.
Wasihun AG, Zemene Y. Bacterial profile and antimicrobial susceptibility patterns of otitis media in Ayder Teaching and Referral Hospital, Mekelle University, Northern Ethiopia. Springerplus 2015;4:701.
Lee JS, Kim MG, Hong SM, Na SY, Byun JY, Park MS, et al
. Changing patterns of bacterial strains in adults and children with otitis media in Korean tertiary care centers. Clin Exp Otorhinolaryngol 2014;7:79-86.
Ikeda K, Misawa S, Kusunoki T. Comparative bactericidal activity of four fluoroquinolones against Pseudomonas aeruginosa
isolated from chronic suppurative otitis media. BMC Ear Nose Throat Disord 2015;15:5.
Xu J, Du Q, Shu Y, Ji J, Dai C. Bacteriological profile of chronic suppurative otitis media and antibiotic susceptibility in a tertiary care hospital in Shanghai, China. Ear Nose Throat J 2021;100:P391-6.
Udden F, Filipe M, Reimer A, Paul M, Matuschek F, Thegerstrom J, et al
. Aerobic bacteria associated with chronic suppurative otitis media in Angola. Infect Dis Poverty 2018;7:42.
Hiremath B, Mudhol RS, Vagrali MA. Bacteriological profile and antimicrobial susceptibility pattern in chronic suppurative otitis media: A 1-year cross-sectional study. Indian J Otolaryngol Head Neck Surg 2019;71:1221-6.
Ayaz Z, Taj B, Yaseen MS, Ishaq U, Laique T, Malik J, et al
. Causality of chronic suppurative otitis media: An observational study. Cureus 2020;12:e9832.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]