Ann Otol RJUnol Lor,ft8Ol101:1992

AEROBIC BACTERIOLOGY OF CHRONIC SUPPURATIVE OTITIS MEDIA WITHOUT CHOLESTEATOMA IN CHILDREN RON DAGAN, MD

DAN M. FLISS, MD NAFTALI MEIDAN, MD

ALBERTO LEmERMAN,

BEER-SHEVA,

MD

ISRAEL

Medical management of chronic suppurative otitis media without cholesteatoma in children was shown recently to be efficacious. We undertook a prospective study in order to determine 1) the organisms associated with the disease and their sensitivity to various antibiotics and 2) their association with clinical variables. Pseudomonas was isolated from 84% of the patients, enteric gram-negative bacilli from 32%, Staphylococcus aureus from 20%, streptococci from 14%, and Hemophilus influenzae from 15%. Pseudomonas aeruginosa was the sole isolate in 48 of the 128 patients (38%). The sensitivity of P aeruginosa (78 isolates) was 100% (of isolates) to mezlocillin and ciprofloxacin, 99% to tobramycin and ceftazidime, 97% to piperacillin, 94% to gentamicin, and 78% to ceftrlaxone. The isolated organisms and their sensitivity to antibiotics were not associated with age, sex, duration ofotorrhea, or the presence ofgranulation tissue or polyps. We believe that our data may contribute to the appropriate choice ofantibiotics when nonsurgical management ofchronic suppurative otitis media without cholesteatoma is considered. KEY WORDS -

aerobes, antibiotic susceptibility, bacteriology, chronic suppurative otitis media, Pseudomonas aeruginosa.

INTRODUCfION

MATERIALS AND METHODS

Chronic suppurative otitis media (CSOM) is a persistent and insidious disease that often leads to destructive changes and irreversible sequelae. 1-4 Although it is still a significant health care problem in the pediatric patient, there is a paucity of information on many aspects ofthe disease, which leads to controversy concerning a standardized management plan. 5,6

Children were enrolled prospectively at the otolaryngology outpatient clinic of the Soroka University Medical Center. The admission criteria were 1) infants and children 6 months to 16 years of age, 2) documented continuous otorrhea through a tympanic membrane perforation or ventilation tube for at least 2 months, 3) failure of at least one complete conventional oral and/or topical antibiotic course, and 4) no topical or systemic antibiotics administered during the week before obtaining the middle ear aspirate.

The separation into two distinct groups (with and without cholesteatoma) is important, since most cases of CSOM are not secondary to cholesteatoma but most likely the result of incompletely or unsuccessfully treated acute or recurrent episodes of otitis media,7,8 This primary classification of the disease was proved to be essential in determining whether medical treatment, surgical treatment, or both are indicated? Recent reports have demonstrated the efficacy of medical treatment in CSOM.lO,11 Therefore, information on the type of organisms isolated from patients with CSOM and their sensitivity to antibiotic agents is important. Kenna and Bluestone 12 reported on the bacteriology of CSOM without cholesteatoma (CSOMWC) in a group of 36 infants and children. However, this report represents only a small group of patients, and additional information from other centers is needed.

Children were not enrolled if any of the following was present: 1) a foreign body in the external auditory canal, 2) an infection of the external auditory canal, 3) the presence of cholesteatoma (follow-up and computed tomography scan), 4) an underlying serious condition such as immune deficiency, malignancy, or cystic fibrosis, or 5) a history of prior otomastoid operative procedures other than insertion of ventilation tubes. The children underwent a complete physical examination by a pediatrician and an otomicroscopic evaluation by an otolaryngologist. Information regarding age, sex, duration of ear discharge, and the presence of underlying disease was obtained and recorded on enrollment. The appearance of the tympanic membrane and the presence of polyps or granulation tissue were recorded. In six children a complete otologic examination was carried out under general anesthesia.

The purposes of this prospective study were to determine 1) the organisms associated with CSOMWC and their sensitivity to various commonly used antibiotic agents and 2) if the bacteriology of CSOMWC is associated with clinical variables.

From the Department of 0t01aryngology (Fliss, Leiberman), the Pediatric Infectious Disease Unit (Dagan), and the Hospital Administration (Meidan), Soroka University Medical Center andthe Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

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Fliss et al, Aerobic Bacteriology

TABLE 2. ORGANISMS RECOVERED FROM EAR ASPIRATES OF 128 PEDIATRIC PATIENTS (170 EARS) WITH CHRONIC SUPPURATIVE OTITIS MEDIA WITHOUT CHOLESTEATOMA

TABLE 1. CLINICAL CHARACTERISTICS OF 128 PEDIATRIC PATIENTS WITH CHRONIC SUPPURATIVE OTITIS MEDIA WITHOUT CHOLESTEATOMA. ON ENROLLMENT Male:female 71:57 55%:45%

Organism

Age (mo) Range Median

Pseudomonas P aeruginosa Pseudomonas spp

11-192 40

Patients with ventilation tubes Patients with bilateral ear discharge Duration of ear discharge (mo) Range Median

6

5%

42

33%

2-123 23

Patients with granulation tissue

33

26%

Patients with polypoid formation

23

18%

The external auditory canal was cleansed, and debris was removed by a regular 18-gauge suction needle. Thereafter, an Alden-Senturia middle ear aspirator was directed under otomicroscopic visualization into the middle ear through the tympanic perforation, and the purulent discharge was removed. No contact was made by the needle tip with the speculum or the auditory canal. In addition, granulation tissue or polyps were removed and sent for histopathologic examination. In the children who underwent general anesthesia a repeated culture of the middle ear was obtained after the external canal was swabbed with povidone iodine and allowed to dry for 2 to 3 minutes. The middle ear aspirate was introduced into Amies transport medium without charcoal (Exogen, Clydebank Industrial Estate, Clydebank, Scotland). The swabs were inoculated within 24 hours onto blood agar (triple sugar iron and 5% sheep blood), chocolate agar, MacConkey's plate, and brain-heart infusion. All culture media were prepared commercially (Hy-Lab Laboratories, Rehovot, Israel). All plates were placed in a 5% carbon dioxide incubator (37°C). No anaerobic cultures were performed. The isolation and identification of bacteria were done by conventional laboratory techniques. Antibiotic sensitivity tests were determined by using standard concentrations of various antimicrobial agents by the disc method. 13

RESULTS From January 1987 to April 1990, 128 patients with 170 chronically discharging ears were enrolled. The clinical characteristics of the study population are presented in Table 1. All children had received previous courses of oral and topical antimicrobials, but not during the week prior to sample collection. Microorganisms were recovered from all 170 ears. The total number of microorganisms recovered was 220 (Table 2). A single pathogen was isolated in 54

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Enteric gram-negative bacilli Escherichia coli Enterobacter spp Proteus mirabilis Proteus morgagnii Klebsiella spp Acinetobacter spp

Staphylococcus S aureus S epidermidis Streptococcus Spyogenes S pneumoniae GroupD Hemophilus influenzae Nontypeable Typee Typeb Others Total isolates

No.ofPts

%Pts

107

84

41

32

26

20

24

19

19

15

3

2

106 1 9 12 12 1 4 3 24

2 15 8 1 17 1 1 220

(42%) of the cases, two microorganisms were isolated in 58 (45%) children, and three organisms were recovered in 16 (13%) of the cases. Middle ear cultures yielded identical microorganisms before and after sterilization of the external ear canal with povidone iodine in the patients who underwent general anesthesia. When both ears had chronic discharge, culture results did not differ between the two ears. Pseudomonas aeruginosa was the most common isolate. In 48 (38%) cases it was the only isolate. Enteric gram-negative bacilli, Staphylococcus aureus, streptococci, and Hemophilus influenzae were also common. When two or three microorganisms were recovered, the two most commonly associated were P aeruginosa and S aureus. Sensitivity of P aeruginosa was tested in 78 isolates. All isolates were sensitive to mezlocillin and ciprofloxacin, 99% were sensitive to tobramycin and ceftazidime, and 97% to piperacillin, 94% to gentamicin, and 78% to ceftriaxone. Sex, age, duration of otorrhea, and presence of granulation tissue or polyps did not show any specific association with the microorganisms isolated from the middle ear.

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DISCUSSION

Although CSOMWC is most likely the result ofan incompletely or unsuccessfully treated acute episode of otitis media, the microorganisms involved in the initial episode are not those isolated from the middle ear while the chronic infection is present. 14 We have found in the present study that all 170 middle ear aspirate cultures from pediatric patients with CSOMWC were positive. The main associated organism was P aeruginosa, often isolated with other organisms. Previous publications documented the isolation of microorganisms from the middle ear discharge of patients with CSOM. However, no categoric separation was made between the groups with or without cholesteatoma and between children and adults in most cases. Furthermore, the methods employed and the specimens available for culture were not uniform and were poorly reported in most cases. IS-24 Kenna and Bluestonel- noted the importance of differentiating between CSOM with cholesteatoma and CSOMWC in predicting the outcome, and were the first to report separately the bacteriology of pediatric patients without cholesteatoma. However, the report by Kenna and Bluestone included only 36 patients and represents patients referred to only one center. The efficacy of medical treatment consisting of systemically administered antibiotics and daily suction and debridement was recently established. 10,1I It is therefore important to have additional information on the bacteriology of CSOMWC, since the antibiotic choice should be made according to the prevailing organisms associated with the disease. Our data are in accordance with those of Kenna and Bluestone.P The precise role played by P aeruginosa in CSOMWC is difficult to define, as it seems that this pathogen evolves insidiously from saprophyte to full-fledged pathogen.P In addition to its striking preponderance in cases with CSOMWC, this microorganism is documented in sites of aggressive, infective processes of the otomastoid area and the temporal bone. 26 Pseudomonal infections of the otomastoid area, like those in other sites such as joints, the urinary tract, and the lower respiratory tract, are characterized by low-grade activity and chronicity rather than a fulminant course. 27,28 Because of the difficult distinction between colonization and infection of the ear by this pathogen, meticulous culture procedures should be employed in order to obtain the effusion

directly from the middle ear cavity and avoid contamination from the edges of the perforations or the external auditory canal. Only such carefully performed cultures can be considered reliable. To date, oral antibiotics approved for pediatric patients are not effective against P aeruginosa. It is therefore not surprising that oral regimens usually do not alter the natural course of CSOMWC. The fact that in most cases of CSOMWC P aeruginosa was isolated, together with the high rate of sensitivity to all tested antipseudomonal drugs, implies that antibiotic therapy may be started with anyone of these drugs. Resolution of otorrhea in children treated with parenteral antipseudomonal drugs confirms the need for such agents for the management of CSOMWC. Furthermore, in a previous study, the recurrence rate of CSOMWC, mainly with P aeruginosa, was not influenced by the administration of amoxicillin prophylaxis; this finding suggests that CSOMWC is a pseudomonal disease.P' It has been postulated that the suppurative complications of CSOMWC are the result of the interaction between extracellular necrotizing pseudomonal enzymes and granulation tissue. 29,30 In the patients presented here the presence of granulation tissue or polyps was not associated with the isolated organisms, severe complications, or the response to therapy. Anaerobic studies were not performed in the present investigation. The presence of anaerobes in CSOM has been previously documented.l 4,16,18,19,31 However, their role incases ofCSOMWC is not clear. The benefit of antianaerobic therapy as suggested by Brookl'' is not clear, since this study was performed without a control group. Variables such as age, sex, duration of drainage, and presence ofpolyps or granulation tissue were not associated with specific isolated microorganisms or their sensitivity. We could not find any comparable data in the literature and do not have an explanation for these findings. We conclude that P aeruginosa is the most common pathogen isolated in CSOMWC, often with other pathogens. In our area, the organism is sensitive to most antipseudomonal drugs. The bacteriologic picture is not influenced by age, sex, duration of drainage, or the presence of polyps or granulation tissue. We believe that our data may contribute to a better understanding of the managementofCSOMWC in children.

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2. Paparella MM, Oda M, Hiraide F, Brady D. Pathology of sensorineural hearing loss in otitis media. Ann Otol Rhinol LuyngoI1972;81:632-47.

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17. Brook I. Chronic otitis media in children. Microbiological studies. Am J Dis Child 1980;134:564-6.

4. Proctor CA. Intracranial complications of otitic origin. Laryngoscope 1966;76:288-308.

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6. Bluestone CD, Carder HM, Coffey JD, et al. Consensus: management of the child with a chronic draining ear. Pediatr Infect Dis 1985;4:607-12. 7. Mawson RS, Ludman H. Disease of the ear. Chicago, Ill: Year Book Medical Publishers, 1979:335-51. 8. Bluestone CD, Klein JO. Intratemporal complications and sequelae of otitis media. In: Bluestone CD, Stool ES, eds. Pediatric otolaryngology. Philadelphia, Pa: WB Saunders, 1983: 513-64. 9. Kenna MA, Bluestone CD, Reilly JS, Lusk RP. Medical management of chronic suppurative otitis media without cholesteatoma in children. Laryngoscope 1986;96: 146-51. 10. Bluestone CD. Current management of chronic suppurative otitis media in children. Pediatr Infect Dis J 1988;7: 137-40. 11. Fliss OM, Dagan R, Houri Z, Leiberman A. Medical management of chronic suppurative otitis media without cholesteatoma in children. J Pediatr 1990;116:991-6. 12. Kenna MA, Bluestone CD. Microbiology of chronic suppurative otitis media in children. Pediatr Infect Dis J 1986;5: 223-5. 13. Lenette E, Balows A, Hasler WJ Jr, Sadomy HJ, eds: Manual of clinical microbiology. 4th ed. Washington, DC: American Society for Microbiology, 1985. 14. Bluestone CD, Kenna MA. Chronic suppurative otitis media: antimicrobial therapy or surgery? Pediatr Ann 1984;13: 417-21. 15. Harker LA, Koontz FP. Bacteriology of cholesteatoma: clinical significance. Trans Pa Acad Ophthalmol Otolaryngol 1977;84:683-6. 16. Karma P, Jokipii L, Ojala K, Jokipii AMM. Bacteriology of the the chronically discharging middle ear. Acta Otolaryngol (Stockh) 1978;86:110-4.

20. Papastavros T, Giarnarellou H, Varlejides S. Preoperative therapeutic considerations in chronic suppurative otitis media. Laryngoscope 1989;99:655-9. 21. Jokipii AMM, Karma P, Ojala K, Jokipii L. Anaerobic bacteria in chronic otitis media. Arch OtolaryngoI1977; 103:27880. 22. MeyerhoffWL, Giebink GS. Pathology and microbiology of otitis media. Laryngoscope 1982;92:273-7. 23. Fairbanks DNF. Antimicrobial therapy for chronic suppurative otitis media. Ann Otol Rhinol Laryngol 1981;90(suppl 84):58-62. 24. Papastavros T, Giamarellou H, Varlejides S. Role of aerobic and anaerobic microorganisms in chronic suppurative otitis media. Laryngoscope 1986;96:438-42. 25. Pollack M. Special role of Pseudomonas aeruginosa in chronic suppurative otitis media. Ann Otol Rhinol Laryngol 1988;97(suppI131):10-3. 26. Leiberman A, Fliss OM. Pseudomonas acute mastoiditis in children. Am J OtolaryngoI1987;8:175-8. 27. Stamey TA. Urinary tract infections. Baltimore, Md: Williams & Wilkins, 1972:279. 28. Reynolds HY, Fick RB. Pseudomonas aeruginosa pulmonary infections (emphasizing nosocomial pneumonia and respiratory infections in cystic fibrosis). In: Sabath LD, ed. Pseudomonas aeruginosa: the organism, diseases it causes, and their treatment. Bern, Switzerland: Haus Huber Publishers, 1980: 71-88. 29. Sade J, Berco E. Bone destruction in chronic otitis media: a histopathological study. J Laryngol OtoI1974;88:413-22. 30. Meyerhoff WL, Kim CS, Paparella MM. Pathology of chronic otitis media. Ann Otol Rhinol LaryngoI1978;87:749-60. 31. Brook I, Finegold SM. Bacteriology of chronic otitis media. JAMA 1979;241:487-8.

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Aerobic bacteriology of chronic suppurative otitis media without cholesteatoma in children.

Medical management of chronic suppurative otitis media without cholesteatoma in children was shown recently to be efficacious. We undertook a prospect...
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