RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and Address(In block letters) / : / Dr. ASHISH JITENDRANATH.
DEPARTMENT OF MICROBIOLOGY.
NAVODAYA MEDICAL COLLEGE, RAICHUR
2. / Name of the Institution / : / NAVODAYA EDUCATION TRUST’S
NAVODAYA MEDICAL COLLEGE, RAICHUR
3. / Course of study and subject / : / M.D. Microbiology
(3 years)
4. / Date of Admission to the course / : / 20th May 2009
5. / Title of Topic / : / Bacterial and fungal profile of Chronic Suppurative Otitis Media in patients attending ENT OPD at Navodaya Medical College Hospital and Research Centre, Raichur
6. / Brief Resume of the intended work
6.1 / Need for the study
· Chronic Suppurative Otitis Media (CSOM) is defined as chronic otorrhea between 6-12 weeks through a perforated tympanic membrane.1
· Cholesteatoma is a post inflammatory pseudotumor which is always a consequence of CSOM with marginal perforation of external tympanic membrane.2
· CSOM is a disease of multiple etiologies and is well known for its persistence and recurrence in spite of treatment.3
· CSOM is a destructive and persistent disease with irreversible sequelae and can proceed to serious intra or extra cranial complications.3
· CSOM is mainly classified based on perforation of tympanic membrane into Tubotympanic and Atticoantral.3
· The close relation of middle ear, cleft to the facial nerve, auditory labyrinth, lateral sinus and the middle and posterior cranial fossae makes it all too easy for complication to develop.4
· In many cases of CSOM the antibiotics are prescribed indiscriminately. The consequences are treatment failure, emergences of resistant strains, super infection, intra cranial and extra cranial complications thereby lengthening treatment cost and suffering.5
· Intracranial complications are abscess, labryinthitis, petrositis and facial nerve paralysis.6
· Indiscriminate use of antibiotics and poor follow up of patients has resulted in persistence of low grade infections.3
· CSOM has profound impact on society in terms of resources utilized in treatment, multiple OPD visits and surgery as well as direct impact that chronic infection has on hearing. CSOM can cause chronic hearing loss which has a negative impact on development of speech, language and social interaction as well as school or work place performance.5
· Situation is more critical in some of the rural areas because of lack of hygiene sense and bathing in stagnant water. This becomes more complicated due to self medication.5
· Previous studies on microbiology of CSOM have revealed that the most frequently isolated bacteria were Staphylococcus aureus, Pseudomonas aeruginosa, Proteus spp, Klebsiella spp. Staphylococcus spp. was more common especially when Cholesteatoma was present.5
· The proportion of Methicillin Resistant Staphylococcus aureus (MRSA) has increased from 2% in 1974 to around 50% in 1997. There are 2 types of MRSA Hospital acquired and Community acquired.7
· The most common organism isolated nowadays are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus spp, Klebsiella spp among aerobes.2
· Most common fungi are Aspergillus spp and Candida spp.8
· Regarding management of CSOM both medical and surgical therapies have same goal that is to achieve a safe ear, eradicate disease, achieve a dry ear free of otorrhoea, avoidance of surgery, stabilize or improve hearing and to prevent further complication.5
· Following advent and usage of newer synthetic antibiotics there has been a change in resistance patterns of the microbial flora, which increases the relevance of reappraisal of modern day flora and their in-vitro antibiotic sensitivity.3
· Keeping in view of the above, the first line of CSOM management is topical antibiotic initiated empirically on the basis of known bacteriological profile. This is more fruitful if it is culture directed.5
· Knowledge of microbial profile and susceptibility pattern is essential to enable efficacious treatment of this disorder.5
· The most common antibiotic susceptibility pattern for gram negative bacilli are Cefotaxim, Gentamycin, Amikacin, Netilicin, Levofloxacin, and Ofloxacin. For gram positive cocci are Clindamycin, Cloxacillin, Ofloxacin, Cefuroxime and Amikacin.4
· The earlier strains of causative organism were sensitive to Streptomycin, Tetracycline and Chloramphenicol. Nowadays the drugs of choice are Aminoglycosides, Quinolones and Cephalosporin’s.3
· CSOM can cause significant morbidity; therefore knowledge of local pathogens can assist in selection of most appropriate treatment regimen.3
6.2 / AIM
To study the bacteriological and mycological profile of CSOM and their antibiotic sensitivity pattern in tertiary care hospital in Raichur.
6.3 / Review of Literature
· CSOM defined as perforation of tympanic membrane with persistent drainage from middle ear for 6-12 weeks. Chronic suppuration can occur with or without Cholesteatoma. Clinical history of ear discharge and hearing loss is similar in both cases. [Harrison principles of internal medicine 16th edition].2
Microbiology
· Nikakhlagh S et al in 2008 showed that the most common pathogens for CSOM were Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella spp & Proteus spp. While the common causative organism for acute otitis media it is Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae. 1
· Nowadays as shown by Park et al in 2008 , an increase in MRSA from 2% in 1974 to 50% in 1997 were seen in cases of CSOM. 7
· Saini S et al in 2006 showed that CSOM etiology was polymicrobial. 4
· The most common fungi are Aspergillus and Candida spp. as shown by Nikakhlagh S et al in 2008. 1
· Rao and Reddy in 1994 showed that Staphylococcus was most prevalent organism but Maji P.K et al in 2007 showed that Pseudomonas aeruginosa to be the most prevalent organism. 8, 5
· Poorey VK and Iyer Arti in 2000 and Maji P.K et al in 2007 showed that Pseudomonas aeruginosa was the most prevalent organism in India, while Ettehad GH et al in 2006 and Nikakhlagh S et al in 2008 showed that Staphylococcus was the most prevalent organism in Iran. 3,5,6,1
· Maji P.K et al in 2007 Questions the random use of over the counter topical antibiotics which often ushers in more serous type of organisms like Pseudomonas which can create both intra and extra cranial complications. 5
· Nikakhlagh S et al in 2008 showed that 10-11 % of organisms were anaerobes comprising Peptostreptococcus, Bacteroides and Peptococcus and 1-2% was fungal which was mainly Aspergillus and Candida spp. 1
· Mital A et al in 1997 showed that the most common fungal agent to be Aspergillus spp which was nearly 83% of all fungal causes of CSOM. The second most common cause was Candida spp. 9
Predisposing factors:
· Seasonal variation was found to be a factor in a study done by Maji PK et al in 2007, with most cases falling between July and September. 5
· Poorey VK and Iyer Arti in 2000 showed 2 major predisposing factors:
1. CSOM was more prevalent amongst the age group 0-10 years with male preponderance.
2. Disease typically follows viral infection of upper respiratory tract which leads to pyogenic infection. 3
Antibiotic susceptibility:
· Nikakhlagh S et al in 2008 showed that Ofloxacin was the most effective antibiotic against Staphylococcus aureus, Pseudomonas aeruginosa and Klebsiella spp. 1
· Trimethoprim and Sulfmethaxole combination was the most effective antibiotic against MRSA as shown by Park et al in 2008. 7
· Maji PK et al in 2007 showed that the most sensitive antibiotic was Amikacin against CSOM. 5
· Pseudomonas aeruginosa is becoming increasingly resistant to most common and routine antibiotics and Rahim E et al in 2007 suggested that Imipenem was the most sensitive drug. 10
· Saini S et al in 2005 suggested the usage of Cefotaxime, Cefuroxime or Gentamicin for gram negative bacilli and Clindamycin, Cloxacillin or Cefuroxime for Staphylococcus aureus. 4
· Nwabuisi and Ologe F.E in 2002 showed that Ofloxacin to be most effective antibiotic in study done, whilst even Cephalosporin’s was found to be effective in therapy.11
· The most effective topical antibiotic was found to be Gentamycin in a study done by Loy et al in 2002.12
· Amikacin was found to be most effective drug followed by Ciprofloxacin, Cefoperazone, Gentamicin, Cefotaxime and Amoxicillin in a study done by Poorey V.K and Iyer Arti in 2000.3
· Poorey V.K and Iyer Arti in 2000 states that initially organism used to be sensitive to Streptomycin, Tetracycline and Chloramphenicol but now these drugs have been replaced by Aminoglycosides, Quinolones and Cephalosporin’s. 3
6.4 / Objectives of the study
1. Isolation of organism from CSOM cases.
2. To study the aerobic bacteriological profile in cases of CSOM.
3. To study fungal organisms causing CSOM.
4. To study the susceptibility pattern to commonly used antibiotics in view of emerging resistance.
5. Evaluation of risk factors involved i.e.
· Seasonal variation
· Age
· Sex
6. In private hospitals/lab setups where culture facilities are not available for bacterial CSOM we can ensure better empirical treatment.
7. / Material and Methods
7.1 / Source of data
· Study will be carried out in the post graduate research laboratory, Department of Microbiology, Navodaya Medical College, Raichur.
· Patients attending ENT OPD at Navodaya Medical College Hospital and Research Center form the source of the sample for study.
· Ear discharge samples coming to department during Study Period of November 2009 to October 2010 constitute the material for study.
7.2 / Methods of collection of data (Including sampling procedure , if any)
Design of study : Prospective study.
Size of the study sample : All the samples that are clinically
suspected of CSOM during the
study period.
Sample material : Aural discharge of more than 6
weeks
Methods:
Inclusion Criteria
1. The patients diagnosed as suffering from CSOM after thorough clinical evaluation by an ENT surgeon.
2. Patients who were not on any antibiotic treatment for minimum of 48 hours.
Exclusion Criteria
1. Patients who have taken systemic antibiotics for CSOM.
Detailed history, general physical examination and local systemic examination were done for each case.
Clinical and demographic data to be collected using a preformed questionnaire.
Two sterile swabs which are procured from Hi-Media are going to be used to collect discharge from patients diagnosed with CSOM with assistance of sterile cotton wool swabs and ear specula.
All care will be taken to avoid surface contamination.
Swabs then transported to microbiology research lab.
First swab to be used for bacteriology.
Second swab to be used to mycology.
Microscopy
1. Direct gram staining will be done from the 1st swab.
2. 10% KOH mount done from 2nd swab, to be observed under microscope for presence of fungal elements
Culture
1. Then 1st swab will be inoculated on Blood Agar,
Chocolate Agar & MacConkey Agar. These plates
are kept at 37 degree celsius for 24-48 hours.
2. Then 2nd swab will be inoculated on 2 Sabouraud Dextrose Agar slopes. One will be kept at 25 degree celsius and another at 37 degree celsius for 24-48 hours.
I) Isolation, identification and characterization of bacteria isolated from clinical material:
Done by
A. Gram stain
B. Colony morphology
C. Biochemical tests which include
1. Indole
2. Citrate
3. Urease
4. Mannitol Motility test
5. TSI test.
In case identification is not established for the test the following test can be done which include
1. Lysine
2. Arginine
3. Ornithine
4. PPA
5. Malonate
II) Isolation, identification and characterization of Yeast like budding cells isolated from clinical material
Done by
1. Germ tube test.
2. Carbohydrate assimilation test.
3. Chlamydospore identification.
II) Isolation, identification and characterization of mycelial forms isolated from clinical material
Done by
1. LPCB for Microscopy.
2. Slide culture for species identification.
Antibiogram study will be performed using Kirby-Bauer disc diffusion method and will be in accordance with CLSI guidelines.
7.3 / Does the study require any investigation or intervention to be conducted on patients or other humans or animals?
No.
The study involves collection of patients ear discharge.
It does not require any other invasive procedures and no animal experiments are required for the study.
7.4 / Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8 / List of References
1. Nikakhlagh. S, Khosrani A. D, Falipour. A Safarzadeh. M and Rahidi. N. “Microbiological finding in Patients with Chronic Suppurative Otitis Media.” J Med Science. 2008; 8(5): 503-506.
2. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Lalwani A et al. “ Harrison’s Principle’s of Internal Medicine”-16th ed. New York: McGraw Hill;2005: 190
3. Poorey. V.K and Iyer Arti. “Study of bacterial flora in CSOM and its clinical significance.” Indian Journal of Otolaryngology and Head and Neck Surgery. 2002; 54: 91-95.
4. Saini S, Gupta N, Aparna, Seema, Sachdeva OP. “Bacteriological study of pediatric and adult chronic suppurative otitis media.” Indian J Pathol Microbiology 2005; 48: 413-416.
5. Maji P.K, Chatterjee T.K, Chatterjee S, Chakrabarty J, Mukhopadhyay B.B. “ The investigation of bacteriology of chronic suppurative otitis media in patients attending a tertiary care hospital with special emphasis on seasonal variation.” Indian J Otolaryngol Head and Neck surg. 2007; 59:128-131.
6. Ettehad Gh, Refahi S, Nammati A, Pirzadeh. A, Daryani. A. “Microbial and antimicrobial susceptibility pattern from patients with Chronic Otitis Media in Arebil.” International Journal of Tropical Medicaine. 2006; 1(2): 62-65.
7. Park Kyun Moo, Jung Ho Myung, Kang Joon Hee, Woo Jeong-Soo, Lee Heung-Man, Jung Hyun Jung, et al. “The change of MRSA infections in chronic suppurative otitis media.” Otolaryngology-Head and Neck Surg. 2008; 8(5): 503-506.
8. Rao B.N and Reddy M.S. “Chronic suppurative otitis media- A prospective study.” Indian Journal of Otolaryngology and Head and Neck Surgery. 1994;3(2)
9. Mittal A, Mann S.B.S, Talwar.P, Mehra.Y.N Panda Naresh. “Secondary Fungal infections in chronic suppurative otitis media.” Indian J Otolaryngol Head and Neck surg. 1997; 49(2)
10. Nwabiusi.C and Ologe F.E. “Pathogenic agents of chronic suppurative otitis media in Ilorin, Nigeria.” East African Medical Journal. 2002; 79: 202-205.
11. . Rahim Ejaz, Gul Alam Asif, Ahmed Shakeel and Ali Liaqat. “Frequency of Pseudomonas aeruginosa in patients and its sensitivity to various antibiotics.” Professional Med.J. Sept 2007; 14(3): 411-415.