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ORIGINAL ARTICLE

Antibiotics in chronic suppurative otitis media:

A bacteriologic study
Shamweel Ahmad *

Department of Clinical Laboratory Sciences, College of Medical Sciences, Salman Bin AbdulAziz University, Saudi Arabia

Received 20 May 2013; accepted 14 June 2013

Available online 12 July 2013

KEYWORDS Abstract Objective: This study sought to determine causative microorganisms of chronic suppu-
Chronic suppurative otitis rative otitis media (CSOM) and to estimate their susceptibility to antibiotic agents.
media; Materials and methods: One hundred sixty-four (164) patients with unilateral or bilateral active
Antibiotic sensitivity; chronic suppurative otitis media were prospectively studied. They had chronic ear discharge and
Topical antibiotics; had not received any antibiotics for the previous 5 days. Swabs were taken from all patients, and
Ear discharge sent to the Microbiology Department for processing. The specimens were cultured and the isolates
were identified using standard microbiological techniques. The antibiotic susceptibilities of the iso-
lates were determined with standard antibiotic discs using the Kirby–bauer disc diffusion method.
Results: This study analyzes the causal organisms and their sensitivity to various antibiotics. The
major organisms isolated were Methicillin sensitive Staphylococcus aureus [MSSA] (45.1%)
followed by Pseudomonas aeruginosa (19.5%). The sensitivity of S. aureus (MSSA) was 79.7% to
ciprofloxacin, 69% to cotrimoxazole, and 82.5% to gentamicin whereas the sensitivity of P.
aeruginosa was 100% to ceftazidime, 84.4% to ciprofloxacin, 90.6% to gentamicin, and 78.1% to
Piperacillin. Majority of the isolates of P. aeruginosa were completely resistant to polymixin B
(71.9%) whereas 50% of S. aureus (MSSA) showed resistance to Ampicillin. All Methicillin
resistant S. aureus (MRSA) isolates showed 100% resistance to Ampicillin, Augmentin and
cephalothin. Among the available topical antibiotic
preparations for use in the ear, we found gentamicin and ciprofloxacin as the best choices.
Conclusion: The study of microbial pattern and their antibiotic sensitivity determines the
prevalent bacterial organisms causing CSOM in the local area to start empirical treatment of otitis
media and its complications for a successful outcome, and thus to prevent the emergence of resistant
strains.
ª 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and
Allied Sciences.

* Tel.: +966 115886315.

1. Introduction
E-mail address: drshamweel@hotmail.com.

Peer review under responsibility of Egyptian Society of Ear, Nose, Chronic suppurative otitis media (CSOM) is defined as a
Throat and Allied Sciences. chronic inflammation of the middle ear and mastoid cavity,
which presents with recurrent ear discharges or otorrhoea
through a tympanic membrane perforation. The disease
usually begins in childhood1,2 as a tympanic membrane
Production and hosting by Elsevier
2090-0740 ª 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied
Sciences. http://dx.doi.org/10.1016/j.ejenta.2013.06.001
192
perforation due to an acute infection of the middle ear, known
as acute otitis media (AOM), or as a sequel of less severe
forms of otitis media (e.g. secretary OM). 3–5 The infection may
occur during the first 6 years of a child’s life, with a peak
around 2 years. 6 The point in time when AOM becomes
CSOM is still controversial. Generally, patients with tympanic
perforations which continue to discharge mucoid material for
periods from 6 weeks7 to 3 months, despite medical treatment,
are recog- nized as CSOM cases. Chronic suppurative otitis
media (CSOM) is a commonly encountered infection of the
middle ear all over the world. In 1990, about 28,000 deaths all
over the world and largely among developing countries were
due to otitis media.8,9 Mortality and disabilities due to otitis
media are primarily related to the complications of CSOM, 10
partic- ularly brain abscess. 11 Population-based estimates in
develop- ing countries range from 0.24% in Thailand to 1.8%
in Africa. In South Korea, 10.4% of CSOM had
complications.12
Chronic suppurative otitis media (CSOM) has assumed
world- wide importance. For instance, the United States
government spends over 2 billion dollars yearly to treat acute
and chronic ear infections.13 In the developing countries, it has
continued to consti- tute a heavy disease burden, with the
prevalence of chronic ear infections being up to 72 cases per
1000 inhabitants.14
So untreated cases of CSOM can result in a broad range
of complications. These may be related to the spread of
bacteria to structures adjacent to the ear or to local damage
in the mid- dle ear itself. Such complications range from
persistent otor- rhoea, mastoiditis, labyrinthitis, facial nerve
paralysis to more serious intracranial abscesses or
thromboses.15–17 So the knowledge of the local pattern of
infection is essential to
enable efficacious treatment of this disorder. The goal of the
management is to achieve a safe, dry ear, eradicate disease
and improve hearing.
The main aim of this study was to determine the microbial
profile (aerobic and anaerobic) and the antibiograms of active
CSOM patients among Saudi population. CSOM is a very
common problem in Saudi Arabia and is seen mostly in pop-
ulations from far flung areas.
2. Methods
This study was conducted on Outpatient basis in the Depart-
ment of Ear, Nose and Throat (ENT) over a period of one
and a half (11/2) years = from September, 2011 to February,
2013. In this prospective study, a total of one hundred sixty-
four (164) patients were involved. All our patients had perfo-
rated tympanic membranes with active purulent discharge. De-
tailed clinical history regarding age, sex, duration of discharge
and antibiotic treatment was taken. Only patients who had not
received antibiotic therapy (topical or systemic) for the previ-
ous 5 days were included in the study. Single use Mini-tip Cul-
ture swabs were used to harvest the middle ear microflora
through the tympanic membrane perforation. Much care was
taken to avoid surface contamination and the swabs were
transported to the microbiology department of the hospital
for culture and sensitivity testing. A total of 164 swabs were
taken from 164 patients, processed aerobically and anaerobi-
cally for the isolation of aerobic and anaerobic bacteria, using
standard microbiological procedures. All organisms isolated
were identified according to standard microbiological
methods.
S. Ahmad
Antibiotic susceptibility testing was carried out using the
Kirby–Bauer disc diffusion technique on Muller–Hinton
agar and commercial antibiotic discs (Oxoid, United
Kingdom) were used for antimicrobial testing.18 The
antibiotic discs used were: Penicillin G (10U), Ampicillin
(10 lg), Augmentin (30 lg), Trimethoprim-
Sulphamethoxazole (1.25/23.75 lg), Cephalothin (30 lg),
Polymixin B (300 U), Ceftazidime (30 lg), Piperacillin
(100 lg), Chloramphenicol (30 lg), Cipro- floxacin (5 lg),
Amikacin (30 lg), Gentamicin (10 lg), Neomy- cin (30 lg)
and Bacitracin (10 U).
Apart from the standard antibiotics, testing was also done
specifically for Gentamicin, Neomycin, Chloramphenicol and
Bacitracin which are available locally as topical antibiotic ear-
drops. The antibiotic disc impregnated culture plates were
incubated at 37 °C overnight. The diameter of the zone of inhi-
bition was measured and recorded as resistant or susceptible
according to the National Committee for Clinical
Laboratory Standards (NCCLS) interpretative criteria.19
3. Results
The mean age of patients was 25 years, with the range being
between 20–47 years (Table 1). From the 164 patients enrolled
in the study, there were 148 (90.2%) isolates. Ninety-four (94)
patients (63.5%) had a single organism isolated from the mid-
dle ear culture, while the remaining 54 patients had two or
more organisms isolated. There were only sixteen patients
(9.8%) who had a sterile culture with no bacteria isolated (Ta-
ble 2). The most common causal organisms isolated were
Methicillin sensitive Staphylococcus aureus [MSSA] (45.1%),
followed by Pseudomonas aeruginosa (19.5%), Methicillin
Resistant S. aureus (MRSA), Coagulase negative Staphylococ-
cus, Proteus mirabilis and Escherichia coli (Table 2). The anti-
microbial sensitivities of the organisms were tested and the
results for the six most common organisms are shown (Ta-
ble 3). Of the four antibiotics that are available commonly as
topical eardrops, gentamicin has the highest susceptibility rate
(88.3%) for all the isolates tested, followed by chlorampheni-
col (72.4%). Neomycin showed 74.3% sensitivity against
Gram negative bacteria while isolates of MSSA, MRSA and
Coagulase negative Staphylococcus showed 78.8% susceptibil-
ity to Bacitracin.
4. Discussion
Chronic suppurative otitis media and its complications are
among the most common conditions seen by otologists and
general practitioners. Chronic suppurative otitis media is a
persistent inflammation of the middle ear or mastoid cavity,
and is characterized by recurrent or persistent ear discharge
through a perforation of the tympanic membrane. 20 Due to
the perforated tympanic membrane, bacteria can gain entry
into the middle ear via the external ear canal. Infection of
the middle ear mucosa subsequently results in ear discharge.
Chronic suppurative otitis media is a common and potentially
Table 1 Age distribution of the patients.
Age group (in years) 0–12 13–20 21–30 31–40 41–50 >50 Total
Number of patients 05 41 52 09 35 22 164
 Antibiotics in chronic suppurative otitis media: A bacteriologic study 193

sensitivity is then essential to allow for effective and cost-sav-

Table 2 Microorganisms isolated in positive cultures.
ing treatment. Microbiology cultures yield many, frequently
Organism Number Percentage (%)multiple, organisms and these vary depending on climate, pa-
Gram Positive tient population and whether antibiotics have or have not been
Staph. aureus (MSSA) Staph. aureus (MRSA) Coagulase -ve Staph.
recently used. Several studies have reported different organ-
Gram Negative Pseudomonas aeruginosa Proteus miribilis 74 45.1
E. coli Citrobacter Spp. 19 11.6 isms in different proportions.17 Our study showed that active
9 5.5 CSOM infection in the Saudi population is mainly due to S.
aureus, P. aeruginosa followed by P. mirabilis. Similar
32 19.5 findings have been reported by Gehanno. 21 S. aureus (MSSA)
6 3.7 was the commonest organism isolated, although various such
4 2.4 studies in different countries have shown P. aeruginosa to be
3 1.8
more common.16 Our study showed the predominance of S.
Anaerobe aureus followed by P. aeruginosa which is in agreement with
Bacteroids spp. 01 0.6 oth- ers.21,23 This finding is in agreement with the pattern of
No growth 16 9.8 CSOM infection within the tropical region. The antibiotic
Total 164 100
susceptibil- ity pattern of MSSA showed that 82% were
rv to genta- micin, 80% were sensitive to ciprofloxacin
sensitive
and 79.7% to Bacitracin. Antimicrobial sensitivity of P.
aeruginosa in our
dangerous clinical condition that is difficult to treat because study revealed that ceftazidime was sensitive in 100%, Genta-
the most common infecting organisms are often resistant to micin was sensitive rv
in 91%, Ciprofloxacin was sensitive
many antibiotics.21 Untreated cases of CSOM can result in a rv in 85% and 78% were sensitive to Piperacillin. Previously
broad range of complications. These may be related to the amoxicillin/ampicillin was used frequently than quinolones
spread of bacteria to structures adjacent to the ear or to local for acute and chronic middle ear infections in our set up.
damage in the middle ear itself. Such complications range But the present study has clearly shown a changing behaviour
from persistent otorrhoea, mastoiditis, labyrinthitis, facial of microorganisms, showing more sensitivity to quinolones,
nerve cephalosporins and gentamicin. Also the clinicians used to
paralysis to more serious intracranial abscesses or thrombo- avoid the use of quinolones due to their adverse effects on car-
ses.15,16 While the incidence of such complications is low, they tilage in growing children after their prolonged usage, however
need to be borne in mind when faced by a patient with active it has been documented that quinolones can be used if required
CSOM. in children without any apprehensions.24,25 So the use of cipro-
Treatment hence needs to be instituted early and effectively floxacin has been found superior both empirically and topi-
to avoid such complications. The treatment of this condition cally. Among the most commonly available topical antibiotic
can be medical; with therapy directed at eradicating patho- solutions gentamicin has shown promising results after cipro-
genic aerobic and anaerobic organisms. 22 Those cases that floxacin. Added advantage of ciprofloxacin ear drops over gen-
are resistant to medical treatment might need surgical tamicin is not being ototoxic.26 There remains, however a
intervention. controversy over the question of ototoxicity with the topical
The mainstay of treatment for uncomplicated CSOM is usage of aminoglycoside (gentamicin) while the systemic
twofold: meticulous aural toilet (with suction/mopping up of usage
ear debris and discharge) and instillation of a topical and sys- of aminoglycoside has been known to have a deleterious effect
temic antimicrobial agent. The therapeutic use of antibiotics is on the inner ear. The fact that the disease process in CSOM it-
usually started empirically prior to results of microbiological self causes a sensorineural hearing loss 26 has led many to con-
culture. Selection of any antibiotic is influenced by its efficacy, clude the benefits derived from the usage of topical
resistance of bacteria, safety, risk of toxicity and cost. Knowl- aminoglycosides in the treatment of CSOM and the
edge of the local microorganism pattern and their antibiotic prevention of attendant complication far outweigh the

Table 3 Antimicrobial susceptibility pattern of major organisms causing CSOM.

Percent of resistant isolates against
Organism P AMP COT AMC CTN PB CAZ PIP C CIP AK GM NEO BAC
Gram positive bacteria
S. aureus (MSSA) 52.7 50.0 31.0 35.1 50.0 NT NT NT 20.3 20.3 21.6 17.5 NT 20.3
S. aureus (MRSA) 100 100 31.6 100 100 NT NT NT 31.6 36.8 21.0 15.8 NT 21.0
Coag. -ve Staph. 55.5 44.4 55.5 44.4 55.5 NT NT NT 33.3 22.2 22.2 11.1 NT 22.2
Gram negative bacteria
Pseudomonas aeruginosa NT NT NT NT NT 71.9 0 21.9 21.9 15.6 21.9 9.4 18.7 NT
Proteus mirabilis NT 33.3 33.3 16.6 NT 50.0 33.3 16.6 33.3 16.6 33.3 16.6 33.3 NT
Escherichia coli NT 25.0 25.0 25.0 100 50.0 25.5 25.0 25.0 0 25.0 0 25.0 NT
P = Penicillin, AMP = Ampicillin, COT = Cotrimoxazole, AMC = Augmentin, CTN = Cephalothin, PB = Polymixin B, CAZ =
Ceftazi- dime, PIP = Piperacillin, C = Chloramphenicol, CIP = Ciprofloxacin, AK = Amikacin, GM = Gentamicin, NEO =
Neomycin, BAC = Bacitracin, NT = Not tested.
194
ototoxic side-effects which may potentially occur. Keeping in
view the high prevalence of S. aureus and P. aeruginosa in
our set up and their high susceptibility to quinolones (cipro-
floxacin) and cephalosporins (ceftazidime), ciprofloxacin ear
drops or systemic therapy of ciprofloxacin, piperacillin or ceft-
azidime can be used safely in all age groups. However injudi-
cious use of such drugs can lead to emergence of drug
resistant isolates especially in Staph. aureus and P. aerugin-
osa,27 as has previously been experienced, there should there-
fore be judicious usage of this class of antibiotics in all types
of otitis media.
The study of microbial pattern and their antibiotic sensitiv-
ity determines the prevalent bacterial organisms causing
CSOM in the local area to start empirical treatment of otitis
media and its complications for successful outcome, and thus
to prevent the emergence of resistant strains.
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