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Ϣ ϴ Σή ϟ ϦϤ Σή ϟ Ϳ Ϣ δΑ University of Khartoum Graduate College Medical and Health Studies Board Bacterial Isolates and Antimicrobial Susceptibility in Patients Attending the E.N.T Hospital in Khartoum By Dr. Nada Abdallah Basheer M.B.B.S (University of Khartoum, 1995) A thesis submitted in partial fulfillment for the requirements of the Degree of Clinical MD in Clinical Pathology, 2010 Supervisor Dr. Nageeb Suleiman Saeed MD, MRCpath Associate Professor of Microbiology Head Department of Microbiology Faculty of Medicine University of Khartoum Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. ϲϟ Ύ ό Η ϝ Ύ ϗ ^ Ϣ ˵ ϴ Ϝ ˶ Τ˸ ˴ ϟ Ϣ ˵ ϴ Ϡ ˶ ό ˴ ϟ ˸ Ζϧ ˴ ˴ Ϛ͉ ˴ ϧ · ˶ Ύ Ϩ ˴ Θ ˴ Ϥ ˸ Ϡ ͉ ϋ ˴ Ύ ϣ ˴ ϻ ͉ · ˶ Ύ Ϩ ˴ ϟ ˴ Ϣ ˴ Ϡ ˸ ϋ ˶ ϻ ˴ Ϛ˴ ˴ ϧ Ύ Τ˸ ˴ Β γ ˵ ˸ Ϯ ϟ ˵ Ύ ϗ } ˴ Ʈ ǀ Ɣ Ƙ ƫ ř Ľř ơŶƇ ş ź Ƥ Ş ƫ ř ş Ź ƺ ſ Š ƿ ǁ ř Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. CONTENTS Page No. Dedication i Acknowledgment ii Abbreviations iii English abstract iv Arabic abstract vi List of tables viii List of figures ix CHAPTER ONE 1. Introduction and literature review 1 1.1. Otitis media 1 1.1.1. Definition 1 1.1.2. Types of otitis media 1 1.1.2.1. Acute Otitis Media (AOM) 1 1.1.2.2. Otitis Media with effusion (OME) 3 1.1.2.3. Chronic suppurative Otitis Media (CSOM) 3 1.1.2.4. Otitis media without effusion 4 1.1.3. Epidemiology 5 1.1.4. Anatomy of the ear 6 1.1.5. Pathophysiology 9 1.1.6. Symptoms 11 1.1.7. Diagnosis 13 1.1.8. Mortality/Morbidity 17 1.1.9. Treatment 18 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.9.1. Antibiotic Selection 20 1.1.9.2. Bacterial resistance after antibiotic therapy failures 24 1.1.9.3. Surgical treatment 25 1.1.10. Causative agents of OM and their antibiotics susceptibility 26 1.2. Objectives 31 1.2.1. General Objective 31 1.2.2. Specific Objectives 31 CHAPTER TWO 2. Patients and methods 32 2.1. Study design 32 2.2. Study period 32 2.3. Study Area 32 2.4. Study population 32 2.5. Sample size 32 2.6. Site of collection 33 2.7. Culture 33 2.8. Data analysis 35 CHAPTER THREE 36 3. Results CHAPTER FOUR 4. Discussion 49 4.1. Conclusion 55 4.2. Recommendations 57 References 58 Appendices 62 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Ň Œ ť ººººƋ Œ Ś Ƹ ư ů Ź ƶ Ƭ ƋŚ Ơ ƫ ř ƶ ǀ ŝ ź ư ƫ ř Ƽţ Ŷƫ ř ƹ ƹ ż ƿ ż Ƙ ƫ ř ƻŶƫ ř ƹ Ƽƫ ř Ɩ Ƌř ƺ Ť ư ƫ ř ŦŰ Ş ƫ ř ř ŸƷ ƻŶƷ ř Ś ƌƿ ř ƶ ƿ ŶƷ ř ƹ Ō ř ż Ŭ ƫ ř ź ǀ ų Ƽƴ Ɨ Ľř Ś ư Ʒ ř ż ū Ƽţ Ś ǀ ů ƼƟ ŭ Ś Ŭ Ƴ ƪ Ƨ ƻŶƷ ř Ś ư Ƹ ǀ ƫ ř Ľř Ŷƿ ź Ƴ Ś Ư Ś ƴ ƫ Ʈ ţ ƼŤ ů ř ƹ ź ŝ Ś Ƈƹ ř ƹ ź Ş Ƈ Ʋƿ Ÿƫ ř ƻŌ Ś ƴ ŝ ř ƹ Ƽū ƹ Ż Ƶ ź ǀ Ɯ ƈƫ ř Ƽţ ź ſ ř Ƽƫ ř Ʋǀ Ƙ ư ū ř Ľř Ʈ Ƹ Ɣ Ơ ů Ƶ ŶŤ ư ư ƫ ř Ƶ ź ǀ Ş ƨƫ ř Ƽţ ź ſ LJ ƹ Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. First of all thanks to ALLAH for giving me strength and power to complete this study. I would like to thank my supervisor Dr.Nageeb Suleiman Saeed, The General Director of the National Health Laboratory and The Head of the Microbiology Department, Faculty of Medicine U of K, for his great patience and valuable guidance. I would like also to give my great thanks to all my colleagues in Bacteriology Department in National Health Laboratory, for their help and support. Especially the senior technologists Ali Khogaly, Mohammed A. Gorga, Amina A, and Ibraheem Ali Elhag. My great thanks to Mr .Hasan the lab assistant in the MD lab and to my colleagues in the ENT Hospital for their great help and cooperation. My thanks to Mr. Hassan Ali the analyst, for his great help ,and to the typist Widad in the Faculty of Medicine, and to all who gave me moral support or Duaa to Allah to aid me in my efforts. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Abbreviations AOM Acute otitis media CSOM Chronic suppurative otitis media MEE Middle ear effusion NCCLS National Committee for clinical laboratory standards OM Otitis media OME Otitis media with effusion TM Tympanic membrane TT Tympanostomy tube UK United Kingdom URI Upper respiratory tract infection US United States Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. ABSTRACT Background: Otitis Media is one of the common diseases especially in childhood, it had great influence on work and school attendance and it may lead to hearing loss if not properly diagnosed and treated. The objectives of this study are to determine the prevalence of the common aerobic bacteria causing otitis media among Sudanese population and their pattern of antimicrobial sensitivity. Methods: This descriptive study was carried out in Khartoum State at the ENT Hospital, out-patient clinic during Dec. 2008 to March 2009. Data were collected by a questionnaire and swabs were taken from ear discharge randomly. Isolation, identification and in-vitro sensitivity tests were performed on all isolates. Results: A hundred and four patients were studied, male to female ratio was 3 : 2, children represented 66.7%, while adults were 43.3%. Bacterial isolates represented 64% of the specimens; fungal isolates were 6.5%, while the rest of specimens showed no pathogenic organisms. Acute otitis media (AOM) comprised 41% of all patients, children represented 88% of them, while chronic suppurative otitis media (CSOM) were 59% and was mainly in adults. The most prevalent organisms causing acute Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. otitis media were Streptococcus pneumomiae (50%), Staphylococcus aureus (38%) and Strept pyogene (12%). Regarding chronic otitis media, Proteus spp was the most common organism (33%) followed by Staphylococcus aureus (30%) and Psuedomonas spp (27%). Most Staph aureus strains (90%) were penicillin resistant and 84% were sensitive to erythromycin. Regarding Strept. Pneumoniae, 93% were sensitive to Coamoxycalve, erythromycin sensitivity was 86%. Proteus spp. sensitivity to both cefotaxime and ceftriaxone was 86%, and their sensitivity to both ciprofloxacin and gentamicin was 79%. Pseudomonas spp. isolates were sensitive to ceftazidime (82%), carbinicillin (73%), cefotaxime (64%) and amikacin was 55% sensitive. Conclusion: This study has shown the main causative organisms of AOM and CSOM and their susceptibility pattern of antibiotic tested. This information can be used as guideline for empiric therapy of otitis media. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. κϠ ΨΘ δϤ ϟ Ɖŷ Ŗŕ Ɣ ż ƅ Ŕ Ƒž Ŗŗ Ŭś ś Ə ¿ŕ ſ ųƛŔ Ƒž ř Űŕ Ŧ ƌ Ÿ œ ŕ Ůƅ Ŕ Śŕ ŗ ŕ Ǝ ś ƅ ƛŔ Ɖƈ ƑųŬƏ ƅ Ŕ ƉŨ ƛŔ Ŗŕ Ǝ ś ƅ Ŕ ŗ Ɔ ť ƀ Ɔ ŕ Ǝ ŠƜŷ ¿ƈ ƍ Ŕ Ŕ Ũ Ŕ Śŕ ž ŕ Ųƈ ƅ Ŕ Ɖƈ ũ Ɣ ŝ Ƅ ƅ Ŕ Ƒƅ Ŕ Ɛŧ Ŏ ś ŧ Ɓ Ə ƌ ŬŔ ũ ŧ ƅ Ŕ Ə ¿ƈ Ÿ ƅ Ŕ Ə ƑųŬƏ ƅ Ŕ ƉŨ ƛŔ Ŗŕ Ǝ ś ƅ ƛ ƌ ŗ ŗ Ŭƈ ƅ Ŕ ƌ Ɣ œ Ŕ Ə Ǝ ƅ Ŕ ŕ Ɣ ũ Ɣ ś Ƅ ŕ ŗ ƅ Ŕ ŵŔ Ə Ɗ Ŕ ř ž ũ Ÿ ƈ ƌ ŬŔ ũ ŧ ƅ Ŕ Ƌ Ũ ƍ Ɖƈ Žŧ Ǝ ƅ Ŕ ŻŒ ť Ƌ ƕ Œ ¿ŕ ƈ Ÿ ś ŬƙŔ ƌ Ÿ œ ŕ Ůƅ Ŕ ƌ Ɣ Ə Ɣ ţƅ Ŕ ŚŔ ŧ ŕ Ųƈ Ɔ ƅ ŕ Ǝ ś Ɣ Ŭŕ Ŭţ ř ŬŔ ũ ŧ Ƌ ũ ŠƊ ţƅ Ŕ Ə ƉŨ ƛŔ Ə ŽƊ ƛŔ Ƒſ Ůś Ŭƈ Ɠž Ƈ Ə ųũ Ŧƅ Ŕ ř Ɣ ƛƏ Ɠž ř ŬŔ ũ ŧ ƅ Ŕ Ƌ Ũ ƍ ŚƔ ũ ŠŔ Śšŕ ƃ Œ ŗ ƒ Şƌ ƈ Ɔ Ɖƈ ƌ ŗ Ə Ɔ ųƈ ƅ Ŕ Śŕ ƈ Ə Ɔ Ÿ ƈ ƅ Ŕ ŚŸ ƈ Š ϮϬϬϵ ūũ ŕ ƈ ϮϬϬϴ ũ ŗ ƈ ŬƔ ŧ Ɖƈ Ř ũ ś ſ ƅ Ŕ Ƒž ƌ Ɣ Šũ ŕ Ŧƅ Ŕ Ƌ ŧ ŕ Ɣ Ÿ ƅ Ŕ Ɠƈ Ɣ Ɔ Ÿ ś ƅ Ŕ ƑŲũ ƈ Ɖƈ ƌ Ɗ Ɣ ŷ ϭϬϰ Ũ ŦŌ Ƈ ś Ƈ Ǝ Ɣ Ə Ũ Ə Ō ƑŲũ ƈ ƅ Ŕ Ɖƈ ř ƍ ŕ ſ Ů ƉŨ Ŕ Ũ ŦŔ ŧ Ÿ ŗ Ɖŕ Ɣ ŗ ś ŬŔ ř ųŬŔ Ə ŗ ƑŲũ ƈ ƅ Ŕ Ƈ Ǝ ƅ Ŕ Ə ţŔ Ə Ƈ Ǝ Ɗ Ƅ ŬƉƄ ŕ ƈ Ŕ Ə Ƈ Ǝ ŷŔ Ə Ɗ Ŕ Ə Ƈ ƍ ũ ŕ ƈ ŷŔ Ɖŷũ ŴƊ ƅ Ŕ űż ŗ ƑųŬƏ ƅ Ŕ ƉŨ ƛŔ Ŗŕ Ǝ ś ƅ Ŕ Ɖƈ ƉƏ Ɗ ŕ Ÿ Ɣ ƌ Ųũ ƈ ƈ ƅ Ŕ ŕ Ɣ ũ Ɣ ś Ƅ ŕ ŗ ƅ Ŕ ř ž ũ Ÿ ƈ Ə ¿Ū ŷ Ƈ ŝ ř ƈ œ Ɯƈ ƅ Ŕ ųŕ ŬƏ ƗŔ Ɠž Ř Ũ Ə Ŧō ƈ ƅ Ŕ Śŕ Ɗ Ɣ Ÿ ƅ Ŕ ¿ Ƅ ř ŷŔ ũ Ū Ƈ ś Ə ƌ Ɣ ŮƔ Ÿ ƈ ƅ Ŕ ƌ Ɣ Ə Ɣ ţƅ Ŕ ŚŔ ŧ ŕ Ųƈ Ɔ ƅ ŕ Ǝ ś Ɣ Ŭŕ Ŭţ ř ŬŔ ũ ŧ Ə ŚŔ ũ Ə Ƅ ƈ ƅ Ŕ Ɠƍ ŧ ŕ ţƅ Ŕ ƑųŬƏ ƅ Ŕ ƉŨ ƛŔ Ŗŕ Ǝ ś ƅ Ŕ Śŕ ŗ ŗ Ŭƈ Ƈ ƍ Ŕ ƉŔ ŧ ŠƏ ƌ ŬŔ ũ ŧ ƅ Ŕ Ƌ Ũ ƍ Ɖƈ ŝő œ ř ƈ ƃ Œ ƌ Ɣ ţŗ Ŭƅ Ŕ ŚŔ ũ Ə Ƅ ƈ ƅ Ŕ ŕ Ǝ Ɣ Ɔ ś Ə ϯϴ ř ŗ ŬƊ ŗ ƌ Ɣ ŗ ƍ Ũ ƅ Ŕ ƌ Ɣ ŧ Ə Ƃ Ɗ Ÿ ƅ Ŕ ŚŔ ũ Ə Ƅ ƈ ƅ Ŕ Ƈ ŝ ϱϬ ř ŗ ŬƊ ŗ ř Ɣ Ə œ ũ ƅ Ŕ ƌ Ɣ ţŗ Ŭƅ Ŕ Ƈ ŝ ϯϯ ř ŗ ŬƊ ŗ ƌ Ÿ œ Ŕ ũ ƅ Ŕ ƌ ŗ Ɔ Ƃ ś ƈ ƅ Ŕ ƌ ŗ ŕ ŗ ŬŔ Ƈ ƍ Ŕ Ɖƈ ž Ɖƈ Ū ƈ ƅ Ŕ ƑųŬƏ ƅ Ŕ ƉŨ ƛŔ Ŗŕ Ǝ ś ƅ Ŕ ŕ ƈ Ŕ ϭϮ ƌ Ɣ ŧ Ɣ ŧ Űƅ Ŕ ƜƔ Ŭŗ Ɔ Ƅ ƅ Ŕ Ŕ ũ Ɣ ŦŔ Ə ϳ ƌ Ɣ Ɗ Ə ƅ Ə Ƃ ƅ Ŕ ƌ Ɣ Ƅ Ɣ ũ Ɣ ŮƛŔ Ƈ ŝ Ϯϳ ƌ Ɣ ũ ŕ ŠƊ Ū ƅ Ŕ ƌ ſ œ Ŕ Ū ƅ Ŕ ŕ Ǝ Ɣ Ɔ ś ϯϬ ř ŗ ŬƊ ŗ ƌ Ɣ ŗ ƍ Ũ ƅ Ŕ ƌ Ɣ ŧ Ə Ƃ Ɗ Ÿ ƅ Ŕ Ƈ Ə ŕ Ƃ ƈ ŕ Ǝ Ɗ ƈ ϵϬ ƉŔ ŧ ŠƏ ƌ Ɣ ŗ ƍ Ũ ƅ Ŕ ƌ Ɣ ŧ Ə Ƃ Ɗ Ÿ ƅ Ŕ ŚƛƜŬƅ ƌ ŗ ŬƊ ƅ ŕ ŗ ƌ Ɣ Ŭŕ Ŭţƅ Ŕ ŚŔ ũ ŕ ŗ ś ŦŔ ʼn Ŕ ũ ŠŔ ŧ Ÿ ŗ ϯ ř Ɣ ŬƊ ŗ ϱϮ Ə ¿Ə Ƅ Ɗ ſ ƈ Ŕ ũ Ə Ɔ Ƅ Ɔ ƅ ūŕ Ŭţϳϲ Ə Ƈ Ɣ ŬƄ ſ Ŭƅ Ŕ Ə ƉƔ ŬƔ ƈ Ə ũ ŝ ũ Ɯƅ ūŕ Ŭţŕ Ǝ Ɗ ƈ ϴϰƏ ƉƔ Ɔ ŬƊ ŗ Ɔ ƅ ϳϵ ƌ Ɣ Ə œ ũ ƅ Ŕ ƌ Ɣ ţŗ Ŭƅ Ŕ ŚŔ ũ Ə Ƅ ƈ ƅ Ŕ ŚƛƜŬƅ ƌ ŗ ŬƊ ƅ ŕ ŗ ϲϳ ƌ ƅ ƌ Ɣ Ŭŕ Ŭţƅ Ŕ ř ŗ ŬƊ ž ƉƔ ŬƄ Ɣ ƅ ŕ ſ Ŭƅ Ŕ ŕ ƈ Ŕ ƉƔ ŬƔ ƈ ŕ ś Ɗ ŠƆ ƅ ϴϲ Ə ƉƔ ŬƄ Ɣ ƅ ŕ ſ Ɣ Ŭƅ Ŕ Ə ŧ Ɣ ŬŌ ƃƊ Ə Ɣ ſ ƅ ŕ Ƅ ƅ Ŕ Ŷ ƈ ƉƔ Ɔ ŬƔ ŬƄ Ə ƈ ƗŔ Ɖƈ ¿Ƅ ƅ ūŕ Ŭţ ϵϯ Ə ƉƔ Ɔ ŬƊ ŗ Ɔ ƅ ūŕ Ŭţ ŕ Ǝ Ɗ ƈ Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Ɖƈ ¿Ƅ ƅ ŕ Ǝ ś Ɣ Ŭŕ Ŭţ ŚƊ ŕ Ƅ ŧ Ƃ ž ƌ Ÿ œ Ŕ ũ ƅ Ŕ ƌ ŗ Ɔ Ƃ ś ƈ ƅ Ŕ ŚƛƜŬ ŕ ƈ Ŕ ƉƔ ŬƔ ƈ ŕ ś Ɗ Šƅ Ŕ Ə ƉƔ ŬƔ ƈ Ə ũ ŝ ũ ƛŔ Ɖƈ ¿Ƅ ƅ ūŕ Ŭţ ŕ ƈ Ŕ ƉƔ Ŭŕ ŬƄ Ə Ɔ ž Ə ũ ŗ Ŭƅ Ŕ Ə ƉƔ ŬƔ ƈ ŕ ś Ɗ Šƅ Ŕ Ɖƈ ¿Ƅ ƅ ϳϵ ŕ ƈ Ɗ Ɣ ŗ ϴϲƉƏ ŬƄ Ɣ Ŕ ũ ś ſ Ɣ Ŭƅ Ŕ Ə Ƈ Ɣ ŬƄ ŕ ś Ə ſ Ɣ Ŭƅ Ŕ Ř ŧ Ɣ ŧ Ů ŚƊ ŕ Ƅ ž ƌ Ɣ ũ ŕ ŠƊ Ū ƅ Ŕ ƌ ſ œ Ŕ Ū ƅ Ŕ ŚƛƜŬ ŕ ƈ Ŕ ϲϰ Ƈ Ɣ ŬƄ Ə ũ Ɣ ſ ŬƆ ƅ Ə ϳϭ ƌ ŗ ŬƊ ƅ Ŕ ŚƊ ŕ Ƅ ž ¿Ə Ƅ Ɗ ſ ƈ Ŕ ũ Ə Ɔ Ƅ ƅ Ŕ ƉƔ Ŭŕ Ƅ Ɣ ƈ Ɯƅ ϱϱ Ə Ƈ Ɣ ŬƄ ŕ ś Ə ſ Ɣ ŬƆ ƅ ϲϰ Ə ϳϯ ř ŗ ŬƊ ŗ ƉƔ Ɔ Ɣ ŬƊ ŗ ũ ŕ Ƅ ƅ Ŕ Ƈ ŝ ϴϮ Ƈ Ɣ ŧ Ɣ Ū ŕ ś ſ ŬƆ ƅ ƌ Ɣ Ŭŕ Ŭţƅ Ŕ Ə Ŕ ŧ ŕ ţ Ŗŕ Ǝ ś ƅ ƛŔ ŵƏ Ɗ ƑƆ ŷ ŧ ƈ ś Ÿ Ɣ ƑųŬƏ ƅ Ŕ ƉŨ ƅ Ŕ Ŗŕ Ǝ ś ƅ Ŕ ŞƜŷ ƉŔ ƉƔ ŗ ś Ɣ ƌ ŬŔ ũ ŧ ƅ Ŕ Ƌ Ũ ƍ Ɖƈ Ƈƒ Ɔ Űř ƃ Œ ŚŔ ŧ ŕ Ųƈ ƅ Ŕ ũ ŕ Ɣ ś ŦŔ Ƒž ƌ ŬŔ ũ ŧ ƅ Ŕ Ƌ Ũ ƍ şœ ŕ ś Ɗ Ɖƈ Ƌ ŧ ŕ ſ ś Ŭƅ Ŕ ƉƄ ƈ Ɣ ƌ ƅ Ŗŗ Ŭƈ ƅ Ŕ ŖƏ ũ Ƅ ƈ ƅ Ŕ ŵƏ Ɗ ƑƆ ŷƏ Ɖƈ Ū ƈ ¿ ƈ Ÿ ś Ŭƈ ƅ Ŕ ƐƏ Ɣ ţƅ Ŕ ŧ ŕ Ųƈ ƅ Ŕ ũ Ɣ Ɣ ż ś Ə Ŕ ř Ɔ ŰŔ Ə ƈ ƅ ƃƅ Ũ Ə ŕ Ǝ Űţſ ƅ ƉŨ ƛŔ Ɖƈ ƌ Ɗ Ɣ ŷ Ũ Ŧŕ ŗ ƑŰƏ Ɗ Ə ƌ ŗ Ŭŕ Ɗ ƈ ƅ Ŕ ƌ Ɣ Ə Ɣ ţƅ Ŕ Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. LIST OF TABLES Page No. Table 1-1: Treatment recommendations for otitis media 20 Table 1: Distribution of patients according to age groups 37 Table 2: Number and percentage of bacterial isolates 37 Table 3: List of organisms isolated 38 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. LIST OF FIGURES Page No. Fig. 1-1: The anatomy of the middle ear 8 Fig. 1: Types of otitis media 39 Fig. 2: Relation between age and types of otitis media 40 Fig. 3: Relation between organisms isolated and types of otitis media 41 Fig. 4: Susceptibility of Staph. aureus 42 Fig. 5: Susceptibility of Strept. Pneumoniae 43 Fig. 6: Susceptibility of Strept. pyogenes 44 Fig. 7: Susceptibility of Proteus sp. 45 Fig. 8: Susceptibility of Pseudomonas sp. 46 Fig. 9: Susceptibility of E. coli 47 Fig. 10: Susceptibility of Klebsiella sp. 48 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1. INTRODUCTION AND LITERATURE REVIEW 1.1. Otitis media: 1.1.1. Definition: Otitis media (OM) is any inflammation of the middle ear without reference to etiology or pathogenesis. OM can be classified into many types on the basis of etiology, duration, symptomatology, and physical findings. (1) Bacterial otitis media in the majority of cases is caused by upper respiratory tract pathogens like Streptococcus pyogenes ,Streptococcus pneumoniae, Moraxella catrrhalis and Haemophilus influenzae. Other possible pathogens include Staphylococcus aureus, Klebsiella sp., Proteus sp., Escherichia coli, and other coliforms, Psuedomonas sp, and Bacteroides sp. (2) 1.1.2. Types of otitis media: 1.1.2.1. Acute Otitis Media (AOM): The rapid and short onset of signs and symptoms of inflammation in the middle ear is characteristic of AOM. Acute suppurative otitis media and purulent otitis media are synonyms still used by some but are not recommended terms. One or more 1 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. local or systemic signs are present: otalgia (or pulling of the ear in the young infant), otorrhea, fever, recent onset of irritability, anorexia, vomiting, or diarrhea. The tympanic membrane is full or bulging, opaque, and has limited or no mobility to pneumatic otoscopy, all of which indicate middle-ear effusion. Erythema of the eardrum is an inconsistent finding. AOM has been defined in the clinical practice guideline presented by the American Academy of Pediatrics and the American Academy of Family Physicians, the criteria for AOM were: a history of acute onset of signs and symptoms, the presence of middle ear effusion, and signs and symptoms of middle ear inflammation. Furthermore, the following elements were described: recent, usually abrupt, onset of signs and symptoms of middle ear inflammation and middle ear effusion that is indicated by any of the following: bulging of the eardrum , limited or absent mobility of the tympanic membrane, air-fluid level as visualized through the tympanic membrane, or otorrhea.(3) 2 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.2.2. Otitis Media with effusion (OME): The persistence of an effusion beyond three months without signs of infection defines otitis media with effusion,(3)formerly termed serous OM or secretory OM, is Middle ear effusion (MEE ) of any duration that lacks the associated signs and symptoms of infection (e.g., fever, otalgia, irritability). OME usually follows an episode of AOM.(1) Pneumatic otoscopy frequently reveals either a retracted or convex tympanic membrane with impaired mobility. Fullness or even bulging may be visualized in some patients. An airfluid level bubbles, or both may be observed through a translucent tympanic membrane. The most important distinction between otitis media with effusion and AOM is that the signs and symptoms of acute infection (e.g., otalgia and fever) are lacking in otitis media with effusion. Hearing loss is usually present in both conditions.(4). 1.1.2.3. Chronic suppurative Otitis Media (CSOM): Is a chronic inflammation of the middle ear that persists at least 6 weeks and is associated with otorrhea through a perforated Tympanic membrane (TM), an indwelling tympanostomy tube (TT), or a surgical myringotomy.(1) 3 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. CSOM involves a perforation in the eardrum and active bacterial infection within the middle ear space for several weeks or more. There may be enough pus that drains to the outside of the ear or the purulence may be minimal enough to only be seen on examination using a binocular microscope. This disease is much more common in persons with poor Eustachian tube function. Hearing impairment often accompanies this disease and the patient is usually asymptomatic.(5) 1.1.2.4. Otitis media without effusion: Is a stage of middle-ear inflammation in which the mucosa of the middle ear is involved, but no effusion is present. This stage of otitis media was recently substantiated, employing tympanocentesis as confirmatory evidence. This stage classically precedes the development of an acute effusion and can be associated with the acute onset of otalgia. One form of this stage of inflammation is commonly encountered in infants and children who have functioning tympanostomy tubes in place. They typically present with acute otalgia, with or without fever, and erythema of the inferior portions of the tympanic membrane, but no otorrhea is present.(6) 4 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Middle-ear effusion: designates a liquid in the middle ear, but not etiology, pathogenesis, pathology or duration. An effusion may be serous (thin, watery liquid), mucoid (thick, viscid, mucus-like liquid), purulent (pus-like liquid) or a combination of these. An effusion can be the result of either AOM or otitis media with effusion. The effusion can be of recent onset (acute) or longer lasting (subacute or chronic). Persistent middle-ear effusion is an effusion that persists in the middle ear after an episode of AOM. Otorrhea: is a discharge from the ear originating at one or more of the following sites: the external auditory canal, middle ear, mastoid, inner ear, or intracranial cavity.(6) 1.1.3. Epidemiology: Otitis media (OM) is the second most common disease of childhood, after upper respiratory infection (URI). OM is also the most common cause for childhood visits to a physician's office.(1) Its incidence is 10-20% for each year of life up to 6 years of age and then decreases dramatically to less than 1% by the age of 12. By definition, these patients require antimicrobial therapy and therefore, this diagnosis accounts for the greatest proportion of antimicrobial prescriptions. (5) 5 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Acute otitis media is the most common infection for which antibiotics are prescribed for children in the USA. Direct and indirect costs of treatment and time lost from school and work because of acute otitis media totaled nearly 3$ billion in 1995. Acute otitis media is most common between 6 and 24 months of age; by age three, more than 80% of children have been diagnosed.(3) In the United Kingdom about 30% of children aged under 3 years visit their general practitioner with acute otitis media each year, and 97% receive antimicrobial treatment. About 1 in 10 children will have an episode of acute otitis media by 3 months of age. It is the most common reason for outpatient antimicrobial therapy. (7) In the less developed nations, OM is extremely common and remains a major contributor to childhood mortality resulting from late presenting intracranial complications. (1) 1.1.4. Anatomy of the ear: The ear is functionally and anatomically divided into three parts: A) The External Ear: that portion external to the tympanic membrane. It serves chiefly to protect the tympanic membrane, but also collects and directs sound waves and plays a role in 6 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. sound localization. The skin of the external ear normally migrates laterally from the umbo of the malleus in the tympanic membrane to the external auditory meatus (at a rate of 2-3 mm per day). This is a unique and essential mechanism for maintaining patency of the canal. (9) B) The Middle Ear: This is an air-containing space which communicates with the nasopharynx via the eustachian tube. It is normally sealed laterally by the tympanic membrane. Its function is to transmit and amplify sound waves from tympanic membrane to the stapes footplate converting energy from air medium to a fluid medium of the membranous labyrinth. The tympanic membrane is an ovoid, three-layered structure consisting of squamous epithelium laterally, respiratory mucosa medially, and an intervening fibrous layer. It normally has a conical shape, with the apex maintained medially by the support of the malleus. The fibrous layer thickens laterally to form the annulus, an incomplete ring which is attached to surrounding bone. Superior to the lateral process of the malleus, this ring is deficient, and this area is known as the pars flaccida. The majority of the drum is composed of the pars tensa. 7 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. C) The Inner Ear: Consists of a fluid-filled labyrinth which functions to convert mechanical energy into neural impulses. The bony labyrinth is subdivided into smaller compartments by the membranous labyrinth. Fluid surrounding the membranous labyrinth is called perilymph; fluid within is called endolymph.(9) Figure 1-1: shows the anatomy of the middle ear 8 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.5. Pathophysiology: Genetic, infectious, immunologic, and environmental factors predispose to ear infections. In most cases, an allergy or upper respiratory tract infection causes congestion and swelling of the nasal mucosa, nasopharynx, and eustachian tube. Obstruction at the eustachian tube results in accumulation of middle ear secretions; secondary bacterial or viral infection of the effusion causes suppuration and features of acute otitis media. The effusion may persist for weeks or months after the infection resolves. Otitis media with effusion may occur spontaneously as a result of Eustachian tube dysfunction after acute otitis media. (5) 1.1.5.1. Genetic base: Recurrent and chronic forms of otitis media are known to have a strong genetic component, but nothing is known of the underlying genes involved in the human population. a previously identified novel semi-dominant mouse mutant allele, Jeff, in which the heterozygotes develop chronic suppurative otitis media and represent a model for chronic forms of otitis media in humans. They demonstrate that Jeff carries a mutation in an F-box gene, Fbxo11. Fbxo11 is expressed in epithelial cells of the middle ears from late 9 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. embryonic stages through to day 13 of postnatal life. In contrast to Jeff heterozygotes, Jeff homozygotes show cleft palate, facial clefting and perinatal lethality. This study also isolated and characterized an additional hypomorphic mutant allele, Mutt. Mutt heterozygotes do not develop otitis media but Mutt homozygotes also show facial clefting and cleft palate abnormalities.(10) FBXO11 is one of the first molecules to be identified, contributing to the genetic etiology of otitis media. In addition, the recessive effects of mutant alleles of Fbxo11 identify the gene as an important candidate for cleft palate studies in the human population. (10) 1.1.5.2. Factors affecting risk of acute otitis media:(21) • Age: Maximal incidence between 6 and 24 months of age; eustachian tube shorter and less angled at this age. Underdeveloped physiologic and immunologic responses to infection in children. • Breastfeeding: it is for at least three months is protective; this effect may be associated with position maintained during breastfeeding, suckling movements, and protective factors in breast milk. 10 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. • Daycare attendance: contact with multiple children and daycare providers facilitates spread of bacterial and viral pathogens. •Exposure to cigarette smoke: Increased incidence with sigarette smoke and air pollution, especially if parents smoke. •Male sex: Slightly increased incidence. •More than one sibling living at home: • Previous antibiotic use & previous otitis media: •Season: Increased incidence in autumn and winter. •Underlying pathology: Increased incidence in children with allergic rhinitis, cleft palate, Down syndrome. 1.1.6. Symptoms: Otalgia: young children may exhibit signs of otalgia by pulling on the affected ear or ears or pulling on the hair. Otalgia apparently occurs more often when the child is lying down. Otorrhea: Discharge may come from the middle ear through a recently perforated TM, through a preexisting TT, or through another perforation. For trauma patients, excluding a basilar skull fracture with associated cerebrospinal fluid (CSF) otorrhea is important. 11 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Headache and concurrent URI symptoms (e.g., cough, rhinorrhea, sinus congestion). Generally, two thirds of children with AOM have a history of fever, although fevers greater than 40°C are uncommon and may represent bacteremia or other complications. Irritability may be the sole early symptom in a young infant or toddler. A history of lethargy, although nonspecific, is a sensitive marker for sick children and should not be dismissed. Gastrointestinal tract symptoms include anorexia, nausea, vomiting, and diarrhea. (1) OME and CSOM their history includes any of the following: • Hearing loss: Most young children cannot provide an accurate history. Parents, caregivers, or teachers may suspect a hearing loss or describe the child as inattentive. • Tinnitus: This is possible, although it is an unusual compliant. • Vertigo: Although true vertigo (i.e., room-spinning dizziness) is a rare compliant in uncomplicated OM, parents may report some unsteadiness or clumsiness in a young child with AOM. • Otalgia: Intermittent otalgia tends to worsen at night.(1) 12 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.7. Diagnosis: Acute otitis media is over diagnosed. Symptoms are neither sensitive nor specific for the diagnosis of otitis media; fever and ear pain are present in only one half of patients. Undue reliance on one feature redness of the tympanic membrane and failure to assess tympanic membrane mobility with pneumatic otoscopy contribute to inaccurate diagnoses. Adequate visualization of the tympanic membrane is often impaired by low light output from old otoscope bulbs and blockage of the ear canal by cerumen. Distinguishing acute otitis media from otitis media with effusion is important because antibiotics are seldom indicated for the latter condition. A key differentiating feature is the position of the tympanic membrane: it is usually bulging in acute otitis media and in a neutral position or a retracted position in otitis media with effusion. Tympanometry and acoustic reflectometry can be useful adjunctive tools to confirm the presence of fluid in the middle ear. Selective use of tympanocentesis in cases of refractory or recurrent middle ear disease can help guide appropriate therapy and avoid unnecessary medical or surgical interventions. (11) 13 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.7.1. Pneumatic otoscopy: Detection of middle ear effusion by pneumatic otoscopy is key in establishing the diagnosis of acute otitis media.(7) The tympanic membrane normally is convex, mobile, translucent, and intact; a normal color and mobility of the membrane indicate that otitis media is unlikely.(5) The tympanic membrane can not be adequately seen while partially occluded by cerumen. Cerumen removal by curette is essential and should be regularly used. If the wax is dry or deep in the auditory canal then cerumenolytics and/or warm water irrigation may necessary. Pneumatic otoscopy has been advocated as an important adjunct to assist in diagnostic accuracy of AOM. (13) Four characteristics of the TM should be evaluated and described in every examination (position, mobility, colour, degree of translucency). The normal TM is in the neutral position (neither retracted nor bulging), pearly gray, translucent and responds briskly to positive and negative pressure, indicating an air filled space. The abnormal TM may be retracted or bulging, and immobile or poorly mobile to positive and/or negative air pressure. The colour of the eardrum is of minor importance although patients with AOM more 14 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. often have a red TM. The key differentiating features of AOM compared to OME on physical exam relate to TM position. In AOM the TM almost always is bulging and in OME it is usually retracted or, occasionally, it is in neutral position. The TM is thickened in both AOM and OME, thereby reducing visibility through it. Sometimes a yellow or grayish middle ear effusion can be seen behind the TM in either condition. (5) 1.1.7.2. Tympanometry and acoustic reflectometry: Each have attributes which make them of value in providing information about the possible presence of a middle ear effusion. The sensitivity, specificity, positive predictive value and negative predictive value of the two instruments have been assessed in comparison with pneumatic otoscopy, audiometry and tympanocentesis findings. As a result both of them have some limitations. Acoustic reflectometry has the advantage of not requiring a seal within the canal which improves its usefulness in the crying child because a reading can be obtained when a child stops crying to take a breath. Tympanometry provides additional information about actual pressures within the middle ear space. (14) 15 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.7.3. Tympanocentesis: Tympanocentesis followed by aspiration and culture of middle ear fluid samples, is useful in children who are toxic, have failed multiple courses of antibiotics, or have immune deficiencies. Although negative nasopharyngeal cultures correlate well with negative middle ear fluid cultures, they are not routinely recommended. Selective use of tympanosynthesis may improve diagnostic accuracy because it validates or refutes the physicians’ impression after visual examination. Certainly proper restraint of the patient and excellent visualization of the TM are essential; mild sedation may also be helpful in some cases. Tympanocentesis should be performed and it is beneficial. (15) 1.1.7.4. Radiography: Radiographic evaluation of the temporal bone is indicated when complications or sequelae of otitis media are suspected or present. Plain radiographs are of limited value in the diagnosis of mastoiditis or cholesteatoma; computed tomography(CT) and magnetic resonance imaging (MRI) are more precise and should be obtained if a suppurative intratemporal or intracranial complication is suspected.(3) 16 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.1.8. Mortality/Morbidity: In about 80% of children the condition resolves without antibiotic treatment in about three days.(7) In US mortality rates are extremely low in this era of antimicrobial therapy (<1 death per 100,000 cases). A study that examined the causes of death in Los Angeles County Hospital from 1928-1933, years prior to the advent of sulfa, showed 1 in 40 deaths was caused by intracranial complications of OM. Morbidity from this disease remains significant, despite frequent use of systemic antibiotics to treat the illness and its complications. In developing nations with limited access to primary medical care and modern antibiotics, mortality rates are higher. (4) A) Intratemporal complications: - Hearing loss (conductive and sensorineural). - TM perforation (acute and chronic). - Chronic suppurative OM (with or without cholesteatoma). - Cholesteatoma. - Tympanosclerosis. - Mastoiditis. - Petrositis. 17 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. - Labyrinthitis. - Facial paralysis. - Cholesterol granuloma. - Infectious eczematoid dermatitis. B) Intracranial complications: Meningitis, subdural empyema, brain abscess, extradural abscess, lateral sinus thrombosis and otitic hydrocephalus. (4) 1.1.9. Treatment: Observation is an acceptable option in healthy children with mild symptoms. Antibiotics are recommended in all children younger than six months, in those between six months and two years if the diagnosis is certain, and in children with severe infection. High-dosage amoxicillin (80 to 90 mg per kg per day) is recommended as first-line therapy. Macrolide antibiotics, clindamycin, and cephalosporins are alternatives in penicillinsensitive children and in those with resistant infections. Patients who do not respond to treatment should be reassessed. Hearing and language testing is recommended in children with suspected hearing loss or persistent effusion for at least three months, and in those with developmental problems.(1) 18 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Should antibiotics be used to treat AOM? Antimicrobial therapy is one of the cornerstones in the management of AOM but some studies have suggested that its routine use is not indicated. Nonetheless, in the preantibiotic era, complications of AOM such as mastoiditis were far more common than they are today; this difference may be due to the current routine use of antibiotics. A recent meta-analysis of 5400 children with AOM indicated that antimicrobial therapy enhanced the ‘primary control’ by 13.7% despite a spontaneous recovery in 81% of cases. Because it is probably not possible to determine which cases of AOM will result in suppurative complications, it is likewise not possible to determine which cases require antimicrobial therapy and which will resolve spontaneously. Therefore, it appears prudent to consider all cases of AOM candidates for antimicrobial therapy in order to minimize the likelihood of complications. Some experts recommend watchful waiting for 48 to 72 h before initiating antibiotic therapy. This approach may be feasible in children over two years of age if good follow-up can be assured; therefore, decisions about whether to withhold antibiotics therapy initially must be made on a patient-by-patient basis.(12) 19 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Table 1-1: CDC Working Group Treatment Recommendations for Acute Otitis Media* Antibiotics in prior month Day 0 Clinically defined treatment failure on day 3 Clinically defined treatment failure on days 10 to 28 No High-dose amoxicillin;† usual-dose amoxicillin High-dose amoxicillinclavulanate (Augmentin);‡cefuroxime axetil (Ceftin); intramuscular ceftriaxone (Rocephin)‡ Same as day 3 Yes High-dose amoxicillin; high-dose amoxicillinclavulanate; cefuroxime axetil Intramuscular ceftriaxone;‡ High-dose clindamycin;§ or amoxicillintympanocentesis clavulanate; cefuroxime axetil; intramuscular ceftriaxone;‡ or tympanocentesis CDC = Centers for Disease Control and Prevention. *--Recommended drugs are those for which strong evidence for efficacy currently exists. Other drugs also may prove efficacious. ‡--High-dose amoxicillin is 80 to 90 mg per kg per day. High-dose amoxicillinclavulanate is 80 to 90 mg per kg per day of amoxicillin component, with 6.4 mg per kg per day of clavulanate (requires newer formulations or combination with amoxicillin). ‡--Intramuscular ceftriaxone has been documented to be efficacious in acute otitis media treatment failures if three daily doses are used. §--Clindamycin is not effective against Haemophilus influenzae or Moraxella catarrhalis. 1.1.9.1. Antibiotic Selection: Acute otitis media: High-dosage Amoxicillin (80 to 90 mg per kg per day) divided into two daily doses for 10 days is recommended as first-line antibiotic therapy in children with acute otitis media. In children older than six years with mild to moderate disease, a five- to seven-day course is adequate. 20 (1)Amoxicillin is Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. effective, safe, and relatively inexpensive, and it has a narrow microbiologic spectrum. First-line treatment with amoxicillin is not recommended in children with concurrent purulent conjunctivitis, after antibiotic therapy within the preceding month, in children taking amoxicillin as chemoprophylaxis for recurrent acute otitis media or urinary tract infection, and in children with penicillin allergy.(1) Cephalosporins may be used in children allergic to penicillin if there is no history of urticaria or anaphylaxis to penicillin. If there is a history of penicillin-induced urticaria or anaphylaxis, a macrolide (e.g., azithromycin ,clarithromycin or clindamycin may be used. A single dose of parenteral ceftriaxone (50 mg per kg) may be useful in children with vomiting or in whom compliance is a concern. Single-dose azithromycin is safe and effective in uncomplicated acute otitis media and compares well with longer courses of azithromycin or other antibiotics.(17) Persistent acute otitis media: If there is no clinical improvement within 48 to 72 hours, the patient must be reassessed to confirm the diagnosis, exclude other causes of illness, and initiate antibiotic therapy in those on symptomatic treatment alone. Patients who are already taking antibiotics should be changed to second-line 21 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. therapy. Options include high-dose amoxicillin/clavulanate cephalosporins, and macrolides. Parenteral ceftriaxone administered daily over three days is useful in children with emesis or resistance to amoxicillin/clavulanate. For children who do not respond to second-line antibiotics, clindamycin and tympanocentesis are appropriate options. Although it is not approved for use in children, levofloxacin is effective in children who have persistent or recurrent acute otitis media.(18) Recurrent Acute Otitis Media: Most children with recurrent acute otitis media improve with watchful waiting. Although antibiotic prophylaxis may reduce recurrence, there are no widely accepted recommendations for antibiotic choice or prophylaxis duration. Minimizing risk factors (e.g., exposure to cigarette smoke, pacifier use, bottle feeding, and daycare attendance) decreases recurrence. Heptavalent pneumococcal vaccine reduces the incidence of acute otitis media, but it does not reduce recurrence.(5). Otitis media with effusion: Persistent middle ear effusion after resolution of acute otitis media does not indicate treatment failure and requires only monitoring and reassurance. Risk factors for persistent acute otitis media with effusion include hearing loss 22 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. greater than 30 dB (decibels), prior tympanostomy tube placement, adenoid hypertrophy, and onset during summer or fall.(19) Clinical examination, pneumatic otoscopy, and tympanometry may be performed during the observation period. There is no role for antihistamines and decongestants; Oral and topical intranasal corticosteroids alone or in combination with an antibiotic produce faster short-term resolution of otitis media with effusion, but there is no evidence of long-term benefit. Auto inflation (i.e., opening the Eustachian tube by raising intranasal pressure) is useful in older children with persistent acute otitis media with effusion who are able to perform the Valsalva maneuver. (20) Children older than two years who have otitis media with effusion and no developmental issues must be seen at three- to sixmonth intervals until effusion resolves, hearing loss is identified, or structural abnormalities of the tympanic membrane or middle ear are suspected. Hearing and language testing is recommended in patients with suspected hearing loss or persistent effusion for at least three months, or when developmental problems are identified. Children with hearing loss of 20 dB or less who do not have speech, language, or developmental problems can be observed. Those with 23 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. hearing loss of 21 to 39 dB can be observed or referred for surgery, and those with hearing loss of 40 dB or more should be referred for surgery.(3) 1.1.9.2. Bacterial resistance after antibiotic therapy failures: During the 1980s, H. influenzae was the most common (46 to 62 percent) pathogen isolated in patients who failed to respond to initial treatment of acute otitis media. Currently, it appears that S. pneumoniae, particularly penicillin-resistant strains, accounts for an increasing number of pathogens in patients who fail to respond to antibiotic therapy. The highest risk for penicillin-resistant S. pneumoniae occurs in patients who have been treated recently with antibiotics (particularly within the preceding month) or who are not improving during a course of antibiotic therapy.(21) With persistent and recurrent acute otitis media, treatment success rates can be expected to be in the range of 60 to 70 percent, even when the most efficacious broad-spectrum oral antibiotics are chosen. Currently, minimal data are available regarding the treatment of acute otitis media caused by highly penicillin-resistant S. pneumoniae. Thus far, only five antibiotics--high-dose amoxicillin, amoxicillin-clavulanate , cefuroxime , cefprozil and ceftriaxone -- 24 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. have demonstrated a modest degree (60 to 80 percent) of clinical efficacy in the treatment of acute otitis media caused by penicillinresistant S. pneumoniae.Studies of other broad-spectrum agents are currently under way.(21) 1.1.9.3. Surgical treatment: The primary objective of surgical treatment of chronic serous otitis media is to reestablish ventilation of the middle ear, keeping the hearing at a normal level and preventing recurrent infection. This involves myringotomy with insertion of a ventilation tube and, at times, adenoidectomy.(22) Myringotomy (an incision in the eardrum membrane) is performed to remove middle ear fluid. A ventilation tube is inserted to prevent the incision from healing and to insure middle ear ventilation. The ventilation tube temporarily takes the place of the eustachian tube in equalizing middle ear pressure. This plastic tube usually remains in place for three to nine months during which time the eustachian tube blockage should subside. When the tube dislodges, the eardrum heals; the eustachian tube then resumes its normal pressure equalizing function. 25 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. In rare cases the membrane does not heal following dislodgement of the tube. The perforation may be repaired later. In adults, myringotomy and insertion of ventilation tube is usually performed in the clinic under local anesthesia. In children general anesthesia is required. The adenoids can be removed if enlarged. In some difficult cases it is necessary to insert a more permanent type of tube, the "mesh" ventilation tube. This tube is more difficult to insert but frequently will remain in place until removed. In children, removal may require an anesthetic. At times a permanent membrane perforation develops when the tube is dislodged or removed. If this perforation persists it can be repaired at a later date when the eustachian tube blockage has subsided. (22) 1.1.10. Causative agents of OM and their antibiotics susceptibility: A descriptive study was conducted in Khartoum state at the ENT hospital, out-patient clinic by Mohammed B. (April2001March2002), fifty samples were collected from different ages and sexes. It revealed that Staphylococcus aureus was responsible for (31.4%) of cases, Proteus sp.(23%), Steptococcus sp. (14.4%), Klebsiella sp(2.8). Most Staph. aureus sp were sensitive to Gentamicin, Norfloxacin and Ciprofloxacin 26 ,resistant to Ampicillin, Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Cotrimoxazole, and Streptomycin. Proteus sp. Were sensitive to Gentamicin, Ciprofloxacin, Norfloxacin,and Cefixime. Resistant to Ampicillin, Cotrimoxazol, and Ceftriaxon. Other isolates were sensitive to Gentamicin, least sensitive to Ampicillin Tetracycline and Streptomycin. (23) In King Abdul-Aziz University Hospital, a study done by Attallah (2000), eighty eight patient diagnosed as chronic suppurative otitis media, the common isolates were Pseudomonas sp. (51%), Staph aureus (31%), Proteus sp.(17%), fungi were (17%).(24) Another study conducted at King Abdul-Aziz University Hospital, by Eiad, et al (2001) for patient diagnosed as acute otitis media , showed that Streptococcus pneumoniae (25%), Haemophilus influenzae (36.6%), St.pyogenes (20%), Staph.aureus (15%), Maroxella catarrhalis(1.6%), Others show no growth .The resistance pattern of Staph.aureus to Penicillin was(36%),while (100%)to both St.pyogen and M.catarrhalis. fifty one percent of St.aureus were Penicillin resistant and (6.7%) were Methecillin resistance isolates.(25) A total of 106 specimens were cultured from middle ear discharge in Addis-Ababa Hospital by Melaku, Iulseged (1999)that 27 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. showed that (37.7%) Proteus sp. followed by Staph aureus, Psuedomonas sp. and other Gm-ve Enterococci.(26) In University of Eyciyes, School of medicine, Keysen, Turkey. In a study conducted by Nicro (2000) exudates of (183) patients with Chronic otitis media aerobic isolates were Psuedomonas sp.Staph aureus, and Klebsiella sp. All were sensitive to topical application of single dose (0.2%) Ciprofloxacin or combination of PolymixinB and Hydrocortisone suspension. (27) Another study conducted by Yavuz K.Ismail (2002) on bacterial isolates from children of AOM done in Sel.UK. University Ankara, showed that Sterpt.pneumoniae (39%), Haemophilus influenzae (27%), Moraxella catarrhalis (10%) Strept.pyogenes (3%), Staph aureus (2%) and (28%) show no pathogenic growth. (5) A prospective study was conducted by Pichichero ME.et al (1995) in department of Pediatrics University of Rochester Medical Center NY, USA. To determine the pathogens isolated from middle ear fluids of 200 specimens in 137 children with persistence AOM (which had not responded to empiric therapy) since October 1989Sept.1992 No bacterial growth in (49%), Strept.pneumoniae (24%), Haemophilus influenzae (7%). Moraxella catarrhalis (7%), Strept.pyogenes 28 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. (6%), Staph aureus (5%). Penicillin resistant isolates were (38%) of Sterpt. pneumoniae isolates Thirty eight percent of Haemophilus influenzae and all Moraxella catarrhalis produced beta-lactamases. For comparison tympanocentesis from previously untreated AOM patients, (30%) showed no bacterial growth. Strept.pneumoniae (36%), from them (8%) were Penicillin resistant. Haemophilus influenza in (13%), (44% were producing beta-lactamase), Moraxella catarrhalis (11%), (83% were producing beta-lactamase). AOM witch was persistent after initial empiric therapy may be caused by middle ear inflammation or involve penicillin resistant Strept. pneumoniae, betalactamase-producing Haemophilus influenza or Moraxella catarrhalis. More common than it occurs in AOM which had not been recently treated. (27) Bacteria were isolated and cultured from ears of patients of chronic suppurative OM who attended the otologic clinic of Kyusha university hospital from 1976-1991, Staph aureus and Psuedomonas sp. were the most common organisms. The incidence of Staph aureus increased gradually over 16 years while Psuedomonas sp. gradually decreases. (28) 29 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Another study showed that Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the most common micro organisms in AOM. The incidence of Streptococcus pneumonia peaked by age of 12 months where as Moraxella catarrhalis at 6 months and Haemophilus influenzae at 20 months of age. Strept.pneumoniae relation with seasons was lesser than the other two. H. influenzae rarely caused the first two AOM episodes, but became increasingly common after the third episode.(29) The American Family Physicians and American Academy of Pediatrics in its Clinical practice guideline (2004) stated that organisms isolated in AOM are Strept.pneumoniae in (40-50%) of cases then Haemophilus influenzaein (30-40%), Moraxella catarrhalis in (10-15%) then followed by Group A streptococcus, Staph. aureus, Gram-negative bacilli in newborns, immunosuppressed patients and those with CSOM. Viruses in less than (10%) and No bacterial pathogen in (20-30%) of cases.(1)Regarding Chronic suppurative otitis media Aerobic organisms were commoner like Psuedomonas sp, Proteus mirabilis,S.aureus, E.coli, or Klebsiella sp. Then anaerobic bacteria like Bacteroides, Peptostreptococcus or propionibacte. 30 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 1.2. OBJECTIVES 1.2.1. General Objective: • To determine the causative organisms of Otitis media among Sudanese patients seen in E.N.T Hospital, Khartoum. • To give a guideline in the empiric antimicrobial management of both acute and chronic otitis media. 1.2.2. Specific Objectives: • To isolate organisms causing both acute and chronic otitis media. • To establish the correlation between the type of organisms and age groups. • To determine the antimicrobial sensitivity pattern of the causative organisms. 31 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 2. PATIENTS AND METHODS 2.1. Study design: This is a descriptive prospective cross-sectional hospital based study. 2.2. Study period: The study was conducted in the period from December 2008 to March 2009. 2.3. Study Area: The Ear, Nose and Throat (ENT) Hospital. The Out-Patients Clinic, in Khartoum State. 2.4. Study population: Patients presented to the out-patients clinic in Khartoum ENT Hospital suffering from otitis media with ear discharge, of different age groups from both sexes were randomly selected. The required data were collected through a questionnaire after verbal consent from patients or their relatives. 2.5. Sample size: According to the annual incidence and the confidence level, the sample size was calculated, 104 clinical specimens (Ear swabs) 32 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. were collected, from patients complaining of otitis media with ear discharge. 2.6. Site of collection: The specimens were collected from patients suffering from Otitis Media with ear discharge, Samples collected with a sterile cotton wool swab aided by good light source. Swabs delivered to the laboratory within 2 hours to be processed. 2.7. Culture: 2.7.1. Inoculation: Under aseptic conditions near Bunsen burner the specimens were inoculated on to blood agar, chocolate (heated blood) agar and MacConkey agar plates. 2.7.2.1ncubation: The inoculated plates were incubated at 37c for 24 hours, one of the blood agar plates were incubated under 5-10%CO2. 2.7.3. Examination of growth: 1- Colonial morphology: The primary cultures on the blood, chocolate and MacConkey agar that showed heavy pure growth were examined for fermentation on MacConkey agar, haemolysis on blood and chocolate agar. The morphological 33 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. character, size, shape, colour, pigment production and haemolysis were studied. The resultant growth was processed for biochemical tests and antimicrobial susceptibility testing. 2- Gram stain (appendix). 3- Biochemical tests (appendix). 2.7.4. Antibiotics susceptibility testing: The suscebililty test was performed using Kirby-Bouer disk diffusion technique. Several colonies of the test organism were transferred to 2 ml sterile saline using a sterile loop. The inoculum turbidity was adjusted to MacFarland No.1 standard turbidity. Suspension of the standard control strains was prepared and processed the same as the tested organisms so as to assess the validity of antibiotics, media and other variables. 2.7.6. Inoculation of Mueller-Hinton Agar: The plates were inoculated by dipping a sterile cotton swabs into the inoculum (tests and controls). Then the swab were streaked over the Mueller-Hinton surface of the medium. All Streptoccoci sp. Blood agar was used for antimicrobial susceptibility. 34 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 2.7.7. Antimicrobial Disc Application: Using sterile forceps, antimicrobial discs were placed at least 24 mm apart on the inoculated plates (9 cm plate). Incubation: The plates were incubated at 37 °C for 24 hours. The chocolate plates were incubated under CO2. 2.7.8. Reading and Interpretation: The diameter of each zone of inhibition (including diameter of the disc) was measured using a ruler, and interpreted according to table 2 of NCCLS for test organisms and table 3 of NCCLS for standard strains. 2.8. Data analysis: Data was entered, checked and analyzed using SPSS software Program. 35 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 3. RESULTS One hundred and four specimens were collected from patients attending, Ear Nose and Throat Hospital (ENT) out-patient clinic. In this study males comprised (60.2%) and females were (39.8%).Regarding age groups, they are shown in (Table1).Type of isolates are shown in (Table 2). In the study, patients with acute otitis media comprised (41.7%), while those with chronic otitis media were (58.3%), as shown in (Fig. 1). The isolated organisms are listed in (Table 3). There was an association between type of infection and age, AOM decreases with age, while CSOM increases with age (Fig. 2).Also an association between the organism isolated and the type of infection, AOM mainly caused by S.pneumoniae, Staph.aureus and S.pyogen, while ChOM mainly by Proteus sp., Psuedomonas sp., E.coli and Klebsiella sp.(Fig. 3).Staph. aureus sensitivity pattern are shown in (Fig. 4), S.pneumoniae (Fig. 5), S.pyogen (Fig. 6), Proteus sp. (Fig. 7), Psuedomonas sp. (Fig. 8), E.coli (Fig. 9) and Klebsiella sp. sensitivity are in (Fig. 10). 36 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Table 1: Distribution of patients according to age groups Age group (in years) Otitis media Total (%) Acute Chronic <1 18 (82.0) 4 (18.0) 22 (20.4) 1 - 15 29 (58.0) 21 (42.0) 50 (46.3) 16 - 30 3 ( 17.0) 15 (83.0) 18 (16.7) 31 - 45 2 (20.0) 8 (80.0) 10 (9.3) 46 - 60 1 (50.0) 1 (50.0) 2 (1.8) - 6 (100) 6 (5.5) 53 (49.0) 55 (51.0) 108 (100) > 60 Total Table 2: Number and percentage of bacterial isolates Isolates Frequency Percentage Bacterial isolates 9 64 Fungal isolates 7 6.5 No growth 28 26 Non-pathogenic 4 3.7 108 100 isolates Total 37 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Table 3: List of organisms isolated Organism isolated Frequency Percentage Staph. aureus 21 27.6 S.pneumoniae 18.5 S. pyogenes .5 Pseudomonas sp. 11 14.5 Proteus sp. 18.5 E. coli 3 3.9 Klebsiella spp. 1 1.3 Fungi 9.2 Total 38 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (1): Types of otitis media (n = 104) 49% 51% Acute otitis media Chronic otitis media 39 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (2): Relation between age and types of otitis media (n = 104) 29 30 25 21 20 18 15 15 10 8 6 4 5 3 2 1 1 0 0 < 1YR 1-15 YRS 16-30 YRS 31-45 YRS ACUTE OTITIS MEDIA 46-60 YRS > 60 YRS CHRONIC OTITIS MEDIA 40 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (3): Relation between organisms isolated and types of otitis media (n = 104) 14 13 12 12 12 10 11 9 8 7 6 4 3 2 3 2 2 1 1 0 0 eus oniae yogen s spp s spp r u na roteu ha um ept.p a p e a m n P p St Str udo pt. e e s r P St ACUTE OTITIS MEDIA 0 0 i col spp ection . a E l l f e l in bsi a e g l n K Fu CHRONIC OTITIS MEDIA 41 0 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (4): Susceptibility of Staph. Aureus 20 19 19 18 18 16 16 14 14 13 12 11 11 10 10 8 8 6 5 4 3 2 2 2 2 0 0 3 0 2 0 PE NIC ILL IN OX AC ILL ER IN YT HR OM YC CO IN -A MO XY CA LV E CE PH AL EX IN CE FIX IM E GE NT CH AM LO ICI RA N MP HE NI CO L 0 5 5 SEN RES. 42 INTER 0 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (5): Susceptibility of Strept. Pneumoniae 14 13 13 13 12 12 11 10 8 6 4 3 2 2 1 1 PE NI CI LL IN OX AC ILL IN ER YT HR OM YC CO IN -AM OX YC AL VE CE PH AL EX IN 0 SEN 43 RES 1 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (6): Susceptibility of Strept. pyogenes 5 5 5 4.5 4 4 4 4 4 3.5 3 3 2.5 2 2 1.5 1 1 1 1 0.5 0 0 PE NI CIL LI OX N AC ER ILL YT HR IN CO OM -AM YCI OX N YC A CE LVE PH AL E GE XIN N CH LO TAM RA ICI N MP HE NIC OL 0 SEN 44 RES 1 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (7): Susceptibility of Proteus spp 10 10 9 9 8 8 8 7 6 6 5 5 5 5 4 4 33 3 3 3 3 22 2 2 3 1 GE NT CH AM LO ICI RA N MP HE NIC OL CE FT RIA XO CI ME PR OF LO XA CIN CE FO TA XIM E CE FU RO XIM E 0 SEN RES 45 INTER Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (8): Susceptibility of Pseudomonas spp. 9 9 8 7 7 6 6 5 5 5 4 3 3 3 2 2 1 1 1 1 0 0 CEFOTAXIME CEFTAZIDIME AMIKACIN SEN RES 46 CARBINCILLIN INTER Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (9): Susceptibility of E. coli 3 3 2.5 2 2 2 2 2 1.5 1 1 1 1 1 0.5 0 CH LO RA MP HE NIC OL CE FT RIA XO ME CIP RO FL OX AC IN CE FO TA XIM E CE FU RO XIM E 0 SEN 47 RES Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Figure (10): Susceptibility of Klebsiella spp. 1 1 1 1 1 1 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 0 0 0 G CH ENT AM LO ICI RA N MP HE NIC CE OL FT RI CIP AXO ME RO FL OX AC CE IN FO TA XIM CE FU E RO XIM E 0 SEN 48 INTER 0 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 4. DISCUSSION This study was done to determine the common bacterial pathogens causing Otitis Media, in Sudanese patients and its distribution according to age and sex, and the pattern of antimicrobial resistance of bacterial isolates. Regarding distribution among age groups the study showed that children below fifteen years were 66%of the studied population , this result was in agreement with Scott-brown`s (1997 )who stated that otitis media is more common in children because their Eustachian tube is shorter, narrower and more horizontal than adults.(30) Regarding sex distribution males were 60.2%, while females were 39.8%. This result is consistent with what is documented in the Clinical Practice guideline of the American Academy of Pediatrics (2004) which stated that Male sex had slightly increased incidence. Regarding the distribution of acute and chronic otitis media among patients, 49% were diagnosed as AOM, while 51% as CSOM. In children below 15 years there is high incidence of CSOM (37.5%) which is different from that written in the literature. Most of these children came from areas outside Khartoum state of low 49 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. socioeconomic status, ignorance and illiteracy. Most of them did not receive any medications or incomplete courses of drugs. Some of them came with complications e.g. hearing problems (three children), low school performance (four), and Otitis externa in one child. In this study, 64% of the cultured ear samples yielded bacterial isolates, fungal isolates were 6.5% and 28% showed no growth of pathogens. These results were consistent with those obtained by M. Bilal (2002) from Sudan that showed 76%bacterial isolates, 4% fungal isolates and the remaining 19% revealed no growth of pathogens. From this study there was a correlation between age groups and the type of infection. In children less than 15 year 62.5% diagnosed as having AOM, while 37.5% had CSOM. Eighty percent of patients in the age group 31-45 years diagnosed as CSOM. In the last age group (over 60 years) only chronic otitis media was their. From these results it was clear that acute otitis media decreased with age, while chronic otitis media increased with age. The causative organisms for otitis media as general (acute and chronic) in this study were Staph.aureus followed by, St. pneumoniae, 50 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Proteus sp. and Psuedomonas sp. .These results were in agreement with the local study conducted by M. Bilal (2002) where Staph.sp were the main causative organism followed by Streptococcus sp ,Proteus sp and Psuedomonas sp. Regarding the bacterial causes of Acute Otitis Media (AOM) in this study, 50% were due to St. pneumoniae, 38% due to Staph.aureus, and 12% were due to St.pyogenes , in comparison to what was obtained by Eiad A (2001) in King Abdul-Aziz University Streptococcus pneumonia comprised 25%, Haemophilus influenzae 36.6%, St.pyogenes 20%, Staph. aureus 15% and Maroxella catarrhalis 1.6%. Comparing with other international studies, in Sel.uk University, Ankara (2002), among children of AOM, Streptococcus pneumoniae 39%, Haemophilus influenzae 27%, Maroxella catarrhalis 10%, St.pyogenes 3% and Staph aureus 2%. Also a study in University of Rochester Medical Centre New York (1995) to determine the causative organisms of persistent AOM Streptococcus pneumoniae 24%, Haemophilus influenzae 7%, Maroxella catarrhalis 7%, St.pyogenes 6%, Staph aureus 5%. 51 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. From all of these results we observe that higher incidence of Staph aureus in this study and other local Sudanese studies as a causative organism of AOM and also the absence of both Haemophilus influenzae and Maroxella catarrhalis. These significant differences might be due to environmental factors, or technical errors, e.g. the absence of the transport media which might affect the growth of these fastidious organisms, also the absence of standard organisms from these strains. The bacterial causes of CSOM in this study showed that Proteus sp. were 33%, While Staph.aureus comprised 30% and 27.5% were due to Psuedomonas sp. Comparing to another study regarding bacterial causes of chronic otitis media done by Attallah MS (2000) in King Abdul-Aziz University Hospital revealed that Pseudomonas sp. were 51%, Staph aureus 31% and Proteus sp.17%. Another study conducted in children Hospital in Addis Ababa (1999) among CSOM. Showed that Proteus sp. were 37.7% followed by Staph aureus and Psuedomonas sp. Both studies showed the same causative organisms of our study but of different percentages. 52 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Regarding the pattern of antimicrobial sensitivity, 90% of Staph.aureus isolates were Penicillin resistant, 10% Methacillin resistant (MRSA), while M. Bilal found that most Staph.aureus strains were resistant to both penicillin. Eiad (2001) at King Abdul-Aziz University Hospital found that, 51% of Staph.aureus isolates were Penicillin resistant, 6.7% were Methacillin resistant isolates. Streptococcus pneumoniae isolates were 79% sensitive to penicillin in this study. While, Eiad A. (2001) at In King Abdul-Aziz University Hospital stated that 64% of St. pneumoniae isolates were sensitive to penicillin. In the study conducted by Pichichero ME. et al (1995) in Rochesrer Medical Centre NY, isolated St. pneumoniae from patient of persistent AOM were (72%) sensitive to penicillin unlike those of AOM not previously treated show (92%) penicillin sensitivity. Psuedomonas aeruginosa isolates were 82% sensitive to Ceftazedime, its sensitivity to Cefotaxime was 64%. These results were agreed by a local study conducted by Amena A. (2006) where 91% of Psuedomonas sp. isolates were sensitive to ceftazidime and cefotaxime sensitivity was 54%. 53 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. From all the obtained results we notice increasing resistance of Staph.aureus isolates to penicillin and the percentages of MRSA. Also increasing resistance of St. pneumoniae isolates to penicillin, and of Psuedomonas aeruginosa to ceftazidime. This rising resistance of microorganisms to the commonly used drugs is mainly due to the misuse of antibiotics, prescribing without strong base, e.g. for viral infections and the ease of issuing any antibiotic over the counter without doctor prescription, also, due to patient non-compliance. 54 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 4.1. CONCLUSION The study concluded that: Among patient complaining of otitis media, males were 65 (60.2%), while females 43 (39.8%). Children below fifteen years comprised (66.7%), from all other age groups. Acute otitis media decreases with age, while chronic otitis media increases. Streptococcus pneumoniae is the main causative organism for AOM followed by Staphylococcus aureus, then Strept.pyogen. Proteus sp was the main causative organism of chronic otitis media, followed by Staph.aureus, then Psuedomonas spp., E.coli and lastly Klebsiella spp. S.pneumoniae strains were (79%) sensitive to Penicillin, (93%) sensitive to both Co-amoxycalve and Cefalexin and (86%) to Erythromycin. Staph.aureus strains were (90%) Penicillin resistant, (85%) sensitive to Cefixime, Chloramphenicol and Gentamicin sensitivity 55 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. were (76% & 52%) respectively, Cefalexin (67%) and Co-amoxycalve sensitivity was (52%). Psuedomonas spp. isolates were highly sensitive to Ceftazidime (82%), followed by Carbencillin (73%), Amikacin (55%) and Cefotaxime (64%). Proteus spp. (86%) were sensitive to both Cefotaxime and Ceftriaxone, (79%) to Ciprofloxacin and (79%) to Gentamicin, (71%) to Chloramphenicol and (64%) to Cefuroxime. 56 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 4.2. RECOMMENDATIONS Otitis Media is one of the common diseases especially in childhood, it had great influence on work and school attendance and it may lead to hearing loss if not properly diagnosed and treated. So we recommend that: • Proper diagnosis and treatment, any patient complaining of otitis media ear swab have to be taken, so as to continue with or to change the empirical treatment. • More studies have to be done to isolate Haemophilus influenzae and Moraxella catrrhalis as causative organisms of otitis media. • Early diagnosis and treatment of otitis media, so as to reduce complications, especially in children. • To establish adequate microbiology service in the major hospitals for accurate diagnosis and to determine the antimicrobial susceptibility patterns and to establish a surveillance system for antimicrobial resistance. 57 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. REFERENCES 1. Muhammad WS, Muhammad AS. Otitis media: Diagnosis and management of acute otitis media eMedicine, July 22, 2008. 2. Cheesbrough M. Collection, transport and examination of ear discharges. In: Medical laboratory Manual for tropical countries, Vol. 2. Cambridge: University Press; 1984. P. 114. 3. Kalyanakrishnan R, Rhonan S, and Waynee B. Otitis media: Diagnosis and Treatment of Otitis Media Am Fam Physic 2007 Dec; 76(11): 13-15. 4. Bluestone CD, Rosenfeld RM. Otitis Media; Definitions, terminology, and classification. 2nd ed. 2003. p. 120–35. 5. Yavuz K, Ismail R. Acute Otitis Media in children. Journal of Ankara Medical School 2002; 55(1): 2-4. 6. Kathy A C, Matthew J W. Diagnosis and management of acute otitis media eMedicine Article Last Updated: Jul 16, 2008. 7. Paddy O'Neill. Acute otitis media. Br Med J 1999; 319: 833-835. 8. Peter W. Alberti. The Anatomy and physiology of the ear and hearing. Paedia Child Health 1998; 3(4): 265-267. 9. Bobby RA. Review of Anatomy-Temporal Bone and Ear. Last Modified: Jan. 23, 2006. 58 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 10. Rachel E. Hardisty, et al. Causes of otitis media in the Jeff mouse. Oxford Journals, Human Molecular Genetics 2006 Oct.; 10: 403. 11. Allan SL, Theodore GG, Edward OC. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion. Pediatrics J 2004; 113: 1412-2. 12. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute otitis media: Metaanalysis of 5400 children from thirty-three randomized trials. J Pediatr 1994; 124: 355-67. 13. Kaleida PH, Stool SE. Assessment of otoscopists’ accuracy regarding middle-ear effusion. Am J Dis Child 1992; 146: 433-435. 14. Block SL, et al. Gradient acoustic reflectometry for the detection of middle ear effusion by pediatricians and parents. Pediatr Infect Dis J 1998; 17: 560-564. 15. Michael E, Pichichero MD. Acute otitis media: Part I. Improvement diagnostic accuracy. Am Fam Physician 2000 April; 61: 2051 – 6. 59 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 16. Carlin SA, Morchant CD, Shurin PA. Host factors and early therapeutic response in acute otitis media. J Pediatr 1991; 118: 178-83. 17. Janak AP, et al. Role of respiratory syncytial virus in acute otitis media: implications for vaccine development. PMC 2007 March; 25(9): 1683 – 89. 18. Michael E, Pichichero MD. Acute otitis media Part II. Treatment in the era of increasing antibiotic resistance. Am Fam Physician 2000 April; 61: 2410-6. 19. Arrieta A, Singh J. Management of recurrent and persistent acute otitis media: new options with familiar antibiotics. Pediatr Infect Dis J 2004; 23 (2 suppl): S115-24. 20. Perera R, Haynes J, Glasziou P, Heneghan CJ. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev 2006; (4): CD006285. 21. American Academy of Pediatrics and American Academy of Family Physicians. Clinical practice guideline. Diagnostics and Management of Acute Otitis Media. Pediatrics 2004; 113:1451–65. 22. Dowell SF, Butlere JC, Giebink GS, et al. Serous otitis media. Pediatr Infect Dis J 1999; 18: 1-9. 60 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 23. Mouhammed BI. Microbial causes of otitis media in Sudanese patients, Thesis for Msc, Sudan University, 2002. 24. Attallah MS. Microbiology of chronic suppurative otitis media. Saudi Med J 1985; 21: 924-927. 25. Eiad A, Hamza A, Gulam J, et al. Microbiology and Sensitivity of suppurative otitis media. Saudi Med J 2000; 19: 417-422. 26. Melako L. Chronic suppurative otitis media in children. Ethiopia. Ethiopia Med J 1999; 37: 237-46. 27. Pichichero ME, Pichichero CL.Persistent acute otitis media. Pediatr Infect Dis J 1995 Mar; 14:178-83. 28. Nicro N, Controlled multicenter study on chronic suppurative Otitis Media. Otolaryngol Head-Neck Surgery 2000; 123: 617-623. 29. Kilpi T, Herva E, Kaijalainen T, Syrjanen R, Takala AK. Bacteriology of acute otitis media in a cohort of Finnish children followed for the first two years of life. Pediatr Infect Dis J 2001; 20: 654-62. 30. Scott B. Scott-Brown’s Otolaryngology, 6th edition. 1997. P. 316 -317. 61 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Appendix (1) Ϣ ϴ Σή ϟ ϦϤ Σή ϟ Ϳ Ϣ δΑ University of Khartoum The Graduate College Medical and Health Studies Board Questionnaire Bacterial causes of Otitis Media in Sudanese patients seen in the E.N.T Hospital in Khartoum Date: .................................................................... Serial No: ........................................................... Lab. No.: ................................................................. Name: .................................................................... Age: ........................................................................... Residence: ......................................................... Gender: Symptoms: - Male ( ) - Female ( ) - Ear pain ( ) - Ear discharge ( ) - Colour: ......................... ( ) - Itching ( ) - Hearing loss Duration of symptoms: ……………………………………………………………………………… Diagnosis: - AOM ( ) - CSOM ( ) Antimicrobial used: ……………………………………………………………………………………..… Laboratory findings: …………………………………………………………………………………………. Morphology: .......................................................................................................................................................... Microscopy: ............................................................................................................................................................... Organism isolated: ............................................................................................................................................. Antimicrobial susceptibility: ............................................................................................................................................................................................................. ............................................................................................................................................................................................................ 62 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Appendix (2) I) Reagents: 1- Oxidase Reagent This is Tetramethyl p-phenylemediamine dihydrochloride obtained from BDH chemicals Ltd, Pool, England as powder and prepared according to cheesborugh (1985). 2- Kovacs Reagent: This is dimethyl amino benzaldehyde obtained from BDH chemicals Ltd and prepared according to cheeshbrough (1985) 3- Sodium chloride (Normal saline ‘0.85% w/v’). Oxoid Ltd, England. Prepared according to Cheesbrough (1985). 4- MacFarland standard: (Dihydrate barium chloride 1.175% w/v + sulphuric acid 1% v/v). Obtained from BDH chemicals Ltd, Poole England and prepared according to Cheesbrough (1985). 5- Hydrogen peroxide 3% 2.8.6 plasma. II) Standard strains: Staphylococcus aureus, ATCC. Pseudomonas aeruginosa, ATCC 27853, USA. Escherichia coli, ATCC. 63 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. Antimicrobial Discs: The following antimicrobial discs used in the research: 1. Penicillin G (P) 10 IU. oxoid, UK 2. Oxacillin (OX) 1 mg. oxoid,UK 4. Coamoxycalve(Au) 20/10 mg. oxoid, UK 5. Cefalexin.(CL) 30 mg. oxoid, UK 6. Cefixime.(CFX) 5mg, Bioanalyse, UK 7. Cefuroxime.(CU) 30 mg, Bioanalyse, UK 8. Cefotaxime (CTX) 30 mg, Abtek Biological Ltd, UK 9. Ceftriaxone (CRO) 30 mg Bioanalyse, UK 10. Ceftazidime (CAZ) 30 mg, Abtek Biological Ltd., UK 11.Gentamicin.(Gen) 30 mg, oxoid,UK 12.Amikacin.(AK) 10 mg, oxoid, UK 13.Chloramphenocol.(C) 30 mg, oxoid, UK 14.Carbincillin.(CAR) 100 mg, Bioanalyse, UK 15.Ciprofloxacin (CIP) 5 mg, oxoid , UK 16. Bacitracin(B) 10IU, oxoid , UK 17. Optochin (Opt) 0.3 IU, oxoid , UK 18.Erythromycin(E) 15mg oxoid , UK 64 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. III) Stains: Aset of Gram Stain: Crystal violet, Lugol iodine, Ethanol 95% and Safranine were Obtained from Sigma company, England and prepared according to Cheesebrough (1985). Procedure: This used to differentiate the bacteria into Gram positive and Gram negative. During examination of smears bacterial shapes and arrangements were studied, the technique was done as follows: 1. A portion of colony was emulsified in a drop of normal saline in clean slides and then spread evenly to prepare thin smear. 2. The smear was fixed by gentle heat and covered with crystal violet for one minute, then washed rapidly with clean water. 3. Lugol iodine was added for one minute and washed with clean water. 4. Alcohol was added for few seconds and washed rapidly by clean water. 5. The smear was covered with safranine (counter stain) for two minutes and then washed with clean water. 65 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. 6. The smear was examined microscopically, after air drying, using oil immersion lens. The results were reported. IV) Biochemical tests: a) Catalase test: The test was done to differentiate bacteria that produce catalase enzyme which break down of H2O2 to oxygen and water. The test was done by inoculating bacteria under test using wood stick in a test tube contains 2 ml of 3% H2O2. The result observed immediately. Active bubbling indicates positive test (Cheesbrough, 2000). b) Coagulase test: The test used to differentiate bacteria that produce the enzyme coagulase from which does not prouce it. Coagulase cause plasma to clot by converting the fibrinogen to fibrin. The test was done by emulsifying bacteria under test in a drop of physiological saline in slide. A drop of plasma was added and mixed gently. Clumping to the organism observed within 10 seconds as positive test. 66 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. c) Oxidase test: This test was done by smearing a portion of colony using wooden stick on filter paper impregnated in oxidase reagent. Phenylene diamine in the reagent will be oxidized to Purple colour appeared within 10 seconds indicating positive for oxidase test (Cheesbrough, 2000). d) Indole production: The test used to identify enterobacteriaceae that break down amino acid tryptophane with release of indole. The test was done by inoculating peptone water with bacteria under test. Then incubated at 37 °C for 24 hours. The indole formations were detected by adding Kovacs reagent. The result observed by presence of pink ring (Cheesbrough, 2000). e) Urease test: Test used to identify some bacteria that produce urease enzyme which break down the urea (2NH2CONH2) into ammonia (NH3) and CO2. The test was done by inoculating urea agar with test organism and incubated at 37 °C for 24 hours. The change in the colour to pink colour indicates positive test (Cheesbrough, 2000). 67 Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark. f) Citrate utilization: The based on the ability of bacteria to use citrate as it is only source of carbon and ammonium salt as source of nitrogen. cimmon citrate agar was inoculated with organism under test then incubated at 37 °C for up to 4 days and checked daily. Bluing of the media indicates positive test for citrate utilization. i) Fermentation of sugars, production of gas and acid: The test based on the ability of bacteria to ferment sugar (lactose and glucose) and production of gas and H2S, under aseptic conditions. KIA was inoculated with the organism under test by using straight wire. Then incubated at 37°C for overnight. Then change in colour crack and production of H2S was observed (Cheesbrough, 2000). 68
