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African Journal of Microbiology Research Vol. 4(13) pp. 1373-1382, 4 July, 2010
Available online http://www.academicjournals.org/ajmr
ISSN 1996-0808 2010 Academic Journals
Impact of multi drugs resistant bacteria on the
pathogenesis of chronic suppurative otitis media
Ihsan E. Alsaimary1*, Ahmed M. Alabbasi2 and Jassim M. Najim1
1Department of Microbiology, Col ege of Medicine, University of Basrah – Republic of Iraq.
2Department of Surgery, Col ege of Medicine, University of Basrah – Republic of Iraq.
One hundred twenty patients with chronic suppurative otitis media (CSOM) in Basrah, 65 (54.2%) males
and 55 (45.8%) females, with male: females ratio (1.2:1) and 60 individual without otological problems as
control group were included in this study, which done during the period between March 2009 and
January 2010. This includes the collection of aural swab samples, culturing of samples, identification of
causative agent’s species and antibiotic sensitivity. Gram’s negative bacteria were the commonest
microorganism comprises (60%). Pseudomonas aeruginosa was common causative agent (19.04%),
followed by Staphylococcus aureus (16.7%) and Klebsiella spp. (14.3%). Mixed infection was found in
high percent (74%), in which P. aeruginosa and other microorganisms were more common. The
antibiotic sensitivity pattern showed that P. aeruginosa was sensitive to Ciprofloxacin, amoxicillin
+clavulanic acid and gentamicin, while other is appeared resistant, S. aureus was sensitive to
ciprofloxacin, amoxicillin+clavulanic acid, erthomycin, cephalexine and it is resistant to penicillin and
ampicillin, klebsiella species were sensitive to ciprofloxacin, amoxicillin +clavulanic acid, gentamicin,
while resistant to tetracycline.
Key words: Pseudomonas aeruginosa
, Staphylococcus aureus
, Klebsiel a
spp., chronic suppurative otitis
media, aural swab, antibiotic sensitivity, gram’s negative bacteria, otological.
Otitis media is inflammation of the middle ear. This is
commonly caused by the build up of fluid behind the ear
CSOM, for the purposes of this document, defined as a
drum, as a result of a blockage to the Eustachian tube.
chronic inflammation of the middle ear and mastoid
Otitis media is more common in children, as their
cavity, which presents with recurrent ear discharges or
Eustachian tube is shorter and more horizontal than
otorrhoea through a tympanic perforation (Howard,
adults and is made up of more flaccid cartilage, which
2007). The disease usual y begins in childhood as a
can impair its opening (Bluestone and KLien, 2001). Otitis
spontaneous tympanic perforation due to an acute
media can cause a mild to moderate hearing loss, due to
infection of the middle ear, known as acute otitis media
the fluid interfering with the transmission of sound
which presents with a rapid onset of signs and
through to the inner ear. It can often affect the tympanic
symptoms, such as pain, fever, irritability; a red bulging
membrane causing it to retract or become inflamed. The
ear drum and middle ear effusion (Jahn, 1991).
fluid can cause the tympanic membrane to bulge and
In CSOM the bacteria may be aerobic (e.g.
become inflamed and occasional y the tympanic
membrane wil perforate. There are three common types
Staphylococcus aureus, Streptococcus pyogenes,
of otitis media, acute purulent otitis media, otitis media
Proteus mirabilis, Klebsiel a
species) or anaerobic (e.g.
with effusion and chronic suppurative otitis media
Bacteroides, Peptostreptococcus, Proprionibacterium
(Saunders et al., 2009; Brook, 1996). The present studies
aimed to identify the bacterial pathogens associated with
CSOM, study the antibiotic susceptibility pattern of
*Corresponding author. E-mail: email@example.com.
antibiotic against bacterial pathogen, and determined the
Bacterial types isolated from healthy person (control
Two groups were included in this study: Group (1) 120 aural swabs
were taken from infected ear of CSOM patients. Group (2) 60 aural
No. of isolates
swab were taken from a control group. Swabs were taken under
sterile condition and transfer immediately to the laboratory by brain
heart broth for aerobic bacteria, thioglycol ate broth for anaerobic
bacteria, and cultured on suitable media at 37˚C for 24 - 48 h.
Primary isolation on (Blood agar, chocolate agar, nutrient agar),
then on selective media identification and biochemical characteri-
zation were carried out according to standard routine techniques
(Fingole and Baron, 2002). Note: Al media are sterilized by
autoclave (121˚C under 15 Ibs pressure for 15 min). Antibiotics disc
Bacterial type isolated from patients with CSOM.
No. of isolates
In order to determine the statistical significance among different
variables, SPSS program (statistical program for social sciences)
ver.11, was used for this purpose. The fol owing statistical testes
were performed: Chi-square (x2) test and the difference between
two proportions by T-test were used to assess the significance of
difference between groups. P-value less than 0.05 was considered
as statistical y significant (S), p-value < 0.01 as highly significant
and (HS), p-value < 0.001 as extremely significant (ES). p-value
more than 0.05 was considered as statistical y not significant (NS).
mode of bacterial isolation and multi drugs resistant
Table 1 show results of isolated bacterial from (60)
healthy persons. The fol owing bacteria were isolated,
20 isolates (40%), fol owed
species 15 isolate (30%). Other
MATERIALS AND METHODS
types distributed according to species in Tables 3 - 8.
Ten samples gave negative result for bacteria culture
A total of 120 patients with CSOM were included in this study, the
diagnosis of CSOM was carried out according to clinical examination
by otoscopic and tuning fork examination, and audiological investigation
Pathogenic bacteria isolated from patients with
(pure tone audiometry and tympanometry under supervision of
specialists of ENT. Microbiological investigation includes (culture,
identification of causative agents and antibiotic sensitivity. The
study was carried out in Basrah General Hospital, out patients
The occurrence of various bacterial isolate among CSOM
E.N.T. clinic, during the period from March 2009 - January 2010.
patients shown in Table 2 presents that P. aeruginosa
was more frequently isolates
40 (19.41%), while S.
fol owed by Pseudomonas
30 (14.56%) Branhamel a catarrhalis
20(9.70%), Heamophilus influenzae
spp. 15(7.28%), E. coli
A total of 60 individuals without otological problems, 30 males and
30 females in various age group, they were regarded as a control
8 (3.88), and Bacil us
Relationship between caustive agents and hearing loss.
No. of isolates with Hearing Loss (%)
No. of isolates
CHL: Conductive hearing loss, SNHL: Senserineural hearing loss and MXHL: Mixed hearing loss.
Standard antibiotic susceptibility test according to diameters of inhibition zone supplied by bioanalysis company.
Zone diameter (mm).
Bacterial pathogens and hearing impairment
Amoxicil in + clavulanic acid (Augmentin) and Gentamicin
are statistical y significantly higher than other types of
The occurance of various caustive agents isolates among
P < 0.01 in percentages of sensitivity between
CSOM patients in three types of hearing loss (CHL,
(50 - 75%) (p < 0.01), while 88% of P. aeruginosa
SNHL, MXHL) are shown in Table 3. P. aeruginosa
isolates was resist by trimethoprim, 85% to Streptomycin,
more frequently isolated in senserineural and profound
and 80% to Vancomycin, while other pattern of resistance
hearing loss (25 - 26.2%), while in conductive and mixed
were between 25 - 78% of various antibiotics p < 0.01.
hearing loss (16.7 - 20.4%) S. aureus
more frequently among CSOM patients with conductive
and mixed hearing loss (20.4 - 25%) than in senserineura
Antibiotic sensitivity of S. aureus
and profound hearing loss (12.5 - 15%) Klebsiel a
species and other organisms isolated in various
Table 6 shows that in each drugs group, the frequency
percentages from these three types of hearing loss.
sensitivity of Ciprofloaxacin, Augmenten, Cephalexin and
Penicil in (57 - 80%) were statistical y significantly higher
sensitive than other antibiotic. P < 0.01, while 83% of S.
Antibiotic sensitivity of P. aeruginosa
isolates was resist to trimethoprim, 83% to
Streptomycin, and 83% to Vancomycin, while other
Table 5 show that the frequency of Ciprofloxacin,
pattern of resistance were between 20 - 77% of various
Antibiotic susceptibility pattern of Pseudomonas aeruginosa
No. of isolates
Antibiotic susceptibility pattern of S. aureus
No. of isolates
Antibiotic susceptibility pattern of Klebsiel a spp
No of isolated
Antibiotic sensitivity of Klebsiella spp.
Table 7 shows that in each drugs group, the frequency of
sensitivity of Ciprofloxacin and Augmentin (67 - 70%)
were statistical y significantly higher than other type of
antibiotic drugs. (p < 0.01), while 73% of Klebsiel a spp
isolates was resist to trimethoprim, 70% to Erythromycin,
and 80% to Vancomycin, while other pattern of resistance
were between 30 - 73% of various antibiotics p < 0.01.
Antibiotic sensitivity of B. catarrhalis
Table 8 shows that in each drugs group, Ciprofloxacin,
Augmentin, Cephalexin, Ampicil in, Gentamicin were
statistical y significantly higher sensitivity (50 - 75%)
Antibiotic susceptibility pattern of Branhamel a spp
Antibiotic susceptibility pattern of Heamophilus spp
Antibiotic susceptibility pattern of Proteus spp
30 - 60% of various antibiotics p < 0.01.
Antibiotic sensitivity of H. influenzae
Table 10 shows that in each drugs group, the frequency
of Ciprofloxacin, Augmentin, Gentamicin, Vancomycin
and Lincomycin (50 - 75%) were statistical y significantly
higher sensitive drugs against H. influenzae
than other (p
< 0.01), while 80% of H. influenzae
isolates was resist to
Streptomycin, 70% Tetracycline, and 70% to Ampicil in,
while other pattern of resistance were between 25 - 65%
Antibiotic sensitivity of Streptococcus spp.
Table 11 shows that in each drugs group the frequency of
Ciprofloxacin, Augmentin, Penicil in, Erythromycin and
tetracycline were statistical y significant higher sensitive
(67 - 80%) than other type of Antibiotics (p < 0.01), while
against Branhamel a
spp than other type of antibiotic (p <
60%, of Streptococcus
spp isolates was resist to
0.01), while 75% of Branhamel a
spp isolates was resist
Trimethoprim, 53.33% to Streptomycin and 46% to
to trimethoprim, 70% to Streptomycin, and 70% to
Ampicil in, while other pattern of resistance were between
Vancomycin, while other pattern of resistance were
20 - 40% of various antibiotics p < 0.01.
between 25 - 60 of various antibiotics p<0.01.
Antibiotic sensitivity of E. coli
Antibiotic sensitivity of Proteus spp.
Table 12 shows that in each drugs group, the frequency
Table 9 shows that in each drugs group, the frequency of
of Ciprofloxacin, Augmentin, Gentamicin, Lincomycin and
Ciprofloxacin, Augmentin, Gentamicin and Trimethoprim
Cephalexin were statistical y significantly higher sensitive
were statistical y significantly higher effective against
drugs (60 - 80%) against E. coli
than other type of drugs
than other type of Antibiotics, (60 - 70%)
(p < 0.01), while 80%, of E. coli
spp isolates was resist to
sensitive (p < 0.01), while 75% of Proteus
Streptomycin, 60% to Trimethoprim and 60% to
was resist to Ampicil in, 70% Erythromycin, and 75% to
Ampicil in, Erythromycin and penicil in, while other pattern
Penicil in, while other pattern of resistance were between
of resistance were between 20 - 40% of various
Antibiotic susceptibility pattern of Streptococcus spp
No. of isolates
Antibiotic susceptibility pattern of E. coli
Antibiotic susceptibility pattern of Corynebacterium spp.
Trimethoprim were statistical y significantly higher
sensitive drugs (75%) against Bacil us spp
Antibiotic sensitivity of Corynebacterium spp.
type of drugs (p < 0.01), while 50%, of Bacil us
isolates was resist to Lincomycin, 50% to Vancomycin
Table 13 shows that in each drugs group, the frequency
and 50% to Cephalexin, Penicil in and Streptomycin,
of Ciprofloxacin, Cephalexin, Erythromycin, Ampicil in
while other pattern of resistance were 25 - 37.5% of
and Penicil in were statistical y significantly higher
sensitive drugs (75%) against Corynebacterium spp (p <
0.01), while 63%, of Corynebacterium
spp isolates was
resist to Lincomycin, 63% to Vancomycin and 50% to
Types of infection according to number of causative
Gentamicin and Cephalexin, while other pattern of
resistance were between 25 - 38% of various antibiotics p
Table 15 shows that the frequency of double causative
agents (55 isolates, 45.83%) was statistical y significantly
higher than single causative agent (38 isolates, 31.66%),
Antibiotic sensitivity of Bacillus spp.
three causative agents (18 isolates, 15%) and more than
three (9 isolates, 7.5%). There was no difference
Table 14 shows that in each drugs group, the frequency
between male and female in the frequency of various
of Ciprofloxacin, Erythromycin, Ampicil in, and
Antibiotic susceptibility pattern of Bacil us spp.
No. of isolates
Modes of isolation of the bacterial pathogens among patients with CSOM.
Modes of isolated
No. of patients (%)
Bacterial agents and antibiotics
fluid build up and ear drum perforation inhibit the
transmission or conduction of sound through the ear
Table 16 shows that in each isolates group the frequency
of susceptibility to antibiotic. P. aeruginosa
Our result goes with the study which was done by Guo
statistical y significantly higher resistance than other
(1994); Engel (1998), that show most patients with
bacterial isolates (10.19%) fol owed by S. aureus
CSOM infected by more than one pathogenic bacteria
(8.73%), Klebsiel a
(7.76%), B. catarrhalis
, Proteus spp
leading to hearing loss, about 40 patients, (33.4%) of
patients with CSOM suffered from bilateral hearing loss,
(0.9%) and Bacil us
spp. (0.9%) p < 0.01.
while (80 patients, 66.6) of patients with CSOM have
unilateral hearing. Guo et al. (1994) studied found the
effect of endotoxic damage to the strial vascularis and
concluded that lipopolysaccharide induced by strial
ototoxicity produced ion imbalance, causing changes in
Chronic suppurative otitis media was develops from a
endolymph composition and energy failure in the middle
chronic bacterial infection. However, the bacteria that
and inner ears organ explaining the pathogenesis of
caused the initial episode of acute otitis media with
perforation are usual y not those isolated from the chronic
Engel et al. (1998) studied the passage of streptolysin-
discharge when there is a chronic infection in the middle
O and albumin through the round window membrane and
ear and mastoid infection usual y polymicrobial and
proposed that the passage of macromolecule, such as
secondary in nature, derived from the external auditory
protease, from a purulent middle ear effusion may be
canal or commensal flora of nasopharynx (Bluestone and
facilitated by pore forming toxins, resulting in middle and
KLien, 2001). The infection causes a build up of fluid in
inner ear organs damage and hearing loss. Karma et al.
the middle ear. The pressure exerted by this fluid can
(1978) have used gram stain not only to confirm the
build up to the point where the ear drum perforated. The
presence of cultured bacteria but to detected and identify
Relationship between causative agents and antibiotics (resistance patterns).
Susceptibility to drugs
Bacterial isolate Type
More than (3)
them as wel , gram stain smear were obtain from 108 ear
with suppurative otitis media, fol owed by methicil in
swab; in 98 (91%) of them bacteria were found, seven of
resistant S. aureus
(3%) and P. aeruginosa
(1%). In our
the 108 ear swab (6%) were devoid of bacteria both in
study, we found that Klebsiel a
species isolated from
culture and in the gram stain. Papastavros et al. (1986)
patients suffering from chronic suppurative otitis media
indicated that this practice considerable error, because
was (30 isolates, 14.56%). our patients infected by
non viable bacteria can be as equal y incriminated as the
Enterobacteriaecea such as Klebsiel a
species, most of
main pathogens present, furthermore, if the patients is
them are among children and infants group, because the
under antimicrobial treatment. In our study, we found
Eustachian tube in children are shorter and wider than
that, the different type of bacterial flora in the external
adult. Bluestone et al. (1974) showed that young children
canal were founded, S. epidermidis
is the most common
have shorter, straighter and more compliant Eustachian
(20 isolates, 40%), fol owed by Corynebacterium
tube than adult; this permits a reflex from nasopharynx to
about (15 isolates, 30%), while other type have various
the middle ear with the consequence of bacterial
percentages of isolation. Our result is agreed with (Pelton
contamination. Brook and Yocum (1989) found that
et al., 1980; Brook et al., 1996), while, it is against the result
Klebsiel a species (6.2%) isolate from patients with
is of (Saunders et al., 2009). Pelton et al., (1980); Brook et
CSOM, while Ostfeld and Rubinstein (1980) stated that
al. (1981) showed that the predominant microflora were S.
(20%) of Klebsiel a species presented in young infant
epidermidis, diphtheroid, and S. aureus.
with acute otitis media, but rarely appear in the middle
In the present study, the number of P. aeruginosa
ear effusion of older children with otitis media.
isolates was (40 isolates, 19.41%). our result agreement
In our work, we found that B. catarrhalis
with studies done by (Aslam et al., 2004); (Verhoeff,
isolates, 9.7%). Faden (1994) found that, Moraxel a
2006) that Pseudomonas
most common agents in
catarrhalis or B. catarrhalis
were common organisms,
patients with CSOM, and not approved with (Saunders et
are considered as part of the normal flora of
al., 2009) found S. epidermidis
most common causative
human upper respiratory tract, classified as causative
agents. Aslam et al. (2004) showed that P. aeruginosa
agents to middle ear infection; it had constituted
the most common isolates from infected mastoid cavity
approximately 10% of al isolates. Hanan (2000) showed
and chronic otitis media and the most common aerobic
bacteria isolated from chronic suppurative otitis media.
(cephalosporinases) may protect these bacteria and
Verhoeff et al. (2006), stated that P. aeruginosa
other type from antimicrobial agents to which the second
most prevalent bacteriological agent in chronic otitis
target pathogen ordinarily might be susceptible, which
media, fol owed by S. aureus
. Saunders et al. (2009)
can be differentiated from the other Neisseriae
spp by its
stated that S. epidermidis
species was the most
lack of carbohydrate fermentation and by its DNase
prevalence bacteriological agent in chronic otitis media.
production. In our study, we found proteus
In this study we found that S. aureus
isolated (20 isolates 9.7%). Iseh and Adegbite (2004)
16.99%) fol owed P. aeruginosa
in their incidence, our
found that proteus species (12.8) isolated from 41
result agree with study done by (Aslam et al., 2006),
patients with acute suppurative otitis media. Vaishnav
while against the study done by (Saunders et al., 2009).
and changani (1981), found that Proteus
Saunders et al. (2009) found that S. epidermidis
highest incidence (44%) of isolates from 100 cases with
was the most common bacteria isolated from patients
In our result, we found that H. influenza
e was (20
Topical treatment is better than systemic therapy; this is
isolates 9.7%), while S. pneumonia
(15 isolates, 7.28%).
probably because a higher local concentration of anti-
Yamanaka et al. (2008) showed that H. influenzae
biotic is achieved. Macfadyen et al. (2006) the antibiotic
are the most prevalent
should have activity against gram negative bacteria,
organisms responsible for acute otitis media. However,
especial y Pseudomonas
, and gram positive bacteria,
most studies from different parts of Africa suggest various
especial y S. aureus
. The amino glycosides and the
bacterial pathogens as accusatives agents. Hence, S.
fluoroquinolones, both of them meet these criteria but the
and S. pyogenes
appear to be the most dominant
former may be ototoxic, failures of the antibiotic are
causative organisms among Africans Hussain et al.
usual y due to failure to penetration of the debris rather
(1991). Bluestone and Klein (2001) found that S.
than bacterial resistance. Marais et al. (1998). Amino-
and H. influenzae
are the most common
glycosides are contraindicated; there is evidence that
bacteria species causing middle ear infection in acute
they may cause hearing loss (Bance et al., 2005).
otitis media. Some European studies found H. influenzae
to be the most common organism fol owed by S.
and B. catarrhalis
(Gray and Canter, 1997). In
our result, we found that, the frequency of E. coli
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PATIENT NAME ____________________________________________ DATE___________________ Primary reason for this dental appointment Do you have a specific dental problem? __________________________________________________________________ Do you have dental examinations on a routine basis? Last visit_______________________________________________ Do you think you have active decay or gum disea
Chemistry Cite this: Org. Biomol. Chem., 2011, 9 , 6506 COMMUNICATION Base-free two-step synthesis of 1,3-diketones and b-ketoesters from a-diazocarbonyl compounds, trialkylboranes, and aromatic aldehydes†‡ Miguel A. Sanchez-Carmona, David A. Contreras-Cruz and Luis D. Miranda* Received 27th January 2011, Accepted 29th July 2011 DOI: 10.1039/c1ob05150d We describe a conver