Medicinski Glasnik, Volumen 8, Number 2, August 2011
NOTES
Microbiology of the chronic suppurative
otitis media
Branko Krišto, Marko Buljan
Department of Otorhinolaryngology, Head and Neck Surgery,
County Hospital of Livno, Bosnia and Herzegovina
Corresponding author:
Branko Krišto; Department of Otorginolaryngology, Head and
Neck Surgery; County Hospital, Livno; Put Sv. Ive bb, 80101
Livno, Bosnia and Herzegovina; Phone/fax.: +387 34 201 423;
E-mail: branko.kristo@tel.net.ba
Original submission: 23 December 2010; Revised submission:
03 March 2011; Accepted: 14 June 2011.
Med Glas Ljek komore Zenicko-doboj kantona 2011; 8(2):284-286
ABSTRACT
The aim of the study was to determine aetiologi-
cal agents of chronic suppurative inflammation
of the middle ear and their susceptibility to an-
tibiotics, which could lead to better therapeutic
decisions and consequently avoidance of appe-
arance of resistance to specific antibiotics. Most
frequently isolated agents were Staphylococcus
aureus (30.6%), Pseudomonas aeruginosa
(22.4%), Klebsiella spp. (10.6%) and Proteus
spp. (7.1%). None of the isolates were resi-
stant to ciprofloxacin. High sensitivity rates to
gentamycin were noted in Staphylococcus and
Klebsiella isolates, and moderate ones in Pse-
udomonas and Proteus isolates. Pseudomonas
spp. has shown low prevalence of resistance to
third-generation cephalosporins, as well as to
imipenem and piperacillin.
Key words: otitis media, microbial sensitivity,
antibiotics
INTRODUCTION
Chronic suppurative otitis media is defined as a
permanent suppurative secretion from ear throu-
gh a perforated tympanic membrane in a period
longer than 6 – 12 weeks (1, 2). It is still a signifi-
cant problem in children and adults in developing
countries. It is estimated that there is an annual
incidence of 39 cases per 100,000 persons under
15 years of age (3).
As the chronic suppurative otitis media is fo-
llowed by a milder or severe defective hearing,
and could cause significant, even life-threate-
284
ning complications, the need for an early targe-
ted treatment becomes obvious (4). Complica-
tions were frequent in pre-antibiotic era, while
the introduction of antibiotics gave clinicians a
tool to be used even without a precise aetiolo-
gical diagnosis (5). The uncritical application
of antibiotics led to the appearance of multi-re-
sistant bacteria and disease complication in re-
turn (6). The changes of bacterial population in
chronic suppurative inflammations of the midd-
le ear, in the last decades, have been confirmed
and described in literature (6,7). Due to all abo-
ve mentioned a microbiological diagnosis is an
essential step in the treatment and follow-up of
this disease.
PATIENTS AND METHODS
The study comprised 85 consecutive patients
examined at the Department of Otorhinolaryngo-
logy, Head and Neck Surgery, County Hospital
of Livno, during the period 2005-2009. All the
patients had permanent or recurrent suppurative
secretion from the ear in the period of 6 to 12
weeks, and a perforated tympanic membrane,
and were not treated with antibiotics for at least
two weeks before the examination. Upon the exa-
mination, the ear swab was taken with a single-
use cotton-tipped applicator in sterile individual
packaging through the ear funnel to avoid con-
tamination from the skin of the auditory canal.
The sample was delivered to the microbiological
laboratory within one hour.
The sample was cultured in accordance with
standard microbiological procedures, and identi-
fication of bacteria was based according to stan-
dard microbiological methods (8). Susceptibility
testing to fifteen antibiotics was done by disk di-
ffusion method in accordance with CLSI (9).
RESULTS
The study included 85 patients in the age range 4-
81 years of age (mean age 51.5), and a predomi-
nance of 40 – 60 years age group was noted in 37
cases (43.5%). The male/female distribution was
47.3%/52.7%. In 60 patients (70.6%) one agent
was isolated, in 13 patients (15.3%) two agents,
while in 12 patients (14.1%) saprophyte flora was
isolated. In 13 patients two swabs were taken (11
swabs from the same ear and in 2 cases from both
ears) (Table 1).
 Notes

Table 1. Microbiologic profile of chronic suppurative otitis media Unusually high prevalence of Candida spp. and
Microorganisms isolated No (%) of isolates Aspergillus spp. in this study could be explained
Staphylococcus aureus 26 (30.6) by an excessive and uncontrolled use of antibio-
Pseudomonas aeruginosa 19 (22.4)
tics as it was reported previously (16). There is
Klebsiella spp. 9 (10.6)
Proteus mirabilis 6 (7.1)
also a possibility that in some cases unrecognized
Streptococcus pneumoniae 5 (5.9) fungal inflammations of the auditory canal might
Haemophyllus influenze 3 (3.5) be the cause of the infection, as well as the insu-
Proteus vulgaris 1 (1.2) fficient toilet of the auditory canal (moist, basal
Morganella morganii 1 (l.2) environment in the pretympanal area) (16).
Serretia marcenscens 1 (1.2)
Gram negative bacilli 1 (1.2)
Antibiotic susceptibility testing the isolates obta-
Candida spp. 8 (9.4) ined in this study was in accordance with the re-
Aspergillus spp. 6 (7.1) sults published elsewhere (11, 15).
Saprophitic flora 12 (14.1) In the light of the importance of local therapy in
The analysis by sex and age did not show a pre- the treatment of chronic suppurative inflammati-
dominance of any particular group of patients re- on of the ear, which is the first line of treatment
lated to any aetiological agents. (17,18), and which frequently excludes the need
for systemic therapy (19), it is important to anal-
None of the isolates were resistant to ciprofloxa-
yze the sensitivity of the agent to locally applied
cillin. Staphylococcus aureus showed a marked
therapy. This is especially important because the
sensitivity to gentamycin (88.5%), erythromycin
concentrations of topically administrated antibi-
92.3%), azitromycin (92.3%), sulphometoxasol/
otics can be 100-1000 times greater than those
trimetoprim (92%), and clindamycin (91.7%).
which can be achieved using systemic admini-
Pseudomonas also showed a marked sensitivity
stration (20). Consequently, sensitivity reports by
to third-generation cephalosporins, from 78.6% to
disc-diffusion method from clinical laboratory are
100%, imipenem (91.7%) and piperacillin (75%),
questionable. Sensitivity testing in the clinical la-
and moderate sensitivity to gentamycin (52.6%).
boratory is designed for the tissue concentrations
Streptococcus pneumoniae isolates were sensiti-
achieved by systemic administration. Likewise,
ve to almost all antibiotics tested (Table 2).
one should bear in mind the possibility of oto-
DISCUSSION toxicity which is usually linked to the application
of aminoglycozydes (21, 22), although this was
The results of this study have shown that most never proved beyond doubt.
frequently isolated bacteria were in accordance
Knowing the aetiological agents of chronic suppu-
with findings of other published studies (10, 11).
rative otitis media infection and their susceptibi-
Comparing causative agents of chronic suppura-
lity to antibiotics is of essential importance for an
tive otitis media infections isolated before and
efficient treatment, prevention of both complica-
after the widespread use of antibiotics, usual iso-
tions and development of resistance to antibiotics,
lated pathogens were Streptococcus pneumoniae
avoidance of possible ototoxicity, and finally, the
and Staphylococcus aureus and Pseudomonas
reduction of the treatment costs (23). The aim of
aeruginosa, respectively (12-15).
Table 2. Antibiotic resistence of chronic suppurative otitis media causative agents
Percentage of resistance to antimicrobial agent*
Causative agent AMX AMC CN CXM CAZ CRO CFP IMI PIP GM E AZM CIP CLI SXT

Staphylococcus aureus 87,1 23.1 NT NT NT NT NT NT NT 11,5 7.7 7.7 0 8.3 8.0

Pseudomonas aeruginosa 100 100 100 100 0 40 21,4 8,3 25 47,4 NT NT 0 NT 100

Klebsiella spp. 100 71.4 100 33.3 0 0 NT NT NT 11,1 NT NT 0 NT 0

Streptococcus spp. 0 NT NT 0 NT NT NT NT NT NT 20 20 NT 0 0
Proteus spp. 66,7 50 83.3 0 0 0 NT NT NT 50 NT NT 0 NT 20
* AMX, amoksicilin (10µg); AMC, amoksicilin-clavulanate (30µg); CN, cefaleksin (30µg); CXM, cefuroksim (3µg), CAZ, ceftazidim (30µg);
CRO, ceftriakson (30µg); CFP, cefoperazon (30µg); IMI, imipinem (10µg); PIP, piperacilin (100µg); GM, gentamycin (10µg); ERY, erythro-
mycin (15µg); AZM, azitromicin (15µg); CIP, ciprofloksacin (5µg); CLI, clindamycin (2µg); SXT, trimethoprim/sulfamethoxazole, SXT (25 µg);
NT, non test

285
 Medicinski Glasnik, Volumen 8, Number 2, August 2011
the conservative therapy is to achieve a “dry ear”
for surgical treatment, but it can also represent the
“final aim” of treatment in non-complicated infla-
mmations in patients who refuse surgery or have
contraindications for surgery (24).
ACKNOWLEDGMENT/DISCLOSURES
Competing interests: none declared.
REFERENCES
1. Matsuda Y, Kurita T, Ueda Y, Ito S, Nakashima T.
Effect of tympanic membrane perforation on midd-
le-ear sound transmission. J Laryngol Otol 2009;
31:81-9.
2. Wright D, Safranek S. Treatment of otitis media with
perforated tympanic membrane. Am Fam Physician
2009; 79:650-4.
3. van der Veen EL, Schilder AG, van Heerbeek N,
Verhoeft M, Zielhius GA, Rovers MM. Predictors
of chronic suppurative otitis media in children. Arch
Otolaryngol Head Neck Surg 2006; 132:1115-8.
4. van Hasset P. Chronic suppurative otitis media.
Comm Ear Hearing H. 2007;4(6):19-21.
5. Shenoi PM. Menagement of chronic suppurative
otitis media. In: Kerr AG, Booth JB, editors. Scott-
Brown´s Otoleryngology, 35th ed. London. Bu-
tterworth and comp. 1987;215-237.
6. Jahn AF. Chronic otitis media: diagnosis and trea-
tment. Med Clin North Am 1991; 75:1277-91.
7. Finegold SM, Wexler HM. Therapeutic implications
of bacteriologic findings in mixed aerobic anaero-
bic infections. Antimicrob agents chemother 1988;
32:611-16.
8. Forbes BA, Sahm DF, Weissfeld AS. Bailey and
Scott´s Diagnostic Microbiology. 12th Edn. St.
Louis: Mosby, 2007: 389-97.
9. CLSI. Performance standards for antimicrobial sus-
ceptilibity testing. CLSI approved standard M100-
S17. Wayne, PA: CLSI,2007.
10. Smith JA, Danner CJ. Complications of chronic oti-
tis media and cholesteatoma. Otolaryngol Clin North
Am 2006; 39:1237-55.
11. Nikakhlag S, Khosravi AD, Fazlipour A, Safarzadeh
M, Rashidi N. Microbiologic findings in patients
with chronic suppurative otitis media. J Med Sci
2008; 8:503-6.
12. Sugita R. Bacteriological studies on chronic otitis
media. J Otolaryngol Jpn 1977; 80:907-19.
13. Brook I, Yocum P. Quantative bacterial cultures and
beta-lactamase activity in chronic suppurative otitis
media. Ann Otol Rhinol Laryngol 1989; 98:293-7.
14. Nakagawa T, Yadohisa O, Komune S, Kemura T. 16-
year survey of changes in bacterial isolates assotia-
ted with chronic suppurative otitis media. Eur Arch
Otorhinolaryngol 1994; 251:27-32.
15. Yeo SG, Park DC, Hong SM, Cha CI, Kim MG. Bac-
teriology of chronic suppurative otitis media- a mul-
ticentre study. Acta Otolaryngol 2007; 127:1062-67.
16. Hueso Gutierrez P, Jimenez Alvarez S, Gil-Carcedo
Sanudo E, Gil-Carcedo Garcia LM. Ramos Sanchez
C, Vallejo Valdezate LA. Presumed diagnosis: oto-
mycosis. A study of 451 patients. Acta Otorrhinola-
ringol Esp 2005; 56:181-86.
286
17. Kapusuz Z, Keles E, Alpay HC, Karlidag T, Kay-
gusuz I, Uzunlar AK, Orhan I, Yalcin S. The effect
of topical ciprofloxacin and steroid-containing ear
drops for chronic suppurative otitis media on the in-
ternal ear. Eur Arch Otorhinolaryngol 2010; 267:35-
41.
18. Brook I. Microbiology and menagement of chronic
suppurative otitis media in children. J Trop Pediatr
2003; 49:196-200.
19. Hannley MT, Denneny JC 3rd, Holzer SS. Use of
ototopical antibiotics in treating three common
ear diseases. Otolaryngol Head Neck Surg 2000;
122:934-40.
20. Parry D, Roland PS. Middle ear, chronic supurative
otitis, medical treatment. www.emedicine.medsca-
pe.com (September 25, 2010)
21. Chiodo AA, Alberti PW. Experimental, clinical and
preventive aspects of ototoxicity. Eur Arch Otorho-
nolaryngol 1994; 251:375-92.
22. Macfadyen CA, Acuin JM, Gamble C. Topical an-
tibiotics without steroids for chronically dischar-
ging ears with underlying eardrum perforations.
Cochrane Database of Systematic Reviews 2005;
4:CD004618.
23. Nikakhlagh S, Khosravi AD, Fazlipour M, Safarza-
deh M, Rashidi N. Microbiologic findings in patients
with chronic suppuratie otitis media. J Medical Sci.
2008;8:503-506
24. Papastavros T, Giamarellou H, Verlejides S. Preope-
rative therapeutic considerations in chronic suppura-
tive otitis media. Laryngoscope 1989; 99:655-9.
Mikrobiologija kronične gnojne upale
srednjeg uha
Branko Krišto, Marko Buljan
Županijska bolnica Livno, Odjel za ORL i cervikofacijalnu kiru-
rgiju, Livno, Bosna i Hercegovina
SAŽETAK
Cilj istraživanja je utvrditi uzročnike kronične
gnojne upale srednjeg uha i odrediti njihovu
osjetljivost na antibiotike, što bi moglo voditi
boljem liječenju bolesti, a posljedično i izbjega-
vanju pojave rezistencije na pojedine antibiotike.
Najčešće izolirani uzročnici bili su Staphyloco-
ccus aureus (30.6%), Pseudomonas aeruginosa
(22.4%), Klebsiella spp. (10.6%) i Proteus spp.
(7.1%). Svi izolirani uzročnici bili su osjetljivi na
ciprofloxacin. Izrazitu osjetljivost na gentamycin
pokazali su izolati Staphylococcus aureus i Kleb-
siella spp., a umjerenu osjetljivost izolati Pseu-
domonas i Proteus vrsta. Izolati Pseudomonas
spp. pokazali su visoku osjetljivost na antibiotike
treće generacije cefalosporina, kao i na imipenem
i piperacillin.
Ključne riječi: upala srednjeg uha, antimikrobna
osjetljivost, antibiotici