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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470 476
www.elsevier.com/locate/amjoto
Abstract
Objective: The objective of the study was to better define changes in the bacteriology of suppurative
otitis in recent years and the role of cultures in the management of these patients.
Study Design: A retrospective review was performed.
Methods: Outpatient records from 170 patients collected over 3 years with information regarding the
bacteria cultured, antibiotic resistance, and clinical diagnosis were analyzed.
Results: A large variety of organisms were seen, with Staphylococcus aureus, Corynebacterium sp,
and Pseudomonas aeruginosa being the most common. Forty percent of cultures showed bacteria
with moderate antibiotic resistance, whereas 5% were sensitive to only intravenous antibiotics.
Resistant bacteria were found in all diagnosis categories and were significantly higher in cases of
chronic mastoiditis. The rate of methicillin-resistant S aureus infections was 7.8% and was
significantly higher in cases of chronic myringitis. Fungus was often cultured in patients without
clinical signs of otomycosis.
Conclusions: Community-acquired ear infections may be caused by antibiotic-resistant bacteria in a
substantial number of patients. In our opinion, outpatient cultures play an important role in the
management of suppurative otitis.
2011 Elsevier Inc. All rights reserved.
1. Introduction
The draining ear is a frequently encountered complaint
in an otolaryngologic practice. Aural drainage may be due
to a variety of causes including otitis externa, myringitis,
otitis media with perforation, infected cholesteatoma,
otorrhea following tympanoplasty tube placement, and
mastoiditis. Ototopical agents and oral antibiotics are the
cornerstone of treatment of the draining ear. These
treatments are generally based on empirical decisions
regarding the most common bacteria for a given diagnosis.
Corresponding author. Section of Otolaryngology, Dartmouth-Hitchcock
Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA.
Tel.: +1 603 650 8124; fax: +1 603 650 0052.
E-mail address: james.saunders@hitchcock.org (J.E. Saunders).
0196-0709/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2010.09.009
J.E. Saunders et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470476
471
Corynebacterium, have also demonstrated resistance patterns that are often refractory to traditional therapy [5,6]. In
addition to identifying resistant strains of bacteria, obtaining
a culture may help identify cases of otomycosis which
commonly present as a painful, draining ear and can be a
great imitator of resistant otorrhea [7,8]. Approximately
10% of otitis externa is of fungal origin [8] and is less likely
to respond to standard antibacterial treatment [9]. The
incidence of fungal infections as a cause for post
tympanostomy tube otorrhea has risen in the period since
the advent of fluoroquinolone drops, with Candida and Aspergillus being the most commonly isolated species [10].
The purpose of this study is to examine trends in culture
data from chronically draining ears over the past 3 years and,
in particular, look for correlations between the specific
diagnosis at the time of culture, the organism(s) cultured, and
the resistance patterns of the bacteria isolated.
2. Methods
The clinic charts and culture results of 170 patients with
draining ears that were cultured and with various underlying
diagnoses were retrospectively reviewed. These diagnoses
included otitis externa, myringitis, otitis media with
perforation, infected cholesteatoma, otorrhea following
tympanostomy tube placement, and mastoiditis. It is our
practice to obtain a culture in ears that do not respond to
empirical therapy, show signs of impending complications,
have a history of resistant organisms, have evidence of
granulation tissue, or show signs suspicious of otomycosis.
Cultures obtained in chronic mastoiditis were taken from
open mastoid cavities. Although cultures were not obtained
from all patients with aural drainage, cultures were obtained
from the vast majority of such cases. All culture specimens
were obtained in the outpatient setting of an academic
otology practice from October 1, 2003, to September 30,
2006. Funding for this study was interdepartmental.
Information obtained from the clinical chart included the
primary and secondary diagnoses, suspicion of fungus at the
time of the initial examination, and culture results. Antibiotic
sensitivity and resistance patterns were assigned according to
National Committee for Clinical and Laboratory Standards
approved procedures for antibiotic sensitivity testing and
reporting. In this way, the antibiotic spectra tested reflect
appropriate antibiotics for the specific bacterial type. Culture
Table 1
Bacteriology results per diagnosis
No. of patients
No. of infections
No. of cultures
No. of bacterial isolates
Cultures with resistant bacteria
Otitis
externa
Myringitis
Chronic otitis
media
Infected
cholesteatoma
Posttube
otorrhea
Chronic
mastoiditis
32
37
39
49
6
32
40
48
47
16
40
55
72
74
17
12
15
16
20
8
48
67
74
92
18
24
29
36
40
15
472
J.E. Saunders et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470476
Table 2
Specific bacteria by diagnosis
Bacteria
Achromobacter xylosoxidans
Acinetobacter baumannii
Alcaligenes xylosoxidans
Bacteroides
Corynebacterium sp
Diphtheroids
Enterobacter cloacae
Escherichia coli
Fusobacterium nucleatum
Gram-neg rod
Haemophilus influenzae
Klebsiella pneumoniae
Morganella morganii
Moraxella catarrhalis
MRSA
Peptostreptococcus sp
Propionibacterium acnes
Proteus mirabilis
P aeruginosa
P fluorescens
Serratia
S aureus
S auricularis
S epidermidis
Staphylococcus, coag neg
Staphylococcus sp
Stenotrophomonas maltophilia
Streptococcus -hem
Streptococcus group A
Streptococcus pneumoniae
S viridans
Other
Otitis externa
Myringitis
Otitis media
w/ perforation
Cholesteatoma
Posttube
otorrhea
Mastoiditis
1 (1.82%)
1(2.00%)
1 (1.75%)
8 (14.04%)
1 (1.75%)
1 (4.76%)
7 (12.73%)
2 (2.15%)
9 (9.68%)
1 (1.08%)
1 (1.08%)
1 (1.08%)
2 (9.52%)
3 (14.29%)
5 (5.38%)
1 (1.08%)
2 (3.64%)
3 (5.26%)
7 (12.73%)
1 (1.75%)
13 (22.81%)
1 (1.82%)
11 (20.00%)
1 (1.75%)
12 (21.05%)
2 (3.64%)
4 (7.02%)
1 (1.82%)
8 (4.55%)
1 (1.82%)
1 (1.82%)
1 (1.75%)
7 (7.53%)
2 (2.15%)
1 (1.08%)
13 (13.98%)
1 (1.08%)
2 (2.15%)
12 (12.90%)
2 (2.15%)
1 (1.08%)
2 (2.15%)
1 (4.76%)
2 (9.52%)
1 (4.76%)
1 (4.76%)
1
1
2
1
1
1
(4.76%)
(4.76%)
(9.52%)
(4.76%)
(4.76%)
(4.76%)
2 (3.64%)
3 (3.23%)
1 (1.08%)
1 (1.08%)
1 (4.76%)
(2.00%)
(20.00%)
(4.00%)
(4.00%)
1 (2.00%)
2 (4.00%)
1 (4.76%)
1 (1.08%)
5 (5.38%)
1 (1.82%)
1 (1.75%)
1
10
2
2
1 (0.96%)
1 (0.96%)
1 (0.96%)
4 (3.85%)
2 (3.51%)
1 (1.75%)
2 (1.92%)
4 (3.85%)
16 (15.38%)
2 (1.92%)
1 (2.00%)
1 (0.96%)
2 (1.92%)
1 (0.96%)
2 (1.92%)
1 (2.00%)
12 (11.54%)
3 (6.00%)
16 (15.38%)
8 (16.00%)
2 (1.92%)
10 (9.62%)
2 (4.00%)
2 (4.00%)
2 (4.00%)
2 (1.92%)
1 (0.96%)
7 (6.73%)
1 (0.96%)
5 (4.81%)
3 (6.00%)
Table 3
Species of resistant bacteria
Bacteria species
No. of isolates
Corynebacterium sp
S aureus
S epidermis
P aeruginosa
A xylosoxidans
S pneumoniae
Bacteroides sp
E coli
M moraxella
S maltophilia
H influenzae
P acnes
Serratia marcescens
S auricularis
S capitis
P mirabilis
-Hemolytic Streptococcus sp
Staphylococcus sp
Peptococcus sp
14
12
12
7
4
4
3
3
3
3
2
2
2
2
2
1
1
1
1
J.E. Saunders et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470476
473
4. Discussion
Antibiotic therapy has greatly facilitated the management
of ear infections; however, frequent antibiotic use and misuse
have led to the development of resistant strains, complicating
the management of the draining ear. The role of culture in
chronic infections of the ear has not been clearly defined. In
this study, we found a wide variety of both bacterial and
fungal organisms. Staphylococcus, Corynebacterium, and
Table 4
Bacterial resistance trends
Year
Infection
events
Total
cultures
MRSA % of
infections
% of infections with
resistant bacteria
Cultures with
quinolone resistance
79
71
93
104
80
102
6.3%
8.5%
8.6%
26.6%
29.6%
26.9%
2.5%
8.4%
4.3%
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J.E. Saunders et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470476
Pseudomonas were the most common genii found. Approximately half of the cultures showed resistance to commonly
used antibiotics including second- and third-generation
penicillins, cephalosporins, azithromycin, clindamycin, and
some fluoroquinolones. When looking at specific diagnoses,
chronic mastoiditis in an open cavity was also found be
significantly associated with a higher incidence of resistant
bacteria. The clinical significance of this rate of resistance is
unclear, as mechanical debridement plays an important role
in the management of these infections.
A worrisome finding is the presence of highly resistant
bacteria that were resistant to all oral antibiotics. These
patients have been challenging to treat successfully and
sometimes require hospitalization or long-term intravenous
antibiotics. The presence of fluoroquinolone-resistant cultures is also concerning, as these medications are routinely
used in patients with otorrhea and are given routinely after
tympanostomy tube placement. Quinolone-resistant Pseudomonas has been reported in a group of pediatric patients
with recurrent otorrhea refractory to initial treatment [11].
In this study, MRSA was isolated from 7.8% of infection
events. This is comparable to previous reports [3,4]. Trends
across the 3 years studied failed to show significant increases
Table 5
Specific fungal isolates by diagnosis
Otitis
externa
S apiospermum
Scopulariopsis sp
Absidia sp
Penicillium sp
R rubra
A flavus
A fumigatus
A niger
C albicans
C lipolytica
C parapsilosis
C tropicalis
Myringitis
Otitis media
w/ perforation
Cholesteatoma
Posttube
otorrhea
Mastoiditis
1 (2.0%)
1 (0.96%)
1 (1.08%)
1 (1.82%)
1 (1.75%)
2 (3.5%)
3 (5.26%)
1 (1.82%)
1 (1.82%)
1 (1.82%)
2 (3.51%)
6 (10.91%)
1 (1.08%)
1 (1.08%)
5 (5.38%)
5 (5.38%)
1 (1.08%)
5 (5.38%
2 (1.92%)
2 (1.92%)
4 (3.85%)
1 (4.75%)
1 (0.96%)
1 (0.96%
3
1
2
2
(6.0%)
(2.0%)
(4.0%)
(4.0%)
J.E. Saunders et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 470476
5. Conclusion
A wide variety of bacterial and fungal pathogens were
isolated from cultures of chronically draining ears. Resistant
organisms were seen in 50.6% of infectious events, and
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