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Bacteriology and resistance patterns of otitis media with effusion
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Bacteriology and resistance patterns of otitis media with effusion a
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Hye Kyu Min , Seok Hyun Kim , Myung Jin Park , Sung Su Kim , Sang Hoon Kim , Seung Geun Yeoa,b,∗ a
Department of Otorhinolaryngology, Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea Medical Research Center for Bioreaction to Reactive Oxygen Species and Biomedical Science Institute, School of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
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A R T I C LE I N FO
A B S T R A C T
Keywords: Otitis media with effusion Antibiotics MRSA Pseudomonas
Objectives: Following the increased use of antibiotics, the emergence of antibiotic-resistant species in pediatric patients with otitis media has become a problem in recent years. The aim of this study was to investigate change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species, such as Methicillinresistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa according to the number of repeated ventilation tube insertion (VTI) procedures in pediatric patients diagnosed with otitis media with effusion (OME). Materials & methods: From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in this study. Bacterial cultures were performed on aseptically collected middle ear effusion (MEF) at the time of VTI and antibiotic sensitivity tests were performed on the identified bacteria. Results: Bacteria were not identified in 195 (70.1%) cultures and identified in 83 (29.9%) cultures. Coagulasenegative staphylococci (CNS) was the most frequently detected species in both the non-recurrent group and the recurrent group. MRSA detection rate was found to be significantly higher in the recurrent group than in the nonrecurrent group (p = 0.029). The two groups showed no significant difference in antibiotic resistance against all antibiotics (p > 0.05). Conclusion: Staphylococcus species were detected most frequently in the MEF of pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates.
1. Introduction Otitis media with effusion (OME) is a disease in which the middle ear fluid (MEF) accumulates in the middle ear without accompanying acute inflammatory symptoms such as otalgia or fever. OME is the most frequent cause of hearing impairment in children, with a prevalence of 15–20% in pediatric patients [1,2]. There are many hypotheses about the etiology of OME. It is known that the Eustachian tube (E-tube) in children is relatively horizontal compared to that of adults, and E-tube dysfunction is often accompanied by immature muscular structure acting on E-tube opening. Furthermore, other secondary factors such as acute upper respiratory infection, chronic rhinosinusitis, and physical obstruction due to allergic rhinitis and adenoid vegetation may lead to E-tube dysfunction, which is known to cause OME [3].
OME is also understood as a sequelae of acute otitis media (AOM), and it has been reported that in patients diagnosed with AOM, MEF is found in 45% of patients after 1 month and 10% after 3 months of initial infection [3,4]. When inflammatory stimuli such as bacteria or viruses increase the production of inflammatory mediators such as TNFalpha, expression of the mucin gene is increased in the middle ear mucosa and mucus secretion is also increased, which causes MEF to persist [5,6]. In addition, inflammatory mediators and/or cytokines secreted by subclinical bacterial infection may induce OME. Positive bacterial cultures from MEF samples are found in one-third of OME patients [3,4]. The presence of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenza (H. influenzae), and Moraxella catarrhalis (M. catarrhalis) was identified in approximately 25% of the cultured MEFs in pediatric OME patients and identified in nearly 80% in polymerase chain reaction (PCR) -based methods. In addition, it has been
∗ Corresponding author. Department of Otorhinolaryngology, Head and Neck Surgery, School of Medicine, Kyung Hee University, 23 Kyung Hee Dae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea. E-mail address: [email protected] (S.G. Yeo).
https://doi.org/10.1016/j.ijporl.2019.109652 Received 4 June 2019; Received in revised form 10 August 2019; Accepted 20 August 2019 Available online 21 August 2019 0165-5876/ © 2019 Published by Elsevier B.V.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
H.K. Min, et al.
2.3. Bacterial culture & antibiotic sensitivity tests
reported that the middle ear mucosal biopsy in these PCR-proven patients showed 92% biofilm formation [7–9]. Although microbial etiology is becoming increasingly important in OME, international guidelines do not recommend the use of antibiotics as an initial therapy. Several studies have shown that antibiotic therapy does not have long-term efficacy in hearing, rate of VTI, and language development, and may affect the emergence of antibiotic-resistant species [10]. While many attempts have been made to control the use of antibiotics, the misuse and abuse of antibiotics is common in medical institutions and the emergence of antibiotic-resistant bacteria in pediatric patients is increasingly becoming a problem [11]. Although there are differences according to the reported area and time, about 20–70% of S. pneumoniae, 40–80% of H. influenzae, and 50–60% of M. catarrhalis detected in the MEF of OME patients are reported to show resistance to penicillin [11,12]. Patients with OME, especially recurrent OME, are more likely to have nosocomial infections due to frequent hospital visits and repeated VTI procedures. Pediatric patients are frequently exposed to OME beginning with AOM, so they are often exposed to antibiotic treatment at the time of AOM diagnosis or by post-operative antibiotic therapy after VTI [1]. The aim of this study was to investigate the change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species such as MRSA and Pseudomonas species according to the number of repeated VTI procedures in pediatric patients diagnosed with OME.
Samples were aseptically collected using a Juhn Tym-Tap collector, embedded on sterilized cotton swabs, and transplanted to Stuart transport medium (COPAN, Brescia, Italia) and finally cultured on blood agar and chocolate agar media (Hangang, Kun-po, Korea) to isolate fastidious organisms, MacConkey agar medium (Hangang, Kunpo, Korea) to isolate Gram negative and enteric bacilli, thioglycollate broth (formulated in our laboratory) to isolate anaerobes and Brucella agar medium (formulated in our laboratory) to isolate Brucella species. Bacteria cultures were incubated at 35 °C for 3 days and resultant colonies were identified by Microflex (Bruker, Billerica, MA, USA). Biochemical and antibiotic sensitivity tests were performed using Microscan (Beckman Coulter, Seoul, Korea). Antibiotic sensitivity tests were performed according to the National Committee for Clinical Laboratory Standards (NCCLS) Guidelines. Gram-positive bacteria were tested for antibiotic sensitivity to ampicillin (AMP), amoxicillin/clavulanate (AUG), azithromycin, cefepime, cefoxitin (CFT), cefuroxime, ciprofloxacin (CIP), clindamycin (CL), daptomycin, ertapenem, erythromycin (EM), fosfomycin, fusidic acid, gentamycin, imipenem (IPM), levofloxacin (LFX), linezolid (LZ), meropenem (MPM), moxifloxacin, mupirocin, nitrofurantoin, penicillin-G (PG), rifampin (RFP), synercid, sulfamethoxazole/trimethoprim (SPT), teicoplanin (TCP), tetracycline, tobramycin, and vancomycin (VAN) using the Dried Gram Positive MIC Panel Type 28 system (Beckman Coulter, Seoul, Korea). Gram-negative bacteria were tested for antibiotic sensitivity to amikacin, ampicillin (AMP), amoxicillin/clavulanate (AUG), aztreonam, cefepime, cefotaxime, ceftazidime, cefuroxime, cephalothin, chloramphenicol, ciprofloxacin (CIP), colistin, doripenem, ertapenem, fosfomycin, gentamycin, imipenem (IMP), levofloxacin (LFX), meropenem (MPM), minocycline, nalidixic acid, nitrofurantoin, norfloxacin, penicillin-G (PG), piperacillin/tazobactam, tetracycline, tigecycline, tobramycin, and sulfamethoxazole/trimethoprim (SPT) using the Dried Gram Negative MIC Panel Type 44 system (Beckman Coulter, Seoul, Korea).
2. Materials & Methods 2.1. Patients From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in the study. Patients were diagnosed with OME if tympanometry showed type B or C, and if amber-color or air bubbles were observed on otoscopic examination without signs of acute inflammation such as perforation of the tympanic membrane, fever, and otalgia. VTI was performed when there was no improvement for more than 3 months, hearing loss of more than 40 dB confirmed by pure-tone audiometry (PTA), or retraction of the tympanic membrane. We investigated age, gender, comorbidities including allergy, adenoid & tonsillar hypertrophy (ATH), chronic hypertrophic rhinitis (CHR), sinusitis, number of VTIs, and culture results from all patients through retrospective chart review. We defined the patients who underwent a single VTI as the non-recurrent group and patients who underwent two or more VTIs as the recurrent group. We excluded patients where no MEF cultures were performed or when culture results were not known because the first VTI was performed at another hospital. Before surgery, the parents or guardians of each patient provided written informed consent for the use of patient samples. The study protocol was approved by the Kyung Hee University Clinical Research Ethics Committee (KMC 2017-12-030).
2.4. Statistical analysis The results are expressed as N (percentage). Differences between the two groups were analyzed by Chi-squared, Fisher's exact, or MannWhitney tests. All data were analyzed using SPSS ver. 20.0 statistical software (SPSS Inc., Chicago, IL). A P value of less than 0.05 was considered statistically significant. 3. Results 3.1. Demographics Among the total 158 patients, 99 patients underwent VTI once, who were classified as the non-recurrent group and 59 patients underwent VTI twice or more who were classified as the recurrent group. Age at the time of the first VTI procedure ranged from 10 months to 17 years. The mean age of all patients was 4.38 years old; 4.48 years in the nonrecurrent group and 4.22 years in the recurrent group. The 158 patients consisted of 102 boys (64.6%) and 56 girls (35.4%). Of these, 65 boys (65.7%) and 34 girls (34.3%) were in the non-recurrent group, and 37 boys (62.7%) and 22 girls (37.3%) were in the recurrent group. However, there were no statistically significant differences between the non-recurrent and recurrent group relative to age of the first VTI and sex ratio (p = 0.381, p = 0.708, respectively). There were no statistically significant differences in the positive culture results between the two groups, 74 cases (74.7%) in the nonrecurrent group and 37 cases (62.7%) in the recurrent group (p = 109). In the case of comorbidities, the number of patients with ATH was significantly higher in the recurrent group (40 patients, 67.8%) than in the non-recurrent group (42 patients, 42.4%) (p = 0.005). Allergy,
2.2. Procedure Ventilation tube insertion (VTI) was performed unilaterally or bilaterally on the affected side diagnosed with OME. First, foreign substances such as cerumen observed in the external auditory canal (EAC) were removed under a microscope and potadine solution irrigation was performed. MEFs were collected using a Juhn Tym-Tap collector (Jacksonville, FL, USA) after radial incision of the anterior inferior quadrant of the eardrum with a myringotome knife. All remaining exudates were removed through suction. The ventilation tube was inserted through the myringotomy site. After the procedure, the patient was regularly followed up at the outpatient clinic at 2- to 3-month intervals until the ventilation tube spontaneously extracted. 2
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
H.K. Min, et al.
Table 1 Demographic characteristics of patients with non-recurrent and recurrent otitis media with effusion.
Age at first onset (yr) Male (N,%) Average no. of VTI (N) Positive culture results (N,%) Comorbidities Allergy (N,%) Adenoid & tonsillar hypertrophy (ATH) (N,%) History of adenotonsillectomy (AT) (N,%) Chronic hypertrophic rhinitis (CHR) (N,%) History of inferior turbinoplasty (ITP) (N,%) Sinusitis (N,%)
Non-recurrent OME (99)
Recurrent OME (59)
Total (158)
P value
4.48 65 (65.7) 1 74 (74.7)
4.22 37 (62.7) 2.96 37 (62.7)
4.38 102 (64.6) 1.73 111 (70.2)
0.381 0.708 0.000 0.109
11 (11.1) 42 (42.4) 36 (36.4) 15 (15.2) 7 (7.1) 4 (4.0)
11 (18.6) 40 (67.8) 37 (62.7) 9 (15.3) 4 (6.8) 5 (8.5)
22 (13.9) 82 (51.9) 73 (46.2) 24 (15.2) 11 (7) 9 (5.7)
0.206 0.005 0.025 0.372 0.260 1.000
CHR, and sinusitis were not significantly different between the two groups (p > 0.05) (Table 1).
Table 2 Isolated bacterial species of middle ear fluid from patients with otitis media with effusion.
3.2. Culture
Organism
No. (%) of isolates
Bacterial culture was performed every time VTI was performed to confirm changes in bacterial species and antibiotic resistance. The total number of cultures from the 158 patients was 278. For the 99 cases classified as the non-recurrent group, only one culture was performed per person, a total of 99 times. In the recurrent group of 59 patients, the total number of cultures performed repeatedly was 179, and the number of the most frequent cultures in the same patient was 8. In three patients in the recurrent group, different species were detected on both sides at the same time. Bacteria were not cultured from 195 (70.1%) samples; 83 samples (29.9%) produced bacterial isolates. The most commonly identified species were CNS (32 times, 11.5%), followed by MRSA (9 times each, 3.2%), Methicillin-sensitive Staphylococcus aureus (MSSA), S. pneumoniae, and H. influenzae (7 times each, 2.5%), Bacillus spp. (4 times, 1.4%), Streptococcus viridans (S. viridans) (3 times, 1.1%), Corynebacterium spp., Haemophilus parainfluenzae (H. parainfluenzae), M. catarrhalis (2 times each, 0.7%), Streptococcus mitis (S. mitis), Staphylococcus intermedius (S. intermedius), Micrococcus spp., Pseudomonas aeruginosa (P. aeruginosa), Acinetobacter baumannii (A. baumannii), Empedobacter brevis (E. brevis), Neisseria spp., and yeast (one each, 0.4%) (Table 2). CNS was the most frequently detected species in the non-recurrent group (10 times, 10.1%), followed by S. pneumoniae and H. influenzae (3 times each, 3%). In the recurrent group, CNS was detected in 22 patients (12.3%), MRSA in 9 cases (5%), and P. aeruginosa was also detected in one patient (0.6%). Only MRSA was found to be significantly higher in the recurrent group (9 cases, 5%) than in the non-recurrent group (0, 0%) (p = 0.029) (Table 3). There was no significant correlation between the number of VTI procedures and the detection rate in all types of species in the recurrent group (p > 0.05) (Table 4).
No growth Growth Gram positive
195 (70.1) 83 (29.9) Coagulase-negative staphylococci (CNS) Methicillin-resistant Staphylococcus aureus (MRSA) Methicillin-sensitive Staphylococcus aureus (MSSA) Streptococcus pneumoniae (S. pneumoniae) Bacillus spp. Streptococcus viridans (S. viridans) Corynebacterium spp. Staphylococcus intermedius (S. intermedius) Streptococcus mitis (S. mitis) Micrococcus spp.
32 (11.5) 9 (3.2)
7 4 3 2 1 1 1
(2.5) (1.4) (1.1) (0.7) (0.4) (0.4) (0.4)
Haemophilus influenzae (H. influenzae) Haemophilus parainfluenzae (H. parainfluenzae) Moraxella catarrhalis (M. catarrhalis) Pseudomonas aeruginosa (P. aeruginosa) Acinetobacter baumannii (A. baumannii) Empedobacter brevis (E. brevis) Neisseria spp.
7 2 2 1 1 1 1 1
(2.5) (0.7) (0.7) (0.4) (0.4) (0.4) (0.4) (0.4)
7 (2.5)
Gram negative
Yeast
Table 3 Comparison of the number of middle ear fluid isolates from patients with nonrecurrent and recurrent otitis media with effusion. Organism
3.3. Antibiotic sensitivity CNS isolates were sensitive to VAN in both non-recurrent and recurrent groups, and MSSA was sensitive to AUG, CFT, CIP, IPM, LFX, LZ, MPM, RFP, SPT, TCP, and VAN in both groups. MRSA was detected only in the recurrent group and was sensitive to CIP, LFX, LZ, RFP, TCP, and VAN and resistant to AMP, AUG, IPM, and PG. S. pneumoniae was sensitive to CIP, LFX, LZ, TCP, and VAN, and all isolates were resistant to EM. Most species showed resistance against AMP and PG regardless of species, and all species were sensitive to VAN. Non-recurrent and recurrent groups showed no significant difference in antibiotic resistance for all antibiotics (p > 0.05) (Table 5). In 3 patients, CNS was detected more than 2 times in the same patient, and the antibiotic sensitivity changed in 2 patients as the number of VTIs increased. One showed a change of antibiotic sensitivity to PG, and one to PG and AMP from sensitive to resistant. In another three patients, S. aureus was
No. (%) of isolates Non-recurrent OME (99)
Recurrent OME (179)
Total (278)
P value
No growth
74 (74.7)
121 (67.6)
0.212
Growth Gram positive CNS MSSA MRSA S. pneumoniae Gram negative H. influenzae M. catarrhalis P. aeruginosa Othersa
25 (25.3)
58 (32.4)
195 (70.1) 83 (29.9)
10 (10.1) 1 (1) 0 (0) 3 (3)
22 (12.3) 6 (3.4) 9 (5) 4 (2.2)
32 (11.5) 7 (2.5) 9 (3.2) 7 (2.5)
0.584 0.427 0.029 0.702
3 2 0 6
4 (2.2) 0 (0) 1 (0.6) 12 (6.7)
7 (2.5) 2 (0.7) 1 (0.4) 18 (6.5)
0.702 0.126 1.000 0.835
(3) (2) (0) (6.1)
0.212
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; S. pneumoniae, Streptococcus pneumoniae; H. influenzae, Haemophilus influenzae, M. catarrhalis, Moraxella catarrhalis; P. aeruginosa, Pseudomonas aeruginosa. a For details of other organisms please see Table 2.
3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
H.K. Min, et al.
Table 4 Relationship between isolates from patients with otitis media with effusion and the number of times ventilation tubes were inserted. Organism
No. (%) of isolates Non-recurrent OME (99)
No growth Growth Gram positive CNS MSSA MRSA S. pneumoniae Gram negative H. influenzae M. catarrhalis P. aeruginosa Othera
Recurrent OME (179) 1st(59)
2nd(62)
3rd(24)
4th(14)
5th(8)
6th(6)
7th(4)
8th(2)
74 (74.7)
41 (69.5)
40 (64.5)
17 (70.8)
10 (71.4)
5 (62.5)
4 (66.7)
2 (50)
2 (100)
10 (10.1) 1 (1) 0 (0) 3 (3)
6 1 2 1
(10.2) (1.7) (3.4) (1.7)
9 3 2 2
(14.5) (4.8) (3.2) (3.2)
3 1 2 0
(12.5) (4.2) (8.3) (0)
1 0 2 1
(7.1) (0) (14.3) (7.1)
1 0 0 0
(12.5) (0) (0) (0)
1 1 0 0
(16.7) (16.7) (0) (0)
1 0 1 0
(25) (0) (25) (0)
0 0 0 0
(0) (0) (0) (0)
3 2 0 6
3 0 0 5
(5.1) (0) (0) (8.5)
1 0 0 5
(1.6) (0) (0) (8.1)
0 0 0 1
(0) (0) (0) (4.2)
0 0 0 0
(0) (0) (0) (0)
0 0 1 1
(0) (0) (12.5) (12.5)
0 0 0 0
(0) (0) (0) (0)
0 0 0 0
(0) (0) (0) (0)
0 0 0 0
(0) (0) (0) (0)
(3) (2) (0) (6.1)
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; S. pneumoniae, Streptococcus pneumoniae; H. influenzae, Haemophilus influenzae, M. catarrhalis, Moraxella catarrhalis; P. aeruginosa, Pseudomonas aeruginosa. a For details of other organisms please see Table 2.
to hearing loss without any middle ear pathology. The bacterial distribution of adenoids was similar in both groups, but S. pneumoniae and M. catarrhalis were significantly higher in the MEW of OME patients, suggesting that the microbial community resulting from the middle ear microenvironment was more related to OME pathogenesis [16]. When performing PCR on MEF and adenoid swabs from both an OME group and a control group without any middle ear disease, there was no significant difference in the local microbiota of adenoids between two groups and there was no correlation between MEF and adenoid microbiota in OME patients [14]. From the MEF of OME patients, CNS, MSSA, MRSA, S. pneumoniae, and H. influenzae were the most frequently detected species. Although there was a slight difference in the order of detection rate of each species in the non-recurrent and recurrent groups, there was no significant difference in the detection rates between the two groups. In several previous studies, CNS species were detected at rates of 11–23%, MRSA at 4–16%, S. pneumoniae at 2–26%, H. influenzae at 6–10%, and M. catarrhalis at 2–6%. Identification of CNS at high rates in various studies should take into account the possibility of contamination from the EAC because CNS is thought to be normal flora of the ear canal. CNS was identified in 75% of EAC specimens in 45 normal adults who had no history of ear disease and were excluded from the possibility of nosocomial infection because they were not working in hospitals [17–19]. Even if we attempted to reduce the possibility of contamination from the EAC by performing potadine irrigation of the EAC before surgery and collecting the MEF carefully with sterile collectors, it was not possible to completely exclude the possibility of contamination from the EAC by cultivating only the MEF rather than biopsied middle ear mucosa. However, in one study, CNS was most frequently detected in the MEF of patients with chronic otitis media, but their subtypes were different from what was detected as normal flora in the EAC [17]. Another study reported the genotypic and phenotypic features of CNS species responsible for their ability to form biofilms in vivo and emphasized the pathogenic character of CNS species in some patients with OME [20]. In addition, bacterial translocation through the normal tympanic membrane is not possible, but changes in permeability of the tympanic membrane due to inflammation or infection have not yet been clarified or ruled out as a possibility. Recently, the possibility of bacterial translocation from the EAC to the middle ear cavity through micro- or macro-perforation of the tympanic membrane has been suggested [21]. Seventy-nine percent of all species detected in pediatric OME patients showed resistance to PG, which was not significantly different in the non-recurrent and recurrent groups. The same species was detected
detected more than 2 times in the same patient and MRSA was repeatedly detected in two patients among them. One patient with repeated MRSA detection showed a sensitivity change for cefoxitin to resistant as the number of VTIs increased. In one patient, MSSA was detected initially, followed by MRSA. Resistance appeared for CFT and PG in the patient with detection of MRSA following MSSA. 4. Discussion In this study, we compared the prevalence of allergy, ATH, CHR, and sinusitis in the non-recurrent and recurrent OME groups, which are co-morbidities thought to affect the pathogenesis of OME. The proportion of ATH in the recurrent group was significantly higher than in the non-recurrent group. With the same context, patients who underwent adenotonsillectomy were also significantly higher in the recurrent group. This is because, in patients with OME, adenoidectomy is an additional recommendation of VTI in patients who require repeated surgery rather than primary treatment. Adenoidectomy was performed in 36 of 99 patients (36.4%) in the non-recurrent group and 37 of 59 (62.7%) in the recurrent group. Of the 37 patients who underwent adenoidectomy in the recurrent group, seven underwent adenoidectomy at the first VTI, 25 at the second VTI, two at the third VTI, and three at the fourth VTI. Sixteen (21.9%) of 73 patients experienced recurrence after adenoidectomy and re-VTI. Paparella type I ventilation tubes were inserted into patients after 1–3 recurrences and Paparella type II ventilation tubes or T-tubes after four and subsequent recurrences. Adenoidectomy is performed to remove the physical obstruction to the nasopharyngeal opening of the E-tube due to adenoids and to reduce the possibility of spreading the microbiota of the adenoid located close to the E-tube opening to the middle ear cavity [13]. In one study, the adenoid tissues of 20 pediatric patients diagnosed with chronic OME and chronic rhinosinusitis were biopsied and cultured. The most common potential pathogens of OME, H. influenzae, S. pneumoniae, and M. catarrhalis were detected in 35%, 30%, and 20%, of samples, respectively, indicating that adenoids could act as reservoir of bacteria in chronic OME and chronic rhinosinusitis [14]. In a comparison of 100 patients with adenoid hypertrophy, 50 patients with OME and 50 without OME, bacteria were detected in adenoid tissues by PCR in 96% of the patients with OME and in 48% of the patients without OME. There was no correlation with adenoid size and bacterial detection rate [15]. In another study, adenoid tissues and middle ear wash (MEW) were collected and PCR was performed in both OME patients with adenoid hypertrophy and patients who received cochlear implants due 4
5
(1st)
(1st)
1/1 1/1 1/1 1/1 1/1
1/1 1/1 1/1 1/1 1/1
2/3 (66.7) 3/3 (100) 1/1 (100)
1/1 (100)
1/1 (100) 0/1 (0)
0/1 (0)
(100) (100) (100) (100) (100)
0/1 (0) 0/1 (0) 0/1 (0)
1/1 (100) 1/1 (100) 1/1 (100)
(100) (100) (100) (100) (100)
0/1 (0)
1/1 (100)
(83.3) (0) (66.7) (50) (0) (0) (0) (100)
(1st)
5/6 0/1 4/6 1/2 0/1 0/1 0/1 1/1
6/6 0/1 6/6 2/2 1/1 0/1 1/1 1/1
(1st)
(100) (0) (100) (100) (100) (0) (100) (100)
AUG
(25) (50) (66.7) (0)
1/1 0/1 1/1 1/1
(100) (0) (100) (100)
0/1 (0) 0/2 (0)
1/4 2/4 2/3 0/1
CFT
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/3 (0) 0/1 (0) 0/1 (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/5 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
CIP
(66.7) (100) (100) (0)
(0) (50) (50) (0) (0)
(0) (0) (33.3) (0) (0)
0/1 (0)
2/3 1/1 2/2 0/1
0/2 1/2 1/2 0/2 0/1
0/1 0/1 1/3 0/1 0/1
3/10 (30) 0/6 (0) 3/9 (33.3) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
CL
(100) (100) (100) (100)
(50) (100) (50) (0) (0)
(100) (0) (66.7) (0) (0)
0/1 (0)
3/3 1/1 2/2 1/1
1/2 2/2 1/2 0/2 0/1
1/1 0/1 2/3 0/1 0/1
4/10 (40) 2/6 (33.3) 7/9 (77.8) 0/3 (0) 0/1 (0) 1/1 (100) 0/1 (0) 0/1 (0)
EM
(100) (0) (66.7) (50) (0) (0) (0) (100)
(100) (100) (100) (100) (100)
0/1 (0)
1/1 (100)
1/1 1/1 1/1 1/1 1/1
0/1 (0) 0/1 (0) 0/1 (0)
0/1 (0)
6/6 0/1 4/6 1/2 0/1 0/1 0/1 1/1
IPM
0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0) 0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0) 0/1 (0)
0/1 (0)
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/1 0/2 0/2 0/1
0/1 0/1 0/2 0/1 0/1
0/1 (0) 0/1 (0)
2/5 (40) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
(11.1) (0) (0) (0) (0)
1/9 0/4 0/8 0/1 0/1
LZ
1/5 (20)
LFX
(100) (0) (50) (0)
1/1 (100) 0/2 (0)
1/1 (100) 0/1 (0)
1/1 (100)
1/1 (100)
0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0)
3/3 0/1 1/2 0/2
MPM
(66.7) (100) (50) (0)
(100) (100) (100) (100) (100)
(100) (100) (66.7) (100) (100)
1/1 (100)
2/3 1/1 1/2 0/1
2/2 2/2 2/2 2/2 1/1
1/1 1/1 2/3 1/1 1/1
8/10 (80) 3/6 (50) 9/9 (100) 2/3 (66.7) 1/1 (100) 0/1 (0) 1/1 (100) 1/1 (100)
PG
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
2/10 (20) 0/5 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
RFP
(33.3) (100) (50) (0)
(50) (50) (0) (0) (0)
(0) (0) (0) (0) (0)
1/3 (33.3) 2/3 (66.7) 1/1 (100)
1/3 1/1 1/2 0/1
1/2 1/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/6 (0) 3/9 (33.3) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
SPT
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
2/10 (20) 0/6 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
TCP
(0) (0) (0) (0)
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/3 0/1 0/2 0/1
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/6 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
VAN
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; AMP, ampicillin; AUG, augmentin (amoxicillin-clavulanate); CFT, cefoxitin; CIP, ciprofloxacin; CL, clindamycin; EM, erythromycin; IPM, imipenem; LFX, levofloxacin; LZ, linezolid; MPM, meropenem; PG, penicillin; RFP, rifampin; SPT, sulfamethoxazole-trimethoprim; TCP, teicoplanin; and VAN, vancomycin.
CNS Non-recurrent Recurrent 1st 2nd 3rd 4th 5th 6th 7th MSSA Non-recurrent Recurrent 1st 2nd 3rd 6th MRSA Recurrent 1st 2nd 3rd 4th 7th S. pneumoniae Non-recurrent Recurrent 1st 2nd 4th H. influenzae Non-recurrent Recurrent 1st 2nd P. aeruginosa Recurrent 5th
AMP
Antibiotic resistance, n (%)
Table 5 Relationship between antibiotic resistance of isolates from patients with otitis media with effusion and the number of times ventilation tubes were inserted.
H.K. Min, et al.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
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pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates.
more than twice in 6 patients, and susceptibility changes from sensitive to resistant to PG was observed in three of the isolates, as the number of VTIs increased. In other studies, species identified in recurrent OME patients showed lower sensitivity to penicillin and erythromycin than those identified in non-recurrent OME patients. Penicillin was the first discovered antibiotic, and penicillin-resistant species have been reported from dates as early as 1942. About 8–34% of S. pneumoniae, 25–30% of H. influenzae, 80% of M. catarrhalis isolated from the MEF of patients diagnosed with AOM, and 20–70% of S. pneumoniae, 40–80% of H. influenzae, and 50–60% of M. catarrhalis detected in the MEF of OME patients were revealed as resistant to penicillin [23]. [23], Betalactamase is a protein that plays an important role in resistance to penicillin, and it can also cause resistance to other beta-lactam antibiotics such as cephalosporins, cephamycins, and carbapenems. The reason for the high resistance to penicillin is that most patients who visit our institution, which is a tertiary center, have a history of previous frequent AOM or OME and already received antibiotic therapy but experienced treatment failure in primary and secondary medical institutions. Furthermore, exposure to nosocomial infections from medical staff or instruments due to frequent hospital visits and repeated VTI procedures may be another reason for the high resistance rate against penicillin. Previously, bacterial species commonly detected in OME included S. pneumoniae, H. influenzae, and M. catarrhalis, but the detection rate of S. aureus species including MRSA is gradually increasing [6,7,9,18,24]. S. aureus is a common pathogen in infectious otorhinolaryngology diseases and is detected as normal flora in 40% of normal adult nasal cavities, mainly spread through skin-to-skin contact. The prevalence of MRSA has been increasing steadily since it was first reported in 1961, probably due to the misuse and abuse of antibiotics, which is a problem throughout the medical community. AOM or OME also progresses to COM when treatment fails. MRSA has been identified more frequently in the MEF of COM patients than in AOM or OME, and MRSA detected in COM patients shows multiple resistance to more types of antibiotics [19]. In our study, highly pathogenic species such as MRSA and Pseudomonas species were detected only in the recurrent group, and the detection rate of MRSA was significantly higher in the recurrent group than in the non-recurrent group. In addition, S. aureus (both MSSA and MRSA) was identified in 16 out of 278 cultures, of which 6 were repeated two times each in 3 patients. Two of the three patients with repeated MRSA isolation showed a change of antibiotic sensitivity to CFT from sensitive to resistant as the number of VTIs increased. One patient with MRSA isolated after MSSA also showed a change of antibiotic sensitivity to CFT and PG. It is important to consider the possibility that multidrug-resistant species have spread through nosocomial infections through medical staff or surgical instruments due to frequent hospital visits and repeated surgery. In addition, pre-treatment antibiotics were used temporarily if there were signs of acute infection during close observation before VTI. Post-treatment antibiotics were also used for one week after VTI. The increase in antibiotic resistance in the recurrent group may not be able to preclude the effect of these preor post-treatment antibiotics. In fact, in one study, MRSA was exposed to the 5th generation cephalosporin in vitro to induce multiple-point mutation of the penicillin-binding protein (PBP), resulting in betalactam resistance and the emergence of new-generation broad-spectrum cephalosporin-resistant MRSA [22]. However, the number of patients was too small to show statistical significance for the change in resistance. Furthermore, there was a symptom-free period of 2–3 years between each isolation, which indicates the possibility of the detection of different species. Additional studies are needed, including genetic analyses, to confirm that resistance changes occurred in the same species.
Funding This study did not receive any grants from public, commercial, or not-for-profit funding agencies. Conflicts of interest There were no conflicts of interest for any authors involved in the study. Acknowledgments This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (NRF2018R1A6A1A03025124). Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijporl.2019.109652. References [1] S.J. Kim, J.H. Chung, H.M. Kang, S.G. Yeo, Clinical bacteriology of recurrent otitis media with effusion, Acta Otolaryngol. 133 (2013) 1133–1141. [2] G.A. Zielhuis, G.H. Rach, A. van den Bosch, P. van den Broek, The prevalence of otitis media with effusion: a critical review of the literature, Clin. Otolaryngol. Allied Sci. 15 (1990) 283–288. [3] H. Atkinson, S. Wallis, A.P. Coatesworth, Otitis media with effusion, PGM (Postgrad. Med.) 127 (2015) 381–385. [4] H. Kubba, J.P. Pearson, J.P. Birchall, The aetiology of otitis media with effusion: a review, Clin. Otolaryngol. Allied Sci. 25 (2000) 181–194. [5] D.W. Teele, J.O. Klein, B. Rosner, Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study, J. Infect. Dis. 160 (1989) 83–94. [6] L. Hall-Stoodley, F.Z. Hu, A. Gieseke, L. Nistico, D. Nguyen, J. Hayes, M. Forbes, D.P. Greenberg, B. Dice, A. Burrows, P.A. Wackym, P. Stoodley, J.C. Post, G.D. Ehrlich, J.E. Kerschner, Direct detection of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media, J. Am. Med. Assoc. 296 (2006) 202–211. [7] J.C. Post, R.A. Preston, J.J. Aul, M. Larkins-Pettigrew, J. Rydquist-White, K.W. Anderson, R.M. Wadowsky, D.R. Reagan, E.S. Walker, L.A. Kingsley, A.E. Magit, G.D. Ehrlich, Molecular analysis of bacterial pathogens in otitis media with effusion, J. Am. Med. Assoc. 273 (1995) 1598–1604. [8] K. Maeda, T. Hirano, I. Ichimiya, Y. Kurono, M. Suzuki, G. Mogi, Cytokine expression in experimental chronic otitis media with effusion in mice, The Laryngoscope 114 (2004) 1967–1972. [9] J.R. Dingman, M.G. Rayner, S. Mishra, Y. Zhang, M.D. Ehrlich, J.C. Post, G.D. Ehrlich, Correlation between presence of viable bacteria and presence of endotoxin in middle-ear effusions, J. Clin. Microbiol. 36 (1998) 3417–3419. [10] F. Simon, M. Haggard, R.M. Rosenfeld, H. Jia, S. Peer, M.N. Calmels, V. Couloigner, N. Teissier, International consensus (ICON) on management of otitis media with effusion in children, Eur. Ann. Otorhinolaryngol. Head Neck Dis. 135 (2018) S33–S39. [11] P.C. Appelbaum, Epidemiology and in vitro susceptibility of drug-resistant Streptococcus pneumoniae, Pediatr. Infect. Dis. 15 (1996) 932–934. [12] M. Davcheva-Chakar, A. Kaftandzhieva, B. Zafirovska, Adenoid vegetations - reservoir of bacteria for chronic otitis media with effusion and chronic rhinosinusitis, Pril (Makedon Akad Nauk Umet Odd Med Nauki) 36 (2015) 71–76. [13] C.L. Chan, D. Wabnitz, J.J. Bardy, A. Bassiouni, P.J. Wormald, S. Vreugde, A.J. Psaltis, The microbiome of otitis media with effusion, The Laryngoscope 126 (2016) 2844–2851. [14] G.P. Buzatto, E. Tamashiro, J.L. Proenca-Modena, T.H. Saturno, M.C. Prates, T.B. Gagliardi, L.R. Carenzi, E.T. Massuda, M.A. Hyppolito, F.C. Valera, E. Arruda, W.T. Anselmo-Lima, The pathogens profile in children with otitis media with effusion and adenoid hypertrophy, PLoS One 12 (2017) e0171049. [15] M.E. Saafan, W.S. Ibrahim, M.O. Tomoum, Role of adenoid biofilm in chronic otitis media with effusion in children, Eur. Arch. Oto-Rhino-Laryngol. 270 (2013) 2417–2425. [16] K.M. Chon, B.N. Yoon, S.H. Park, I.W. Lee, E.K. Goh, S.G. Wang, Microbiologic study of the ear canal in Koreans, Korean. J. Otolaryngol.-Head Neck Surg. 48
5. Conclusion Staphylococcus species were detected most frequently in the MEF of 6
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[21] S.J. Han, P.M. Jung, H. Kim, J.E. Kim, J. Hong, E.H. Hwang, I. Seong, Multiple intestinal ulcerations and perforations secondary to methicillin-resistant Staphylococcus aureus enteritis in infants, J. Pediatr. Surg. 34 (1999) 381–386. [22] L.C. Chan, A. Gilbert, L. Basuino, T.M. da Costa, S.M. Hamilton, K.R. Dos Santos, H.F. Chambers, S.S. Chatterjee, PBP 4 mediates high-level resistance to new-generation cephalosporins in Staphylococcus aureus, Antimicrob. Agents Chemother. 60 (2016) 3934–3941. [23] C.C. Ngo, H.M. Massa, R.B. Thornton, A.W. Cripps, Predominant bacteria detected from the middle ear fluid of children experiencing otitis media: a systematic review, PLoS One 11 (2016) e0150949. [24] S.H. Kim, E.J. Jeon, S.M. Hong, C.H. Bae, H.Y. Lee, M.K. Park, J.Y. Byun, M.G. Kim, S.G. Yeo, Bacterial species and antibiotic sensitivity in Korean patients diagnosed with acute otitis media and otitis media with effusion, J. Korean Med. Sci. 32 (2017) 672–678.
(2005) 8–12. [17] J.M. Bernstein, D. Dryja, E. Neter, The role of coagulase-negative staphylococci in chronic otitis media with effusion, Otolaryngol. Head Neck Surg. 90 (1982) 837–843. [18] H. Jung, S.K. Lee, S.H. Cha, J.Y. Byun, M.S. Park, S.G. Yeo, Current bacteriology of chronic otitis media with effusion: high rate of nosocomial infection and decreased antibiotic sensitivity, J. Infect. 59 (2009) 308–316. [19] M.K. Park, D.W. Nam, J.Y. Byun, S.M. Hong, C.H. Bae, H.Y. Lee, E.J. Jeon, M.G. Kim, S.H. Kim, S.G. Yeo, Differences in antibiotic resistance of MRSA infections in patients with various types of otitis media, J. Int. Adv. Otol. 14 (2018) 459–463. [20] J. Paluch-Oleś, A. Magryś, M. Kozioł-Montewka, A. Niedzielski, J. Niedźwiadek, G. Niedzielska, M. Kotowski, The phenotypic and genetic biofilm formation characteristics of coagulase-negative staphylococci isolates in children with otitis media, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 126–130.
7
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Bacteriology and resistance patterns of otitis media with effusion a
a
a
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a
Hye Kyu Min , Seok Hyun Kim , Myung Jin Park , Sung Su Kim , Sang Hoon Kim , Seung Geun Yeoa,b,∗ a
Department of Otorhinolaryngology, Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Republic of Korea Medical Research Center for Bioreaction to Reactive Oxygen Species and Biomedical Science Institute, School of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
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A R T I C LE I N FO
A B S T R A C T
Keywords: Otitis media with effusion Antibiotics MRSA Pseudomonas
Objectives: Following the increased use of antibiotics, the emergence of antibiotic-resistant species in pediatric patients with otitis media has become a problem in recent years. The aim of this study was to investigate change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species, such as Methicillinresistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa according to the number of repeated ventilation tube insertion (VTI) procedures in pediatric patients diagnosed with otitis media with effusion (OME). Materials & methods: From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in this study. Bacterial cultures were performed on aseptically collected middle ear effusion (MEF) at the time of VTI and antibiotic sensitivity tests were performed on the identified bacteria. Results: Bacteria were not identified in 195 (70.1%) cultures and identified in 83 (29.9%) cultures. Coagulasenegative staphylococci (CNS) was the most frequently detected species in both the non-recurrent group and the recurrent group. MRSA detection rate was found to be significantly higher in the recurrent group than in the nonrecurrent group (p = 0.029). The two groups showed no significant difference in antibiotic resistance against all antibiotics (p > 0.05). Conclusion: Staphylococcus species were detected most frequently in the MEF of pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates.
1. Introduction Otitis media with effusion (OME) is a disease in which the middle ear fluid (MEF) accumulates in the middle ear without accompanying acute inflammatory symptoms such as otalgia or fever. OME is the most frequent cause of hearing impairment in children, with a prevalence of 15–20% in pediatric patients [1,2]. There are many hypotheses about the etiology of OME. It is known that the Eustachian tube (E-tube) in children is relatively horizontal compared to that of adults, and E-tube dysfunction is often accompanied by immature muscular structure acting on E-tube opening. Furthermore, other secondary factors such as acute upper respiratory infection, chronic rhinosinusitis, and physical obstruction due to allergic rhinitis and adenoid vegetation may lead to E-tube dysfunction, which is known to cause OME [3].
OME is also understood as a sequelae of acute otitis media (AOM), and it has been reported that in patients diagnosed with AOM, MEF is found in 45% of patients after 1 month and 10% after 3 months of initial infection [3,4]. When inflammatory stimuli such as bacteria or viruses increase the production of inflammatory mediators such as TNFalpha, expression of the mucin gene is increased in the middle ear mucosa and mucus secretion is also increased, which causes MEF to persist [5,6]. In addition, inflammatory mediators and/or cytokines secreted by subclinical bacterial infection may induce OME. Positive bacterial cultures from MEF samples are found in one-third of OME patients [3,4]. The presence of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenza (H. influenzae), and Moraxella catarrhalis (M. catarrhalis) was identified in approximately 25% of the cultured MEFs in pediatric OME patients and identified in nearly 80% in polymerase chain reaction (PCR) -based methods. In addition, it has been
∗ Corresponding author. Department of Otorhinolaryngology, Head and Neck Surgery, School of Medicine, Kyung Hee University, 23 Kyung Hee Dae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea. E-mail address: [email protected] (S.G. Yeo).
https://doi.org/10.1016/j.ijporl.2019.109652 Received 4 June 2019; Received in revised form 10 August 2019; Accepted 20 August 2019 Available online 21 August 2019 0165-5876/ © 2019 Published by Elsevier B.V.
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2.3. Bacterial culture & antibiotic sensitivity tests
reported that the middle ear mucosal biopsy in these PCR-proven patients showed 92% biofilm formation [7–9]. Although microbial etiology is becoming increasingly important in OME, international guidelines do not recommend the use of antibiotics as an initial therapy. Several studies have shown that antibiotic therapy does not have long-term efficacy in hearing, rate of VTI, and language development, and may affect the emergence of antibiotic-resistant species [10]. While many attempts have been made to control the use of antibiotics, the misuse and abuse of antibiotics is common in medical institutions and the emergence of antibiotic-resistant bacteria in pediatric patients is increasingly becoming a problem [11]. Although there are differences according to the reported area and time, about 20–70% of S. pneumoniae, 40–80% of H. influenzae, and 50–60% of M. catarrhalis detected in the MEF of OME patients are reported to show resistance to penicillin [11,12]. Patients with OME, especially recurrent OME, are more likely to have nosocomial infections due to frequent hospital visits and repeated VTI procedures. Pediatric patients are frequently exposed to OME beginning with AOM, so they are often exposed to antibiotic treatment at the time of AOM diagnosis or by post-operative antibiotic therapy after VTI [1]. The aim of this study was to investigate the change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species such as MRSA and Pseudomonas species according to the number of repeated VTI procedures in pediatric patients diagnosed with OME.
Samples were aseptically collected using a Juhn Tym-Tap collector, embedded on sterilized cotton swabs, and transplanted to Stuart transport medium (COPAN, Brescia, Italia) and finally cultured on blood agar and chocolate agar media (Hangang, Kun-po, Korea) to isolate fastidious organisms, MacConkey agar medium (Hangang, Kunpo, Korea) to isolate Gram negative and enteric bacilli, thioglycollate broth (formulated in our laboratory) to isolate anaerobes and Brucella agar medium (formulated in our laboratory) to isolate Brucella species. Bacteria cultures were incubated at 35 °C for 3 days and resultant colonies were identified by Microflex (Bruker, Billerica, MA, USA). Biochemical and antibiotic sensitivity tests were performed using Microscan (Beckman Coulter, Seoul, Korea). Antibiotic sensitivity tests were performed according to the National Committee for Clinical Laboratory Standards (NCCLS) Guidelines. Gram-positive bacteria were tested for antibiotic sensitivity to ampicillin (AMP), amoxicillin/clavulanate (AUG), azithromycin, cefepime, cefoxitin (CFT), cefuroxime, ciprofloxacin (CIP), clindamycin (CL), daptomycin, ertapenem, erythromycin (EM), fosfomycin, fusidic acid, gentamycin, imipenem (IPM), levofloxacin (LFX), linezolid (LZ), meropenem (MPM), moxifloxacin, mupirocin, nitrofurantoin, penicillin-G (PG), rifampin (RFP), synercid, sulfamethoxazole/trimethoprim (SPT), teicoplanin (TCP), tetracycline, tobramycin, and vancomycin (VAN) using the Dried Gram Positive MIC Panel Type 28 system (Beckman Coulter, Seoul, Korea). Gram-negative bacteria were tested for antibiotic sensitivity to amikacin, ampicillin (AMP), amoxicillin/clavulanate (AUG), aztreonam, cefepime, cefotaxime, ceftazidime, cefuroxime, cephalothin, chloramphenicol, ciprofloxacin (CIP), colistin, doripenem, ertapenem, fosfomycin, gentamycin, imipenem (IMP), levofloxacin (LFX), meropenem (MPM), minocycline, nalidixic acid, nitrofurantoin, norfloxacin, penicillin-G (PG), piperacillin/tazobactam, tetracycline, tigecycline, tobramycin, and sulfamethoxazole/trimethoprim (SPT) using the Dried Gram Negative MIC Panel Type 44 system (Beckman Coulter, Seoul, Korea).
2. Materials & Methods 2.1. Patients From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in the study. Patients were diagnosed with OME if tympanometry showed type B or C, and if amber-color or air bubbles were observed on otoscopic examination without signs of acute inflammation such as perforation of the tympanic membrane, fever, and otalgia. VTI was performed when there was no improvement for more than 3 months, hearing loss of more than 40 dB confirmed by pure-tone audiometry (PTA), or retraction of the tympanic membrane. We investigated age, gender, comorbidities including allergy, adenoid & tonsillar hypertrophy (ATH), chronic hypertrophic rhinitis (CHR), sinusitis, number of VTIs, and culture results from all patients through retrospective chart review. We defined the patients who underwent a single VTI as the non-recurrent group and patients who underwent two or more VTIs as the recurrent group. We excluded patients where no MEF cultures were performed or when culture results were not known because the first VTI was performed at another hospital. Before surgery, the parents or guardians of each patient provided written informed consent for the use of patient samples. The study protocol was approved by the Kyung Hee University Clinical Research Ethics Committee (KMC 2017-12-030).
2.4. Statistical analysis The results are expressed as N (percentage). Differences between the two groups were analyzed by Chi-squared, Fisher's exact, or MannWhitney tests. All data were analyzed using SPSS ver. 20.0 statistical software (SPSS Inc., Chicago, IL). A P value of less than 0.05 was considered statistically significant. 3. Results 3.1. Demographics Among the total 158 patients, 99 patients underwent VTI once, who were classified as the non-recurrent group and 59 patients underwent VTI twice or more who were classified as the recurrent group. Age at the time of the first VTI procedure ranged from 10 months to 17 years. The mean age of all patients was 4.38 years old; 4.48 years in the nonrecurrent group and 4.22 years in the recurrent group. The 158 patients consisted of 102 boys (64.6%) and 56 girls (35.4%). Of these, 65 boys (65.7%) and 34 girls (34.3%) were in the non-recurrent group, and 37 boys (62.7%) and 22 girls (37.3%) were in the recurrent group. However, there were no statistically significant differences between the non-recurrent and recurrent group relative to age of the first VTI and sex ratio (p = 0.381, p = 0.708, respectively). There were no statistically significant differences in the positive culture results between the two groups, 74 cases (74.7%) in the nonrecurrent group and 37 cases (62.7%) in the recurrent group (p = 109). In the case of comorbidities, the number of patients with ATH was significantly higher in the recurrent group (40 patients, 67.8%) than in the non-recurrent group (42 patients, 42.4%) (p = 0.005). Allergy,
2.2. Procedure Ventilation tube insertion (VTI) was performed unilaterally or bilaterally on the affected side diagnosed with OME. First, foreign substances such as cerumen observed in the external auditory canal (EAC) were removed under a microscope and potadine solution irrigation was performed. MEFs were collected using a Juhn Tym-Tap collector (Jacksonville, FL, USA) after radial incision of the anterior inferior quadrant of the eardrum with a myringotome knife. All remaining exudates were removed through suction. The ventilation tube was inserted through the myringotomy site. After the procedure, the patient was regularly followed up at the outpatient clinic at 2- to 3-month intervals until the ventilation tube spontaneously extracted. 2
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Table 1 Demographic characteristics of patients with non-recurrent and recurrent otitis media with effusion.
Age at first onset (yr) Male (N,%) Average no. of VTI (N) Positive culture results (N,%) Comorbidities Allergy (N,%) Adenoid & tonsillar hypertrophy (ATH) (N,%) History of adenotonsillectomy (AT) (N,%) Chronic hypertrophic rhinitis (CHR) (N,%) History of inferior turbinoplasty (ITP) (N,%) Sinusitis (N,%)
Non-recurrent OME (99)
Recurrent OME (59)
Total (158)
P value
4.48 65 (65.7) 1 74 (74.7)
4.22 37 (62.7) 2.96 37 (62.7)
4.38 102 (64.6) 1.73 111 (70.2)
0.381 0.708 0.000 0.109
11 (11.1) 42 (42.4) 36 (36.4) 15 (15.2) 7 (7.1) 4 (4.0)
11 (18.6) 40 (67.8) 37 (62.7) 9 (15.3) 4 (6.8) 5 (8.5)
22 (13.9) 82 (51.9) 73 (46.2) 24 (15.2) 11 (7) 9 (5.7)
0.206 0.005 0.025 0.372 0.260 1.000
CHR, and sinusitis were not significantly different between the two groups (p > 0.05) (Table 1).
Table 2 Isolated bacterial species of middle ear fluid from patients with otitis media with effusion.
3.2. Culture
Organism
No. (%) of isolates
Bacterial culture was performed every time VTI was performed to confirm changes in bacterial species and antibiotic resistance. The total number of cultures from the 158 patients was 278. For the 99 cases classified as the non-recurrent group, only one culture was performed per person, a total of 99 times. In the recurrent group of 59 patients, the total number of cultures performed repeatedly was 179, and the number of the most frequent cultures in the same patient was 8. In three patients in the recurrent group, different species were detected on both sides at the same time. Bacteria were not cultured from 195 (70.1%) samples; 83 samples (29.9%) produced bacterial isolates. The most commonly identified species were CNS (32 times, 11.5%), followed by MRSA (9 times each, 3.2%), Methicillin-sensitive Staphylococcus aureus (MSSA), S. pneumoniae, and H. influenzae (7 times each, 2.5%), Bacillus spp. (4 times, 1.4%), Streptococcus viridans (S. viridans) (3 times, 1.1%), Corynebacterium spp., Haemophilus parainfluenzae (H. parainfluenzae), M. catarrhalis (2 times each, 0.7%), Streptococcus mitis (S. mitis), Staphylococcus intermedius (S. intermedius), Micrococcus spp., Pseudomonas aeruginosa (P. aeruginosa), Acinetobacter baumannii (A. baumannii), Empedobacter brevis (E. brevis), Neisseria spp., and yeast (one each, 0.4%) (Table 2). CNS was the most frequently detected species in the non-recurrent group (10 times, 10.1%), followed by S. pneumoniae and H. influenzae (3 times each, 3%). In the recurrent group, CNS was detected in 22 patients (12.3%), MRSA in 9 cases (5%), and P. aeruginosa was also detected in one patient (0.6%). Only MRSA was found to be significantly higher in the recurrent group (9 cases, 5%) than in the non-recurrent group (0, 0%) (p = 0.029) (Table 3). There was no significant correlation between the number of VTI procedures and the detection rate in all types of species in the recurrent group (p > 0.05) (Table 4).
No growth Growth Gram positive
195 (70.1) 83 (29.9) Coagulase-negative staphylococci (CNS) Methicillin-resistant Staphylococcus aureus (MRSA) Methicillin-sensitive Staphylococcus aureus (MSSA) Streptococcus pneumoniae (S. pneumoniae) Bacillus spp. Streptococcus viridans (S. viridans) Corynebacterium spp. Staphylococcus intermedius (S. intermedius) Streptococcus mitis (S. mitis) Micrococcus spp.
32 (11.5) 9 (3.2)
7 4 3 2 1 1 1
(2.5) (1.4) (1.1) (0.7) (0.4) (0.4) (0.4)
Haemophilus influenzae (H. influenzae) Haemophilus parainfluenzae (H. parainfluenzae) Moraxella catarrhalis (M. catarrhalis) Pseudomonas aeruginosa (P. aeruginosa) Acinetobacter baumannii (A. baumannii) Empedobacter brevis (E. brevis) Neisseria spp.
7 2 2 1 1 1 1 1
(2.5) (0.7) (0.7) (0.4) (0.4) (0.4) (0.4) (0.4)
7 (2.5)
Gram negative
Yeast
Table 3 Comparison of the number of middle ear fluid isolates from patients with nonrecurrent and recurrent otitis media with effusion. Organism
3.3. Antibiotic sensitivity CNS isolates were sensitive to VAN in both non-recurrent and recurrent groups, and MSSA was sensitive to AUG, CFT, CIP, IPM, LFX, LZ, MPM, RFP, SPT, TCP, and VAN in both groups. MRSA was detected only in the recurrent group and was sensitive to CIP, LFX, LZ, RFP, TCP, and VAN and resistant to AMP, AUG, IPM, and PG. S. pneumoniae was sensitive to CIP, LFX, LZ, TCP, and VAN, and all isolates were resistant to EM. Most species showed resistance against AMP and PG regardless of species, and all species were sensitive to VAN. Non-recurrent and recurrent groups showed no significant difference in antibiotic resistance for all antibiotics (p > 0.05) (Table 5). In 3 patients, CNS was detected more than 2 times in the same patient, and the antibiotic sensitivity changed in 2 patients as the number of VTIs increased. One showed a change of antibiotic sensitivity to PG, and one to PG and AMP from sensitive to resistant. In another three patients, S. aureus was
No. (%) of isolates Non-recurrent OME (99)
Recurrent OME (179)
Total (278)
P value
No growth
74 (74.7)
121 (67.6)
0.212
Growth Gram positive CNS MSSA MRSA S. pneumoniae Gram negative H. influenzae M. catarrhalis P. aeruginosa Othersa
25 (25.3)
58 (32.4)
195 (70.1) 83 (29.9)
10 (10.1) 1 (1) 0 (0) 3 (3)
22 (12.3) 6 (3.4) 9 (5) 4 (2.2)
32 (11.5) 7 (2.5) 9 (3.2) 7 (2.5)
0.584 0.427 0.029 0.702
3 2 0 6
4 (2.2) 0 (0) 1 (0.6) 12 (6.7)
7 (2.5) 2 (0.7) 1 (0.4) 18 (6.5)
0.702 0.126 1.000 0.835
(3) (2) (0) (6.1)
0.212
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; S. pneumoniae, Streptococcus pneumoniae; H. influenzae, Haemophilus influenzae, M. catarrhalis, Moraxella catarrhalis; P. aeruginosa, Pseudomonas aeruginosa. a For details of other organisms please see Table 2.
3
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
H.K. Min, et al.
Table 4 Relationship between isolates from patients with otitis media with effusion and the number of times ventilation tubes were inserted. Organism
No. (%) of isolates Non-recurrent OME (99)
No growth Growth Gram positive CNS MSSA MRSA S. pneumoniae Gram negative H. influenzae M. catarrhalis P. aeruginosa Othera
Recurrent OME (179) 1st(59)
2nd(62)
3rd(24)
4th(14)
5th(8)
6th(6)
7th(4)
8th(2)
74 (74.7)
41 (69.5)
40 (64.5)
17 (70.8)
10 (71.4)
5 (62.5)
4 (66.7)
2 (50)
2 (100)
10 (10.1) 1 (1) 0 (0) 3 (3)
6 1 2 1
(10.2) (1.7) (3.4) (1.7)
9 3 2 2
(14.5) (4.8) (3.2) (3.2)
3 1 2 0
(12.5) (4.2) (8.3) (0)
1 0 2 1
(7.1) (0) (14.3) (7.1)
1 0 0 0
(12.5) (0) (0) (0)
1 1 0 0
(16.7) (16.7) (0) (0)
1 0 1 0
(25) (0) (25) (0)
0 0 0 0
(0) (0) (0) (0)
3 2 0 6
3 0 0 5
(5.1) (0) (0) (8.5)
1 0 0 5
(1.6) (0) (0) (8.1)
0 0 0 1
(0) (0) (0) (4.2)
0 0 0 0
(0) (0) (0) (0)
0 0 1 1
(0) (0) (12.5) (12.5)
0 0 0 0
(0) (0) (0) (0)
0 0 0 0
(0) (0) (0) (0)
0 0 0 0
(0) (0) (0) (0)
(3) (2) (0) (6.1)
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; S. pneumoniae, Streptococcus pneumoniae; H. influenzae, Haemophilus influenzae, M. catarrhalis, Moraxella catarrhalis; P. aeruginosa, Pseudomonas aeruginosa. a For details of other organisms please see Table 2.
to hearing loss without any middle ear pathology. The bacterial distribution of adenoids was similar in both groups, but S. pneumoniae and M. catarrhalis were significantly higher in the MEW of OME patients, suggesting that the microbial community resulting from the middle ear microenvironment was more related to OME pathogenesis [16]. When performing PCR on MEF and adenoid swabs from both an OME group and a control group without any middle ear disease, there was no significant difference in the local microbiota of adenoids between two groups and there was no correlation between MEF and adenoid microbiota in OME patients [14]. From the MEF of OME patients, CNS, MSSA, MRSA, S. pneumoniae, and H. influenzae were the most frequently detected species. Although there was a slight difference in the order of detection rate of each species in the non-recurrent and recurrent groups, there was no significant difference in the detection rates between the two groups. In several previous studies, CNS species were detected at rates of 11–23%, MRSA at 4–16%, S. pneumoniae at 2–26%, H. influenzae at 6–10%, and M. catarrhalis at 2–6%. Identification of CNS at high rates in various studies should take into account the possibility of contamination from the EAC because CNS is thought to be normal flora of the ear canal. CNS was identified in 75% of EAC specimens in 45 normal adults who had no history of ear disease and were excluded from the possibility of nosocomial infection because they were not working in hospitals [17–19]. Even if we attempted to reduce the possibility of contamination from the EAC by performing potadine irrigation of the EAC before surgery and collecting the MEF carefully with sterile collectors, it was not possible to completely exclude the possibility of contamination from the EAC by cultivating only the MEF rather than biopsied middle ear mucosa. However, in one study, CNS was most frequently detected in the MEF of patients with chronic otitis media, but their subtypes were different from what was detected as normal flora in the EAC [17]. Another study reported the genotypic and phenotypic features of CNS species responsible for their ability to form biofilms in vivo and emphasized the pathogenic character of CNS species in some patients with OME [20]. In addition, bacterial translocation through the normal tympanic membrane is not possible, but changes in permeability of the tympanic membrane due to inflammation or infection have not yet been clarified or ruled out as a possibility. Recently, the possibility of bacterial translocation from the EAC to the middle ear cavity through micro- or macro-perforation of the tympanic membrane has been suggested [21]. Seventy-nine percent of all species detected in pediatric OME patients showed resistance to PG, which was not significantly different in the non-recurrent and recurrent groups. The same species was detected
detected more than 2 times in the same patient and MRSA was repeatedly detected in two patients among them. One patient with repeated MRSA detection showed a sensitivity change for cefoxitin to resistant as the number of VTIs increased. In one patient, MSSA was detected initially, followed by MRSA. Resistance appeared for CFT and PG in the patient with detection of MRSA following MSSA. 4. Discussion In this study, we compared the prevalence of allergy, ATH, CHR, and sinusitis in the non-recurrent and recurrent OME groups, which are co-morbidities thought to affect the pathogenesis of OME. The proportion of ATH in the recurrent group was significantly higher than in the non-recurrent group. With the same context, patients who underwent adenotonsillectomy were also significantly higher in the recurrent group. This is because, in patients with OME, adenoidectomy is an additional recommendation of VTI in patients who require repeated surgery rather than primary treatment. Adenoidectomy was performed in 36 of 99 patients (36.4%) in the non-recurrent group and 37 of 59 (62.7%) in the recurrent group. Of the 37 patients who underwent adenoidectomy in the recurrent group, seven underwent adenoidectomy at the first VTI, 25 at the second VTI, two at the third VTI, and three at the fourth VTI. Sixteen (21.9%) of 73 patients experienced recurrence after adenoidectomy and re-VTI. Paparella type I ventilation tubes were inserted into patients after 1–3 recurrences and Paparella type II ventilation tubes or T-tubes after four and subsequent recurrences. Adenoidectomy is performed to remove the physical obstruction to the nasopharyngeal opening of the E-tube due to adenoids and to reduce the possibility of spreading the microbiota of the adenoid located close to the E-tube opening to the middle ear cavity [13]. In one study, the adenoid tissues of 20 pediatric patients diagnosed with chronic OME and chronic rhinosinusitis were biopsied and cultured. The most common potential pathogens of OME, H. influenzae, S. pneumoniae, and M. catarrhalis were detected in 35%, 30%, and 20%, of samples, respectively, indicating that adenoids could act as reservoir of bacteria in chronic OME and chronic rhinosinusitis [14]. In a comparison of 100 patients with adenoid hypertrophy, 50 patients with OME and 50 without OME, bacteria were detected in adenoid tissues by PCR in 96% of the patients with OME and in 48% of the patients without OME. There was no correlation with adenoid size and bacterial detection rate [15]. In another study, adenoid tissues and middle ear wash (MEW) were collected and PCR was performed in both OME patients with adenoid hypertrophy and patients who received cochlear implants due 4
5
(1st)
(1st)
1/1 1/1 1/1 1/1 1/1
1/1 1/1 1/1 1/1 1/1
2/3 (66.7) 3/3 (100) 1/1 (100)
1/1 (100)
1/1 (100) 0/1 (0)
0/1 (0)
(100) (100) (100) (100) (100)
0/1 (0) 0/1 (0) 0/1 (0)
1/1 (100) 1/1 (100) 1/1 (100)
(100) (100) (100) (100) (100)
0/1 (0)
1/1 (100)
(83.3) (0) (66.7) (50) (0) (0) (0) (100)
(1st)
5/6 0/1 4/6 1/2 0/1 0/1 0/1 1/1
6/6 0/1 6/6 2/2 1/1 0/1 1/1 1/1
(1st)
(100) (0) (100) (100) (100) (0) (100) (100)
AUG
(25) (50) (66.7) (0)
1/1 0/1 1/1 1/1
(100) (0) (100) (100)
0/1 (0) 0/2 (0)
1/4 2/4 2/3 0/1
CFT
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/3 (0) 0/1 (0) 0/1 (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/5 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
CIP
(66.7) (100) (100) (0)
(0) (50) (50) (0) (0)
(0) (0) (33.3) (0) (0)
0/1 (0)
2/3 1/1 2/2 0/1
0/2 1/2 1/2 0/2 0/1
0/1 0/1 1/3 0/1 0/1
3/10 (30) 0/6 (0) 3/9 (33.3) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
CL
(100) (100) (100) (100)
(50) (100) (50) (0) (0)
(100) (0) (66.7) (0) (0)
0/1 (0)
3/3 1/1 2/2 1/1
1/2 2/2 1/2 0/2 0/1
1/1 0/1 2/3 0/1 0/1
4/10 (40) 2/6 (33.3) 7/9 (77.8) 0/3 (0) 0/1 (0) 1/1 (100) 0/1 (0) 0/1 (0)
EM
(100) (0) (66.7) (50) (0) (0) (0) (100)
(100) (100) (100) (100) (100)
0/1 (0)
1/1 (100)
1/1 1/1 1/1 1/1 1/1
0/1 (0) 0/1 (0) 0/1 (0)
0/1 (0)
6/6 0/1 4/6 1/2 0/1 0/1 0/1 1/1
IPM
0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0) 0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0) 0/1 (0)
0/1 (0)
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/1 0/2 0/2 0/1
0/1 0/1 0/2 0/1 0/1
0/1 (0) 0/1 (0)
2/5 (40) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
(11.1) (0) (0) (0) (0)
1/9 0/4 0/8 0/1 0/1
LZ
1/5 (20)
LFX
(100) (0) (50) (0)
1/1 (100) 0/2 (0)
1/1 (100) 0/1 (0)
1/1 (100)
1/1 (100)
0/1 (0) 0/1 (0)
0/1 (0)
0/1 (0)
3/3 0/1 1/2 0/2
MPM
(66.7) (100) (50) (0)
(100) (100) (100) (100) (100)
(100) (100) (66.7) (100) (100)
1/1 (100)
2/3 1/1 1/2 0/1
2/2 2/2 2/2 2/2 1/1
1/1 1/1 2/3 1/1 1/1
8/10 (80) 3/6 (50) 9/9 (100) 2/3 (66.7) 1/1 (100) 0/1 (0) 1/1 (100) 1/1 (100)
PG
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
2/10 (20) 0/5 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
RFP
(33.3) (100) (50) (0)
(50) (50) (0) (0) (0)
(0) (0) (0) (0) (0)
1/3 (33.3) 2/3 (66.7) 1/1 (100)
1/3 1/1 1/2 0/1
1/2 1/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/6 (0) 3/9 (33.3) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
SPT
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/2 (0) 0/1 (0) 0/1 (0)
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
2/10 (20) 0/6 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
TCP
(0) (0) (0) (0)
(0) (0) (0) (0) (0)
(0) (0) (0) (0) (0)
0/1 (0)
0/3 0/1 0/2 0/1
0/2 0/2 0/2 0/2 0/1
0/1 0/1 0/3 0/1 0/1
0/10 (0) 0/6 (0) 0/9 (0) 0/3 (0) 0/1 (0) 0/1 (0) 0/1 (0) 0/1 (0)
VAN
CNS, coagulase-negative staphylococci; MSSA, methicillin-sensitive Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus; AMP, ampicillin; AUG, augmentin (amoxicillin-clavulanate); CFT, cefoxitin; CIP, ciprofloxacin; CL, clindamycin; EM, erythromycin; IPM, imipenem; LFX, levofloxacin; LZ, linezolid; MPM, meropenem; PG, penicillin; RFP, rifampin; SPT, sulfamethoxazole-trimethoprim; TCP, teicoplanin; and VAN, vancomycin.
CNS Non-recurrent Recurrent 1st 2nd 3rd 4th 5th 6th 7th MSSA Non-recurrent Recurrent 1st 2nd 3rd 6th MRSA Recurrent 1st 2nd 3rd 4th 7th S. pneumoniae Non-recurrent Recurrent 1st 2nd 4th H. influenzae Non-recurrent Recurrent 1st 2nd P. aeruginosa Recurrent 5th
AMP
Antibiotic resistance, n (%)
Table 5 Relationship between antibiotic resistance of isolates from patients with otitis media with effusion and the number of times ventilation tubes were inserted.
H.K. Min, et al.
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109652
H.K. Min, et al.
pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates.
more than twice in 6 patients, and susceptibility changes from sensitive to resistant to PG was observed in three of the isolates, as the number of VTIs increased. In other studies, species identified in recurrent OME patients showed lower sensitivity to penicillin and erythromycin than those identified in non-recurrent OME patients. Penicillin was the first discovered antibiotic, and penicillin-resistant species have been reported from dates as early as 1942. About 8–34% of S. pneumoniae, 25–30% of H. influenzae, 80% of M. catarrhalis isolated from the MEF of patients diagnosed with AOM, and 20–70% of S. pneumoniae, 40–80% of H. influenzae, and 50–60% of M. catarrhalis detected in the MEF of OME patients were revealed as resistant to penicillin [23]. [23], Betalactamase is a protein that plays an important role in resistance to penicillin, and it can also cause resistance to other beta-lactam antibiotics such as cephalosporins, cephamycins, and carbapenems. The reason for the high resistance to penicillin is that most patients who visit our institution, which is a tertiary center, have a history of previous frequent AOM or OME and already received antibiotic therapy but experienced treatment failure in primary and secondary medical institutions. Furthermore, exposure to nosocomial infections from medical staff or instruments due to frequent hospital visits and repeated VTI procedures may be another reason for the high resistance rate against penicillin. Previously, bacterial species commonly detected in OME included S. pneumoniae, H. influenzae, and M. catarrhalis, but the detection rate of S. aureus species including MRSA is gradually increasing [6,7,9,18,24]. S. aureus is a common pathogen in infectious otorhinolaryngology diseases and is detected as normal flora in 40% of normal adult nasal cavities, mainly spread through skin-to-skin contact. The prevalence of MRSA has been increasing steadily since it was first reported in 1961, probably due to the misuse and abuse of antibiotics, which is a problem throughout the medical community. AOM or OME also progresses to COM when treatment fails. MRSA has been identified more frequently in the MEF of COM patients than in AOM or OME, and MRSA detected in COM patients shows multiple resistance to more types of antibiotics [19]. In our study, highly pathogenic species such as MRSA and Pseudomonas species were detected only in the recurrent group, and the detection rate of MRSA was significantly higher in the recurrent group than in the non-recurrent group. In addition, S. aureus (both MSSA and MRSA) was identified in 16 out of 278 cultures, of which 6 were repeated two times each in 3 patients. Two of the three patients with repeated MRSA isolation showed a change of antibiotic sensitivity to CFT from sensitive to resistant as the number of VTIs increased. One patient with MRSA isolated after MSSA also showed a change of antibiotic sensitivity to CFT and PG. It is important to consider the possibility that multidrug-resistant species have spread through nosocomial infections through medical staff or surgical instruments due to frequent hospital visits and repeated surgery. In addition, pre-treatment antibiotics were used temporarily if there were signs of acute infection during close observation before VTI. Post-treatment antibiotics were also used for one week after VTI. The increase in antibiotic resistance in the recurrent group may not be able to preclude the effect of these preor post-treatment antibiotics. In fact, in one study, MRSA was exposed to the 5th generation cephalosporin in vitro to induce multiple-point mutation of the penicillin-binding protein (PBP), resulting in betalactam resistance and the emergence of new-generation broad-spectrum cephalosporin-resistant MRSA [22]. However, the number of patients was too small to show statistical significance for the change in resistance. Furthermore, there was a symptom-free period of 2–3 years between each isolation, which indicates the possibility of the detection of different species. Additional studies are needed, including genetic analyses, to confirm that resistance changes occurred in the same species.
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5. Conclusion Staphylococcus species were detected most frequently in the MEF of 6
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