Abstract
Aims
To know the microorganism causing rhinosinusitis & to study the antibiotic sensitivity pattern for the isolated nasal microbiota in this region.
Background
Rhinosinusitis is inflammatory condition of nose and paranasal sinuses [1]. It is multifactorial condition, in which microorganisms play pathogenic role [2]. Interactions between microorganisms, mucosa and environmental changes influence on composition of bacterial ecosystem [2]. Though antibiotics are frequently used for medical management of rhinosinusitis, sensitivity directed antibiotics are rarely prescribed. So, this study is directed to know microbial isolate in rhinosinusitis and its antibiotic sensitivity pattern.
Methodology
in this 6 months prospective study during March to September 2022, done at Department of Otorhinolaryngology, Raichur Institute of Medical Sciences, Raichur; patients attending Otorhinolaryngology outpatient department and diagnosed to have rhinosinusitis were selected. Nasal swabs were collected from the middle meatus by diagnostic nasal endoscopy and were sent for culture and sensitivity. Statistical tests were applied for results(Size = 100).
Results
Out of 100 patients, 52 were males, 48 were females; 88 were adults & 12 were paediatric patients. 59 patients had acute, 32 chronic and 9 had recurrent rhinosinusitis. Most common organisms isolated in acute rhinosinusitis was Klebsiella 28%, Staphylococcus aureus 56% & 66% in chronic & recurrent rhinosinusitis respectively. Klebsiella was sensitive to beta lactams & quinolones, while Staphylococcus aureus was sensitive to beta lactams & cephalosporins.
Conclusion
Increase in antibiotic use has led to antibiotic resistance. Hence judicious, sensitivity directed antibiotic usage reduces the risk of antibiotic resistance and unnecessary use of antibiotics.
Keywords: Rhinosinusitis, Nasal Microbiota, Culture Sensitivity
Introduction
Rhinosinusitis is inflammation of nose and one or more paranasal sinuses affecting 5% of general population [1]. Term microbiota refers to collection of various organisms in defined environment [2].
Most common cause of Acute rhinosinusitis(ARS) is viral & only 0.5-2% of patients develop acute bacterial rhinosinusitis(ABRS).Viral infection causes invasion of virus into respiratory epithelium leading to mechanical damage to nasal and sinus mucosa leading to ciliary damage. Vicious cycle of congestion, mucus retention, impaired gas exchange and altered pH prevents clearance of inflammatory products and debris producing medium for bacterial growth causing acute bacterial rhinosinusitis [3].
Symptomatic treatment, nasal douching and topical nasal decongestants are primary line of treatment for viral rhinosinusitis. If symptoms does not subside even after 10 days of treatment, bacterial etiology needs consideration where antibiotic treatment may be required.
Question arises as to which antibiotics to be prescribed. For this, treating physician/ surgeon should have knowledge on microorganism causing rhinosinusitis. For definitive treatment of the disease, antibiotics should be advised based on the sensitivity pattern of isolated organism.
Common organisms isolated in acute bacterial rhinosinusitis include, S. pneumonia, H. influenza, M. catarrhalis and rarely S. pyogenes and S. aureus [4] while in chronic rhinosinusitis with nasal polyposis, S. aureus is common.
Organisms isolated in chronic rhinosinusitis are Staphylococcus aureus, S. epidermidis, anaerobic and Gram-negative bacteria. S. epidermidis are likely colonizers. S. aureus are isolated in around 50% of CRS with nasal polyposis (CRSwNP) [5], and Methicillin resistant Staph aureus (MRSA) is increasingly isolated. While in cases of CRS without nasal polyposis, biofilms are more common. Other organisms isolated in chronic rhinosinusitis are P. aeroginosa, S. aureus, S. pneumonia, H. influenza and M. catarrhalis.
In ARS, penicillins, cephalosporins and macrolides are effective. While in CRS it is macrolides.
This study is conducted to know bacteria causing acute, chronic and recurrent rhinosinusitis and to know the sensitivity pattern of isolated organism, thus providing culture sensitivity directed antibiotic treatment to patients and reducing unnecessary antibiotic overload and resistance to antibiotics.
Objectives
To know the microorganism causing rhinosinusitis & to study the antibiotic sensitivity pattern for the isolated nasal microbiota in this region.
Materials and Methods
Type of Study
Prospective study.
Place of Study
Department of ENT, Raichur Institute of Medical Sciences, Raichur.
Source of data
Patients attending ENT outpatient department.
Duration of Study
6 months (March 2022- September 2022).
Sample size
100 patients.
Method of Collection of data
nasal swab from right and left middle meatus by Diagnostic Nasal Endoscopy.
Inclusion Criteria
Patients of all ages and both sexes, diagnosed with acute/ chronic / recurrent rhinosinusitis cases after surgery.
Exclusion Criteria
Patients not willing for the study and those diagnosed of having nasal diseases other than rhinosinusitis, granulomatous diseases of nose .
Nasal swabs were collected for the patients coming to ENT OPD with complaints of nasal discharge, nasal obstruction, headache and diagnosed with either acute or chronic rhinosinusitis including recurrent rhinosinusitis cases after surgery. Nasal swab from right and left middle meatus were collected by diagnostic nasal endoscopy and sent for culture and sensitivity and results assessed.
Statistical Analysis of Study
Data was analyzed statistically by SPSS software version 21. Percentages & proportions for qualitative data. Other statistical tests were applied wherever necessary.
Ethical Clearance
Ethical clearance was obtained from Institutional Ethical Committee (IEC).
Results
In our study, number of patients with acute rhinosinusitis were 59 followed by chronic rhinosinusitis 32 and recurrent rhinosinusitis 9(Table 1).
Table 1.
Percentage of acute, chronic and recurrent rhinosinusitis patients
| Rhinosinusitis | Number of patients (%) |
|---|---|
| Acute rhinosinusitis | 59 |
| Chronic rhinosinusitis | 32 |
| Recurrent rhinosinusitis | 9 |
There were 52 males & 48 females in study, of which adults were 88 & paediatric patients 12. (Tables 2 and 3).
Table 2.
Sex distribution
| Sex | Number (%) |
|---|---|
| Male | 52 |
| • Acute rhinosinusitis | 31 |
| • Chronic rhinosinusitis | 16 |
| • Recurrent rhinosinusitis | 05 |
| Female | 48 |
| • Acute rhinosinusitis | 28 |
| • Chronic rhinosinusitis | 16 |
| • Recurrent rhinosinusitis | 04 |
Table 3.
Adult & paediatric patients with rhinosinusitis
| Number (%) | |
|---|---|
| Adult | 88 |
| • Acute rhinosinusitis | 47 |
| • Chronic rhinosinusitis | 32 |
| • Recurrent rhinosinusitis | 09 |
| Paediatric | 12 |
| • Acute rhinosinusitis | 11 |
| • Chronic rhinosinusitis | 01 |
| • Recurrent rhinosinusitis | 00 |
Most common organism isolated in acute rhinosinusitis was Klebsiella species (17) followed by Staphylococcus aureus (13), Escherichia coli (12) and Methicillin resistant Staphylococcus aureus (10). There was no growth in 3(5%) specimens and 2(3%) had mixed normal flora (Table 4).
Table 4.
List of organisms isolated in ARS
| Acute rhinosinusitis | Number (%) |
|---|---|
| Klebsiella species | 17 (28%) |
| Staphylococcus aureus | 13 (22%) |
| Escherichia coli | 12 (20%) |
| Staphylococcus aureus(MRSA) | 10 (16.9%) |
| No growth | 3 (5%) |
| Klebsiella pneumonia | 2 (3%) |
| Mixed flora | 2 (3%) |
In chronic rhinosinusitis, most common organism isolated was Staphylococcus aureus (18) followed by Haemophilus influenza (10), Pseudomonas aeruginosa (3) and Streptococcus pneumonia (1)(Table 5).
Table 5.
List of organisms isolated in CRS
| Chronic rhinosinusitis | Number (%) |
|---|---|
| Staphylococcus aureus | 18 (56%) |
| Haemophilus influenza | 10 (31%) |
| Pseudomonas aeruginosa | 3 (9%) |
| Streptococcus pneumonia | 1 (3%) |
In recurrent rhinosinusitis, most common organism isolated was Staphylococcus aureus (6), Pseudomonas aeruginosa (2) and Haemophilus influenza (1)(Table 6).
Table 6.
List of organisms isolated in Recurrent rhinosinusitis
| Recurrent rhinosinusitis | Number(%) |
|---|---|
| Staphylococcus aureus | 6 (66%) |
| Pseudomonas aeruginosa | 2 (22%) |
| Haemophilus influenza | 1 (11%) |
Sensitivity pattern of isolated organisms in the study showed Klebsiella sensitive for beta lactams, quinolones, penicillin groups, cephalosporins and carbapenems.
Sensitivity pattern for Staphylococcus aureus was beta lactams, cephalosporins, macrolides, oxazolidinones and aminoglycosides.
Sensitivity pattern of Escherichia coli was aminoglycosides, cephalosporins, quinolones, penicillin group and carbapenems.
Methicillin Resistant Staph Aureus(MRSA) was sensitive for aminoglycosides, lincomycin antibiotics, oxazolidinones and tetracyclines.
For Haemophilus influenza, sensitivity pattern was beta lactams, cephalosporins, quinolones and aminoglycosides.
For Pseudomonas aeruginosa, sensitivity pattern was cephalosporins aminoglycosides and quniolones.
Streptococcus pneumonia was sensitive for beta lactams, aminoglycosides and penicillin group.(Table 7).
Table 7.
Antibiotic sensitivity for the isolated organisms
| Organisms | Antibiotic sensitivity |
|---|---|
| Staphylococcus aureus | Amoxycillin, Amox + clav, Ampicillin, Cefotaxime, Daptomycin, Gentamycin, Linezolid, Oxacillin,Rifampicin, Teicoplanin, Tetracycline, Tigecyclin ,Trimethoprim + sulfamethoxazole ,Vancomycin |
| Methicillin Resistant Staphylococcus Aureus | Clindamycin, Cotrimoxazole, Erythromycin, Gentamycin ,Linezolid, Rifampicin, Tigecyclin, Vancomycin |
| Klebsiella | Amoxicillin, Ciprofloxacin, Imipenem, Levofloxacin, Piperacillin + tazobactam, Meropenem |
| Klebsiella pneumonia | Amikacin, Aztreonam, Cefipime, Ceftazidime, Cefaperazone + sulbactum, Dorepenem,Ciprofloxacin, Gentamycin, Imipinem, Levofloxacin,Minocycline, Piperacillin + tazobactam, Meropenem, Tigecyclin, Ticarcillin + clav,Trimethoprim + sulfamethoxazole |
| Pseudomonas aeruginosa |
Cefuroxime axetil, Ceftazidime, Cefaperazone + sulbactam, Ciprofloxacin, Gentamycin Levofloxacin, Vancomycin |
| Haemophilus influenza |
Amoxicillin + calv, Amoxicillin, Ampicillin, Cefotaxime, Ciprofloxacin, Erythromycin Levofloxacin |
| Escherichia coli |
Amikacin, Cefaperazone + sulbactam, Ciprofloxacin, Ertapenem, Gentamycin, Nalidixic acid Piperacillin + tazobactam, Meropenem, Trimethoprime + sulfamethoxazole |
| Streptococcus pneumonia | Amoxicillin + clav, Amoxicillin, Ampicillin, Erythromycin |
Discussion
In our study, there were 52% males & 48% females in study, of which adults contributed to 88% & paediatric patients to 12%. In study by Osama et al. [4], 78% were males. In a study conducted by Madhavi Jangalaet al [18] of 188 patients 89 were children 99 adolescents.
Of 52 males, 31(60%) had ARS, 16(31%) CRS & 5(9%) had recurrent rhinosinusitis. Of 48 females, 28(59%) had ARS, 16(33%) had CRS & 4(8%) had recurrent rhinosinusitis. Of 88 adult patients, 47(54%) had ARS, 32(36%) had CRS & 9(10%) had recurrent rhinosinusitis. Of 12 paediatric patients with rhinosinusitis, 11(92%) had ARS & 1(8%) had CRS.
59 patients had acute rhinosinusitis, 32 had chronic rhinosinusitis and 9 patients had recurrent rhinosinusitis.
Organisms Isolated in Acute Rhinosinusitis
Among 59 acute rhinosinusitis patients in our study, 19(28%) Klebsiella species, 13(22%) had Staphylococcus aureus, 12(20%) Escherichia coli, 10 Methicillin Resistant Staphylococcus aureus(17%), 3(5%) had no growth and 2(3%) had mixed flora.
In a study conducted by Santosh Malshetti et al., of 100 patients, common organisms were- coagulase positive S. aureus (17.77%), S. pneumoniae (7.77%), Enterobactiaceae (7.77%) and H. influenza (5.55%) [17].
In a study by Osama et al.., among 93 patients with bacterial ARS, common bacteria was Staphylococcus aureus in 46 patients (49.5%), Klebsiella species (20 cases; 21.5%) and Escherichia coli (7 cases; 8.6%) [4].
In a study by Carolyn et al.., in ARS, majority were polymicrobial (55%) and included Streptococcus species (58%), Staphylococcus species (49%; including methicillin-resistant S aureus [MRSA], 11%), and anaerobic bacteria (35%), S pneumoniae (9.0%), Hemophilus species (4.5%) [12].
In a study by Tellez et al.., on 110 patients with ARS, Hemophilus influenzae (26%), Moraxella catarrhalis (15%), Streptococcus pneumoniae (14%), methicillin-sensitive Staphylococcus aureus (7%), Enterobacteriaceae (6%), Pseudomonas aeruginosa (2%) and miscellaneous (3%) were isolated [22].
Organisms Isolated in Chronic Rhinosinusitis
Among 32 chronic rhinosinusitis patients in our study, 18(56%) had Staphylococcus aureus, 10(31%) had Haemophilus influenza, 3(9%) had Pseudomonas aeruginosa and 1(3%) had Streptococcus pneumonia.
In a study conducted by Namit Kant Singh et al., on 120 patients, of 60 CRS cases ,43(72%) had Staphylococcus species and 4(7%) H. influenzae and 1(2%) had no growth [16].
In a study conducted by Madhavi Jangalaet al., of 188 patients, S.aureus was the most frequently cultured organism (59.9%), S. pneumonia (21.5%), P. aeruginosa (11.4%), Klebsiella sp. (11.4%). klebsiella sp. was identified more frequently (60%) in polymicrobial infections [18].
In a study conducted by M. Panduranga Kamath et al. of 100 patients 51.24% culture isolates ; 41.32% were aerobic organism and 7.4% were fungi. Staphylococcus aureus was seen in 43%, Klebsiella spp (9%), MRSA (3%) [19].
In a study conducted by Sam Boase et al., 38 CRS and 6 controls were taken in study. 33 different bacterial species were detected in CRS. Staphylococcus aureus and Propionibacterium acnes were the most common organisms in CRS and controls, respectively [8].
In a study conducted by Neil Bhattacharyaet al, total of 290 cultures were performed in 125 patients after endoscopic sinus surgery. 87 (30.0%) had no growth, gram-positive cocci 37.9%, gram-negative rods 14.8% [6].
In a study conducted by Santosh Malshetti et al., of 100 patients, anaerobic Pepto streptococcus (16.66%), S. aureus (11.11%) and Fusobacterium (6.66%) were isolated [17].
Among 9 recurrent rhinosinusitis in our study, 6 had Staphylococcus aureus, 2 had Pseudomonas aeruginosa and 1 had Haemophilus influenza.
Antibiotic Sensitivity Pattern for Acute Rhinosinusitis
Sensitivity pattern of Klebsiella was beta lactams, quinolones, penicillin groups, cephalosporins and carbapenems. Sensitivity pattern for Staphylococcus aureus was beta lactams, cephalosporins, macrolides, oxazolidinones and aminoglycosides. Sensitivity pattern of Escherichia coli was aminoglycosides, cephalosporins, quinolones, penicillin group and carbapenems. Methicillin Resistant Staph Aureus (MRSA) was sensitive for aminoglycosides, lincomycin antibiotics, oxazolidinones and tetracyclines.
In a study by Osama et al.., in 93 patients with ARS, MSSA showed sensitivity to cephalosporins, quinolones and clindamycin. MRSA were sensitive to vancomycin. Enterobacteriaceae was sensitive to cephalosporins and quinolones [4].
In a study by Tellez et al.., a total of 110 patients with ARS were enrolled, 28% of H. influenzae were resistant to ampicillin. Penicillin-sensitive S. pneumoniae (PSSP) and penicillin-intermediate-resistant S. pneumonia (PISP) accounted for 21% and 79% of the S. pneumoniae strains, respectively. H. influenzae was the most common isolated organism. About 55% of those isolates were found in patients!18 years old and only 25% were resistant to ampicillin [22].
In a study by Carolyn et al.., in ARS, sensitivity pattern was Vancomycin, cephalosporin, metronidazole in 37; Vancomycin, ampicillin-sulbactam in 23; Clindamycin, ampicillin-sulbactam in 12; Ampicillin-sulbactam in 8; Clindamycin, cefotaxime in 3; Vancomycin, meropenem in 1; Vancomycin, cefotaxime, clindamycin in 1; Vancomycin, imipenem in 1; Vancomycin, aztreonam, metronidazole in 1; Cefazolin in 1; Clindamycin in 1 [12].
Antibiotic Sensitivity Pattern for Chronic Rhinosinusitis
Haemophilus influenza was sensitive to beta lactams, cephalosporins, quinolones and aminoglycosides, Pseudomonas aeruginosa to cephalosporins aminoglycosides and quinolones & Streptococcus pneumonia to beta lactams, aminoglycosides and penicillin group.
In a study by Namit Kant Singh et al., MRSA was sensitive to Vancomycin, Teicoplanin and Linezolid, Rifampicin, Netilmicin and Clindamycin. H.infleunza was sensitive to cephalosporins [16].
In a study conducted by Santosh Malshetti et al., of 90 cultures Amoxy-Clav was sensitive in 66 (87%), Cefpodoxime in 59 (78%), levofloxacin in 52 (60%) and Ciprofloxacin-Tinidazole in 43 (57%). All aerobes were sensitive to Amoxy-Clav, Cephalosporin, Levofloxacin, Cephalosporin. All anaerobes were sensitive to Amoxy-Clav, Ciprofloxacin-Tinidazole [17].
In a study conducted by Madhavi Jangalaet al, Staphylococcus aureus was sensitive to cefotaxime (95.8%), Streptococcus pneumoniae for ofloxacin (100%), cefazolin (89.5%), and cefotaxime (89.5%), Pseudomonas aeruginosa for amikacin (100%) and ciprofloxacin (80%) and Klebsiella pnuemoniae for amikacin (80%) [18].
Conclusion
Increase in antibiotic use has led to antibiotic resistance. Our study showed that Klebsiella was more common organism isolated in acute rhinosinusitis and Staphylococcus aureus in chronic and recurrent rhinosinusitis. Klebsiella was sensitive to beta lactams & quinolones. Staphylococcus aureus was sensitive to beta lactams & cephalosporins.
Diagnosing the case correctly & appropriately using the antibiotics with correct dose & duration reduces complications and need for surgery. Hence judicious, sensitivity directed antibiotic usage reduces unnecessary use of antibiotics & risk of developing antibiotic resistance.
Acknowledgements
none.
Abbreviations
- ARS
Acute Rhinosinusitis
- ABRS
Acute Bacterial Rhinosinusitis
- CRS
Chronic Rhinosinusitis
- DNE
Diagnostic Nasal Endoscopy
- MRSA
Methicillin Resistant Staphylococcus Aureus
- MSSA
Methicillin Sensitive Staphylococcus Aureus
- CRSwNP
Chronic Rhinosinusitis with Nasal Polyposis
- CRSsNP
Chronic Rhinosinusitis without Nasal Polyposis
Funding
none.
Declarations
Conflict of Interest
none.
Informed Consent
obtained.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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