MICROBIOLOGICAL SCREENING OF OTORRHOEA FROM PEOPLE COMING TO HOSPITAL IN MAHAJANGA

Otorrhoea commonly hits young people. Risk factors of otitis occurrence as described by literature, are the presence of smokers among patients [1,2], chronic otorrhoea over twelve months and the number of children living on the same roof [3]. Ciprofloxacin and rifampicin are the two ear drop antibiotics commonly used for the probabilistic treatment of otitis in Madagascar. Discharge in the ear known as otorrhoea is a common reason for medical consultation. Otitis media is an infectious disease widely found around the world. In the United States, it represented 42% of antibiotic treatment prescribed in ambulatory [4].


INTRODUCTION
Otorrhoea commonly hits young people. Risk factors of otitis occurrence as described by literature, are the presence of smokers among patients [1,2], chronic otorrhoea over twelve months and the number of children living on the same roof [3]. Ciprofloxacin and rifampicin are the two ear drop antibiotics commonly used for the probabilistic treatment of otitis in Madagascar. Discharge in the ear known as otorrhoea is a common reason for medical consultation. Otitis media is an infectious disease widely found around the world. In the United States, it represented 42% of antibiotic treatment prescribed in ambulatory [4].
The change of behaviour of these pathogens because of antibiotics should lead to new reflexions on how therapy must be conducted [5]. Identifying bacteria involved in otitis media is a prerequisite for possible drugs to be tested to deal with otitis media and later, to do an 26 samples were then headed to the laboratory in less than 30 minutes and immediately tested.

Method:
A questionnaire was established and completed for each patient at the ENT unit for demographic data. The samples of otorrhoea were collected and sent for following examination at the laboratory where culture media were used: chocolate agar plate, Hektoen agar which is a selective media for Gram-negative rods, Uriselect chromogenic agar to identify bacteria using colour, Mueller Hinton for the antibiogram. Sensitivity test drugs used were Ciprofloxacin (5µg charge disc, Oxoid, Grande Bretagne) and Rifampicin disc (5µg charge disc, Oxoid, Grande Bretagne).

DISCUSSION
Otorrhoea is a medical condition with a common reason for ENT consultation. Results showed that there is no significant association between gender and the occurrence of otorrhoea. Authors, in Italia, reported a similar result in which female gender represented 55,6% [6]. The bacteria involvement is predominant with a monomorphic culture; the association of most pathogenic bacteria is also reported by other authors [7,8]. Pseudomonas aeruginosa that colonise the ears is predominant (Table I). It is the case found by other authors in Niger [9] but in South Africa, it comes in the second position after Proteus sp [10]. The pool of bacteria reported in the study is similar to the results, but as noted, the predominance of Pseudomonas aeruginosa as causative organisms of otitis externa varies according to studies [11]. In the US, authors reported 37,7% of Pseudomonas aeruginosa [12].
For acute otitis media, we found 60% of Pseudomonas aeruginosa. Which is not the case in France, where Husson reported 4,7% [13]. In France, Haemophilus influenza is the first causative agent of acute otitis media, followed by Streptococcus pneumoniae. AOM is very common, and at least 75 % of children have contracted it before starting school [14].
For the chronic otitis media, a predominance of Pseudomonas aeruginosa and Proteus sp. was found with respectively 40% and 26%. In India, Tanmoy D. and Debabrata R., reported in 2012, 37% of Pseudomonas aeruginosa and 17% of Proteus [15]. But in Mali, the prevalence of proteus (34,79%) is much higher than that of Pseudomonas (4,35%) as reported by a study in 2014 [16]. Fluoroquinolone represents the topical treatment of this condition because of its broad antimicrobial spectrum, a well-suited action against more colonising strains and due to its lack of otitis related toxicity [17].
The fungal organisms of otitis are not to be excluded. Causative agents of otitis mycosis belong exclusively to the genus Aspergillus and Candida. The frequently encountered germ in Europe is Candida albicans, followed by Aspergillus niger and Aspergillus flavus.
Regarding the use of ciprofloxacin, all bacteria of Pseudomonas aeruginosa were sensitive to the antibiotic. It is also the case in South Africa [9]. But in other countries like Pakistan, sensitivity is reduced, 70,8% in 2012 [18] and of 37,7% in Nigeria in 2010 [19]. The sensitivity of S. aureus to ciprofloxacin decreased. This phenomenon is due to the gene mutation of the bacteria. The use of a sole therapy of ciprofloxacin enhances the gene mutation favourably. In 2015, the sensitivity of otitis S. aureus found in India was 29,41% [20]. On the opposite, rifampicin remained the topical drug to treat otitis in the case of S. aureus for Madagascar. No resistance was found during the study. As for enterobacteria or pseudomonas, rifampicin is naturally resistant to but ciprofloxacin remains the effective antibiotic for Gram-negative bacillus in case of otitis in Madagascar. Throughout the study, the identification of the otitis associated bacteria is used to guide the anti biotherapy even if the antibiogram fails to come.

CONCLUSION
In Mahajanga, the most pathogenic bacteria of otorrhoea were primarily Pseudomonas aeruginosa and Proteus sp, but fungal involvement is not to be excluded. Indeed, the use of rifampicin or fluoroquinolone must follow indication depending on the type and origin of otitis, knowing that the bacteria mutation and the resistance rate of these bacteria to these antibiotics. Rifampicin ear drop in ambulatory treatment is not advised until S. aureus is being identified.
Clinical use of study: Though the size of the sample is limited, these results reflect the benefit of microbiological screening of otorrhoea.