{"id":299,"date":"2023-09-16T22:21:05","date_gmt":"2023-09-16T21:21:05","guid":{"rendered":"https:\/\/microregistrar.com\/?p=299"},"modified":"2023-09-16T22:21:06","modified_gmt":"2023-09-16T21:21:06","slug":"uk-smi-notes-ear-infections","status":"publish","type":"post","link":"https:\/\/microregistrar.com\/?p=299","title":{"rendered":"UK SMI notes \u2013 Ear Infections."},"content":{"rendered":"\n<h2 class=\"wp-block-heading\"><strong>Type of specimen:<\/strong><\/h2>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Ear swab<\/td><td>Middle ear fluid<\/td><td>Scraping of material from the ear canal (for fungal infection)<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Expected organisms<\/strong><\/h2>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Otitis Externa<\/strong><\/h4>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Acute localised otitis externa<\/td><td><strong>Staphylococcus aureus<\/strong>&nbsp;<strong>Group A Streptococcus<\/strong><\/td><td>furuncle Erysipelas<\/td><\/tr><tr><td>Acute diffuse otitis externa<\/td><td><strong>Pseudomonas aeruginosa<\/strong>&nbsp;<strong>S. aureus<\/strong>&nbsp;<strong>Anaerobes<\/strong><\/td><td>Treatment \u2013 topical cleaning of debris. Antibiotics are not useful.<\/td><\/tr><tr><td>Chronic otitis externa<\/td><td><strong>Colonisation by<\/strong>&nbsp;<strong>Enterobacteriaceae<\/strong>&nbsp;<strong>Fungi<\/strong><\/td><td>Treatment \u2013 topical, cleaning of debris. Antibiotics are not useful.<\/td><\/tr><tr><td>Malignant otitis externa<\/td><td><strong>P. aeruginosa.<\/strong><\/td><td>Invasive, necrotising infection. Needs aggressive antibiotic therapy and debridement.  At-risk groups are diabetic, older people, immunocompromised people.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Otitis media<\/strong><\/h4>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Acute otitis media<\/td><td><strong>Streptococcus pneumoniae,<\/strong>&nbsp;<strong>Haemophilus influenza and<\/strong>&nbsp;<strong>Moraxella catarrhalis<\/strong>&nbsp;<strong>Respiratory viruses.<\/strong>&nbsp;<strong>Less common:<\/strong>&nbsp;<strong>Staph aureus<\/strong>&nbsp;<strong>Group A Streptococcus<\/strong>&nbsp;<strong>Gram-negative organisms<\/strong><\/td><td>co-existence of fluid in the middle ear and signs and symptoms of acute illness.<\/td><\/tr><tr><td>Chronic suppurative otitis media<\/td><td><strong>Pseudomonads<\/strong>&nbsp;<strong>MRSA<\/strong>&nbsp;<strong>Anaerobes<\/strong><\/td><td>Chronic, suppurative destructive infection leading to hearing loss.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Specimen processing:<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Processing is done in containment level 2, except for the process which develops&nbsp;infectious aerosols (use microbiological safety cabinet).<\/li>\n\n\n\n<li>Gram stain \u2013 if middle ear effusion is sent.<\/li>\n\n\n\n<li>Expected turnaround time \u2013&nbsp;16\u201372hr<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Plates<\/strong><\/h2>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>Otitis Externa<\/td><td><strong>Blood agar<\/strong>&nbsp;(pick up target organisms, pick up any pure growth)&nbsp;<strong>Staph\/strep&nbsp;selective agar<\/strong>&nbsp;(may not be available in some labs, pick up Staph aureus, GAS)&nbsp;<strong>CLED<\/strong>&nbsp;(Enterobacteriaceae, Pseudomonads)&nbsp;<strong>SAB<\/strong>&nbsp;(Fungi)<\/td><\/tr><tr><td>Otitis media \u2013 swab<\/td><td><strong>Blood agar<\/strong>&nbsp;(pick up target organisms, pick up any pure growth)&nbsp;<strong>Staph\/strep&nbsp;selective agar<\/strong>&nbsp;(may not be available in some labs, pick up Staph aureus, GAS)&nbsp;<strong>CLED<\/strong>&nbsp;(Enterobacteriaceae, Pseudomonads) SAB (Fungi) and&nbsp;<strong>Neomycin&nbsp;fastidious&nbsp;anaerobe agar&nbsp;with&nbsp;metronidazole<\/strong>&nbsp;<strong>5 \u00b5g disc<\/strong>&nbsp;(Anaerobes)<\/td><\/tr><tr><td>Middle ear effusion<\/td><td><strong>Chocolate agar (any organism)<\/strong>&nbsp;<strong>Fastidious&nbsp;anaerobe agar&nbsp;with<\/strong>&nbsp;<strong>metronidazole&nbsp;5 \u00b5g disc (anaerobes)<\/strong><\/td><\/tr><tr><td><em>Note:&nbsp;<\/em><\/td><td><em>If chocolate agar has bacitracin, a separate blood agar should be used for&nbsp;M. catarrhalis and S. pneumoniae.&nbsp;<\/em><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Up to what level identification is required?<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Fungi \u2013 genus level<\/li>\n\n\n\n<li>Yeast \u2013 yeast level<\/li>\n\n\n\n<li>Pseudomonas spp. and anaerobes \u2013 Pseudomonads and anaerobe level, respectively.<\/li>\n\n\n\n<li>Enterobacteriaceae \u2013 coliform<\/li>\n\n\n\n<li>Beta haemolytic Strep \u2013 Lancefield group level.<\/li>\n\n\n\n<li>Pseumococcus, Staph aureus, Neisseria, Moraxella, Haemophilus \u2013 species level<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Management of otitis externa:<\/h2>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Localised otitis externa \u2013&nbsp;<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Analgesic, local heat (warm flannel)<\/li>\n\n\n\n<li>Oral antibiotic (flucloxacillin\/clarithromycin 7 days) \u2013only when spreading inflammation, systemic signs of infection, or a patient is at risk of complications.<\/li>\n\n\n\n<li>Drainage of pus (not required in most cases).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Acute diffuse otitis externa \u2013&nbsp;<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Cleaning the ear canal \u2013 under direct visualisation; may need ENT input, esp. if the tympanic membrane is compromised.<\/li>\n\n\n\n<li>Topical agents \u2013 Astringent (Aluminium acetate)\/ corticosteroid\/ antibiotics (neomycin,&nbsp;clioquinol, chloramphenicol, aminoglycoside, quinolone, polymyxin). Some antibiotics (aminoglycoside\/ polymyxin) are contraindicated in the presence of a tympanic membrane perforation unless advised by a specialist (ENT).<\/li>\n\n\n\n<li>ENT input.<\/li>\n\n\n\n<li>The usual duration of treatment is 7-days<\/li>\n\n\n\n<li>Oral antibiotics are rarely needed (inflammation extending beyond the ear canal, Unable to use topical treatment or patient at risk of complications).<\/li>\n\n\n\n<li>Abstain from water sports for 7-10 days and use.<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Chronic diffuse otitis externa \u2013<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Avoiding exposure to offending agent\/chemical.<\/li>\n\n\n\n<li>Treatment of fungal infection \u2013 Clotrimazole, clioquinol containing preparation.<\/li>\n\n\n\n<li>Topical steroids, topical antifungal trial in some cases<\/li>\n<\/ul>\n\n\n\n<p><em>(Ref: NICE CKS, BNF)<\/em><\/p>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Malignant Otitis externa<\/strong>&nbsp;\u2013<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>For Pseudomonas, antiPseudomonas antibiotic \u2013 Systemic. Ciprofloxacin +\/-&nbsp; an antipseudomonal beta-lactam for 6-8 weeks.<\/li>\n\n\n\n<li>For Aspergillus \u2013 Voriconazole\/ isavuconazole\/ amphotericin 8 \u2013 12 weeks.<\/li>\n\n\n\n<li>Surgery \u2013 selected cases [<a href=\"https:\/\/link.springer.com\/article\/10.1007\/s00405-020-05842-x\">Peled<\/a>,&nbsp;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6224839\/\">Singh<\/a>,&nbsp;<a href=\"https:\/\/www.medscape.com\/answers\/845525-103220\/what-is-the-role-of-surgery-in-the-treatment-of-malignant-otitis-externa-meo#:~:text=Because%20of%20the%20histopathology%20of,bony%20sequestrum%2C%20and%20abscess%20drainage.\">medscape<\/a>]<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Acute otitis media:<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Usually, resolve in 3-7 days.<\/li>\n\n\n\n<li>Admission needed\/considered in \u2013 children &lt;3mo, children &lt;6mo with fever, acute complications or severe infection (specialist\/ENT opinion)<\/li>\n\n\n\n<li>Antibiotic- severe\/systemic infection\/complication, otorrhoea, children with bilateral disease, deteriorating signs and symptoms.<\/li>\n\n\n\n<li>Antibiotics that can be used: Preferred \u2013 Amoxicillin or macrolide. 2nd line \u2013 coamoxiclav.<\/li>\n\n\n\n<li>Recurrent cases may need a specialist opinion and removal of potential contributory factors \u2013 GORD, smoking etc.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Type of specimen: Ear swab Middle ear fluid Scraping of material from the ear canal (for fungal infection) Expected organisms [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center 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